One in a series
Michelle Palmer made a costly mistake last year when she went to the emergency department at Mercy St. Anne Hospital seeking help for a respiratory condition.
Mrs. Palmer, 55, of Temperance was searching for an urgent-care center on March 2, 2014, and had been told by a family member there was one behind the hospital on Secor Road.
There was an urgent care next door, ProMedica Urgent Care in the Toledo Clinic building, but Mrs. Palmer instead walked into St. Anne’s ER entrance in the back of the hospital.
It wasn’t until she received the $1,155.33 bill that she discovered her error. Instead of going to a lower-cost urgent-care facility, Mrs. Palmer had been treated in one of the most expensive places in all medical systems, an emergency room.
“The doctor saw me for less than 10 minutes. It was probably less than five. I was diagnosed with bronchitis and sinusitis, got two prescriptions, and I was done,” she said.
After her insurance company, Anthem Blue Cross and Blue Shield, reduced her bill to $607.53, Mrs. Palmer made monthly payments to Mercy to cover the balance.
St. Anne’s ER has the highest chargemaster rates for services of all the Mercy hospitals in the Toledo area. The chargemaster rates for hospitals are what some call the retail price. All patients are charged these rates initially, but private insurance companies and the federal government negotiate prices with hospitals for their patients, including ER charges.
Setting prices
Most people with insurance never pay the chargemaster rates, but their final out-of-pocket expense varies dramatically depending on which insurance plan they have and their annual deductible.
Mrs. Palmer is one of many Blade readers who submitted medical bills in response to The Blade series on the cost of medical care in the Toledo area. Mrs. Palmer, like many others, is perplexed by the cost of emergency room services and questioned why a relatively short visit — for what appeared to be a minor problem — resulted in charges in the thousands of dollars.
The ER is probably the number one service that the public uses at area hospitals, said Sarah Bednarski, spokesman for Mercy Health. But she said there is little understanding of how the charges are generated and what goes into the final bill.
Mercy, like all other Toledo hospitals, has set prices for ER visits, and every patient visit is categorized as a level 1, 2, 3, 4, or 5, with 1 being the least serious and least expensive. Level 5 is the most serious and most expensive.
Mrs. Palmer’s visit was considered Level 3, said Amy Szymkowiak, regional director for health information management for Mercy Health.
She said it does not take long to get to a Level 3 in an ER setting, and the charges have little to do with how much time the doctor spends with a patient. The charges and levels are more connected to the time the nursing and other auxiliary staff spend with a patient and the number of times the nurse visits a patient’s room.
Doctors, using a similar 1-through-5 scale, bill for their services separately, she said. This is why patients who visit an ER receive one bill from the hospital and an additional bill from doctors for their services, Ms. Szymkowiak said. There are also separate charges generated for tests such as MRIs, so one ER visit can result in multiple bills for a patient.
“[Mrs. Palmer’s] stay was a little longer than five minutes. She presented with congestion and sinus pressure. If you go into the system and put that in as the presenting problem or the diagnosis, it comes up automatically as a Level 2,” Ms. Szymkowiak said.
“What took her up to a Level 3, which is where she ended up — we had an additional nursing assessment — so she had another nurse that came in the room, assessed her, checked her vitals, checked her face, and looked in her ears and that kind of stuff, that is what drove her to a Level 3 — that one nursing note,” Ms. Szymkowiak added.
A costly toothache
Jim Glanzman, 67, is also dismayed over how his short visit to ProMedica Flower Hospital’s emergency room last year for an abscessed tooth resulted in a Level 4 and an initial charge of $2,073.
Mr. Glanzman, a Holland resident, doesn’t have dental insurance and admits he let a toothache go on much too long without seeking medical help. He woke up on Feb. 19, 2014, and was having difficulty breathing.
“I started gagging because my throat was swelling shut,” he said.
His fiancee, a registered nurse, urged him to rush to the ER. Once there, however, he said he received very little treatment.
“They said, ‘Well this is a dental problem. Here’s a pill.’ That was it. My whole time there,” Mr. Glanzman said.
ProMedica officials said Mr. Glanzman was in the ER a total of 40 minutes.
“A charge entry specialist entered clinical information into the system, which automatically generated a level based on the severity of [the] situation. Mr. Glanzman’s abscessed tooth put him into a Level 3. It was increased to a Level 4 due to his level of pain,” Tedra White, spokesman for ProMedica, said in a written response.
Mr. Glanzman is on Social Security, and initially his Medicare insurance company, Humana, rejected his claim because it was related to a dental problem. He appealed and won.
Humana agreed to pay the hospital system the Medicare rate, which for his bill was $274, and Mr. Glanzman was responsible for $65. In total, ProMedica received $339 for what was originally a bill exceeding $2,000.
ProMedica officials said that a month after Mr. Glanzman visited Flower Hospital, ProMedica switched from a manual process to a computerized system that uses software to make billing and ER levels more consistent and fair across all of its hospitals.
Care levels
Mercy, ProMedica, and the University of Toledo Medical Center, the former Medical College of Ohio Hospital, all use the same 1-through-5 scale to determine charges for ER visits.
Mercy and ProMedica follow guidelines established by the Centers for Medicare and Medicaid, and both use a computer software program to calculate points based on what services are rendered to patients during a visit.
The software system adds up all of the different codes and points for each individual procedure and then comes up with one summarized point. That point then maps to one of five ER levels, said Haley Studer, vice president of revenue cycles for ProMedica.
Exactly how those points are determined and the number of points needed to reach a Level 3, for example, “is confidential and only shared with government agencies by request,” ProMedica officials said.
“It’s all built into the software, and different points are awarded for different activities,” Ms. Studer said.
The system even differentiates between how a patient arrives at the ER. Those who walk in themselves are assigned a lower number of points than those who arrive by ambulance, Ms. Szymkowiak said.
Overhead costs
In addition to services rendered, the point system also builds in the cost of running an ER 24-hours-a-day, seven-days-a week into the patient’s bill, she said.
“It uses really two things to get to those point levels. The first thing is the patient’s presenting problem, so what did the patient walk in the door with — what is the patient saying to the nurse. The other thing is what other resources did it take for us to manage that patient, so what other kind of things did we use,” Ms. Szymkowiak added.
The overhead costs that hospitals incur have to be part of the equation and built into the price because hospitals cannot turn anyone away, even those who cannot pay, said David Morlock, chief executive officer of UTMC.
“If you’re taking federal dollars, Medicare or Medicaid money, then you’ve got to follow a set of rules. One of the sets of rules is you don’t get to deny people treatment in the emergency room. An emergency room has to be staffed, equipped, and prepared to take care of the sickest of the sick and the most hurt of the hurt,” Mr. Morlock said.
There are no national standards or regulations around the levels that hospitals assign to ER visits, so each hospital system is free to create its own approach, he said.
UTMC, like most other medical centers in the country, follow guidelines established by the American College of Emergency Physicians to determine if an ER visit is Level 1 through 5.
“The doctor has to code, here is the diagnosis, here is the procedure that we did. And then typically the coding group takes that information and can decide if this is a Level 2, 3, 4, or whatever,” Mr. Morlock said.
Because there is not one national standard, theoretically Level 2 could mean different things at all three hospital systems in town. Despite the lack of regulations, “I doubt they are vastly different from each other. There should not be huge disparities despite different systems,” he said.
No regulation
There are also no government rules or oversights over what hospital systems charge for services, so each is free to set its own price for the different ER levels. In the Toledo area, Level 3 chargemaster rates can range in price from $785 at UTMC to $1,317 at St. Anne.
The chargemaster rates are typically paid only by those who do not have insurance. However, noninsured patients can also apply for discounts from each hospital system, but their eligibility for discounts is income dependent.
Some noninsured patients end up paying nothing, Ms. Studer said.
ProMedica charges the same ER rates no matter which hospital a patient visits, said Ms. Studer. The ER charges range from $340 for a Level 1 visit, which is very rare, to more than $2,500 for a Level 5 visit.
Mercy has taken a different approach, and ER charges are different at each hospital. A Level 3 visit can range from $820 at St. Vincent Medical Center to St. Anne’s $1,317.
“The pricing list from St. Anne stems from Riverside. When we transitioned all services from Riverside Hospital to St. Anne, the chargemaster was included,” Ms. Bednarski said. Mercy closed Riverside Hospital, which was near downtown, in 2002 and St. Anne, in West Toledo, opened a month later. All of the staff from Riverside moved to the new facility along with Riverside’s retail price list, Ms. Bednarski said.
“Mercy is working to standardize rates across the hospitals,” but it will take time to align all of them, she added.
Mercy also operates a standalone ER in Perrysburg and is building a similar facility in Sylvania Township. The Perrysburg ER is considered an extension of St. Vincent and will share its price list. The new Sylvania facility will share the St. Anne price list, Ms. Bednarski added.
UTMC’s ER charges are the lowest in the Toledo area, with retail prices that range from $220 to $1,886. It has just one hospital in South Toledo, though.
“Sometimes you are going to go through testing [in the ER] to find out it’s bad Mexican food. Then you’re going to get a bill and it’s going to be like they charged me for a Level 4. I had this MRI exam and they charged me on top of it for the MRI exam. I just racked up a $3,000 bill and I had indigestion and that just feels for the person with indigestion, that doesn’t feel fair. I get that,” Mr. Morlock said.
Mrs. Palmer said the ordeal and having to pay what she considered an unfair price for bronchitis and sinusitis has opened her eyes. Going forward she plans to shop around for medical services.
“I need to go where the sale is. Ultimately if the chargemaster price is lower, our deductible and out-of-pocket will end up being lower,” she said.
Contact Marlene Harris-Taylor at: mtaylor@theblade.com or 419-724-6091.
First Published May 24, 2015, 4:00 a.m.
