Why are ER bills so horrible? Sarah Kliff spent a year finding out

Dan: Tom Karches says his 17 year old son was crying, from the pain in his ear. And the stuff the doctor had suggested— like Advil— was not helping. 

 

Tom Karches: And all this time his ear is hurting more and more and more. And so it’s just like, what do I do? It’s like I don’t know what to do. So it’s like nine or 10 at night at this point. And um, so I called, I called the phone number to see about where I can take him at night because I know, I know I don’t want to go to the emergency room if I can avoid it. And it turns out there is no, there is no place you can take them other than the emergency room after 8:00 PM.

 

Dan: This is near Raleigh, North Carolina. And full disclosure, Tom is a supporter of the show on Patreon. 

 

Tom Karches: So we go to the emergency room and we sit around for just a short while 

 

Dan: His son gets a throat culture, for strep. That’s negative. So: it’s an ear infection. They give him a dose of penicillin, and a dose of prednisone— a steroid— to take down the inflammation that’s causing the pain. 

 

Tom Karches: And everything’s great and the doctor is really nice. And then we go home.

 

Dan: And then, a few weeks later, he gets the bill: More than 33 hundred bucks.

 

Tom Karches: I mean I just was sort of stunned that it was a big number and then of course I called them and I said please send me some detail— and the bill detail had exactly the same information on it as the bill I’d gotten before. There was no more detail. 

 

Dan: There was a LITTLE bit of detail on the original bill: Two charges for drugs— that’s the antibiotic and the prednisone— total, twenty bucks. And a charge for lab work— that’s gotta be the throat culture:  two hundred twenty four bucks.

 

And then a charge for “Emergency Room General”: 31 hundred dollars.

 

And Tom knows that’s not for the doctor’s service— that came on another bill. Couple hundred— a lot less after insurance.

 

Tom Kareches: So what is that 3100 dollars? It doesn’t tell you anything about what it is. It’s like, this is ridiculous, I’m paying this much for an expense and there’s zero explanation as to what any of this. And he just means

 

Dan: Tom is not alone in finding a charge like this… confusing.  

 

This is “An Arm and a Leg,” a show about the cost of health care. I’m Dan Weissmann. (And full disclosure: Tom Karches supports this show via Patreon)

 

Sarah Kliff has been reporting on health care for years— first at the Washington Post, now at Vox dot com. She thought she knew as much as anybody about our health care system.

 

And then she got an email from a reader.  He had been trimming his baby’s fingernails and… gone a little too deep suddenly there’s blood. And it’s late at night.

 

He goes to the ER, and they give him band-aid. And the bill is six hundred twenty-nine bucks. And he can’t figure out— why so much for a band-aid? He sends Sarah the bill. It stumps her too.

 

Sarah Kliff: I did not understand this bill.but I decided to find out.

 

Dan: And what did you find out? 

 

Sarah Kliff:  So I found out that um, the bandaid itself was actually, um, I hate to say it’s like was cheap. It was $7, like that’s an insanely expensive. You can buy a lot of bandaids at cvs for $7, but the bandaid only represented $7 of this charge.

 

Dan: The rest? WTF, man. 

 

Sarah Kliff: I mean, it’s like, so opaque, like if you look at this bill, there’s just a bunch of charges. It doesn’t say, it says reason code mg like, what does that mean? If it says service code? See One, like I, I, I write about healthcare for living. I don’t know what reason code mg Ids and service code c one are, yeah, this was all totally news to me.

 

Dan: Does that happen a lot? 

 

Sarah Kliff: Oh yeah. Because I mean it’s like a super confused, like healthcare is so confusing. Like I’m constantly running into things I don’t understand. 

 

Dan: She did have someone to call. A researcher in California who is also an ER doc.

 

Sarah Kliff: And she’s like, Oh yeah, that’s the facility fee. That’s obvious. Um, and then like I’m like back, you’re googling like what is an emergency room facility fee.

 

Dan: Turns out, it’s like a cover charge at a night club: The price of admission.

 

She wrote a story about the band-aid thing, and what she’d learned: that facility fees exist. And at the end of the story, she invited readers to chime in. Just a line. 

 

Sarah Kliff: What did I say? Oh, it’s just at the very end. Have you faced a medical bill like this? Tell us about it. Email your story to Sarah Kliff here. 

 

Dan: And that link goes directly to your inbox and what happened? 

 

Sarah Kliff: And I get hundreds of emails of people being like, yeah, I have a story like this.

 

Dan: One was a guy who cut his hand doing dishes and ended up with “liquid stitches.” 

 

And… 

 

because the visit was late at night. It started at like, one was it, it was like around 11 at night and it ended up one in the morning. 

So they build for two days worth of services. 

 

Dan: Nice touch man. And so, and, and so that I was like, wait, that’s when we hit. That was about, that’s not the doctors, just the hospital. Oh my God. And so what? And yeah. And did this surprise you? 

 

Sarah Kliff: Yeah, the two day thing I thought was pretty bold. 

 

But she never got to the bottom of: What’s the deal with these facility fees, anyway?  

 

Sarah Kliff: I just thought it would be. It was such a mysterious charge to me and I wanted to know more about it and I kind of had this like pie in the sky idea, like wouldn’t it be cool if we could just figure out what facility fees are by collecting a ton of bills 

 

Dan: This would be a big project: They’d have to build a database— a SECURE database, to hold people’s medical records— and a system for telling people HOW to send in their records. But if she got enough of them, she could start to answer some questions about the bigger picture. 

 

Dan: She wasn’t sure it was going to work.

 

Sarah Kliff: I was like, who’s going to send in their bills to like a stranger? Um, but it turns out a lot of people wanted to because they were really frustrated. 

 

Dan: By the time I met Sarah, almost exactly a year after the project launched, she had more than a thousand ER bills from all across the country. 

 

In a minute, we’ll hear about all the crazy stuff she learned. And how she feels about it now.

 

But first, real quick … 

 

We’re taking a break after next week, to get ready for Season Two, and I want to recommend a podcast you might enjoy in the meantime:  It’s called The Nocturnists.  

 

They won’t say this, because they worry about get sued, but I can tell you:  It’s basically like the Moth— except ALL the storytellers are doctors and health care workers.  

 

The show’s first season is out now. It includes stories about 

an… incident at the morgue, 

And what it’s like to be a doctor and have your 90 year-old patient tell you he wants to die. Like, today. 

 

Season one of The Nocturnists is out now, and Season Two kicks off February 2019. Wherever you get podcasts, or at The Nocturnists, dot com. 

 

OK, back to the show.

 

So, what did Sarah Kliff learn from a thousand ER bills?

 

First: A giant tab, just for walking in the door? Not so unusual.

 

Sarah has added up all the thousand bills people sent her, and got a total of four million dollars, just in facilities fees. 

 

That’s an average of four thousand dollars per ER visit. Just for showing up.

 

Turns out the guy with that 600-dollar band-aid was getting off easy.

 

She also got to see the huge variety of things that LAND people in the emergency room.

 

Sarah Kliff: I, there are so many weird things that happen to people, you know, people, there were so many odd encounters that land people in the emergency room, um, people being hit by baseballs at professional, like MLB Games, um, people were being attacked by raccoons. 

 

Dan: So, speaking of animal attacks, she looks up the bills she has involving… rabies.

 

She added a keyword search where I can search for rabies and see we actually have 13 bills of people who went into the emergency room and there something in their visit description mentions rabies. And what were the like, what’s the toe we do we know what the total damages for all for 13 cases of rabies see? 

 

Um, I don’t think it totals them up for me. I mean, all of them are high each. The Cheapest Facility fee was 830— the highest 16 thousand.

 

Dan: Jesus, really? WHAT? 

 

In fact, Sarah says how much these fees vary from hospital to hospital was one of the things that really jumped out at her, once she had a thousand bills to look at. 

 

Sarah Kliff: Like I knew there was variation but I didn’t understand like you’re really rolling the dice depending on which hospital you go to. Two hospitals very close to each other could have wildly different fees and you just have like no idea what you’re getting into and you have no way to figure it out in advance. 

 

Dan: Yeah, and then if the facility fee ends up being SIXTEEN THOUSAND DOLLARS, what does that look like? 

 

Sarah Kliff: So I wonder if that’s the cost of the rabies shot, um, This was someone who’s been bit by a cat. Um, yeah. So then she sends the bill and I can look at it. I’m like, wow. So I seen this is why it’s so confusing. So literally there were six different charges on her bill and they’re all just labeled emergency room. 

 

One emergency room charges $10,000. Another is $3,000. The total of 16. So she told them everything she was built for. My hunch is the $10,000, just having reviewed a lot of rabies bills now at the $10,000, the cost of the actual rabies shot, but there’s a $1,500 bill. There’s an 1100 $3,500 and then two bills, $109. I have no idea what those are. 

 

Dan: Oh my God. And this is the actual bill?

Sarah Kliff: Yeah, this is. So this is what sickness and char cynicism or insurer and looking to see if there’s a hospital bill and then she also got built, it looks like from the doctor’s separately. Um, so the doctor was like the. Yeah, so she was getting billed by the hospital and the doctors. So these are the things that, these are the bills that drive me crazy, that there’s no specificity. There’s a bunch of charges and it just says emergency room for all of them. 

 

Dan: Oh my God. 

 

Yeah. It turns out there’s no standard. Any hospital can charge… whatever they think they can get, I guess. 

 

And then, once Sarah had a chance to look at a WHOLE LOT of bills a while, she noticed something else.

 

Sarah Kliff: So one of the things, so first I learned facility fees exist. I’m like okay, that’s kind of weird and interesting. And then as I start getting more bills I realized Oh it’s actually more complicated that it’s not one cover charge. There’s five different levels of coverage charges depending on how many services you used. 

 

Dan: So like…

 

Sarah Kliff: So you are coded level one through five and your facility fee is higher if you’re a level five.

 

Dan: And the levels are like how complex your problem is? I mean this is something that’s a little bit familiar to me. It’s like, you know, a five. 

So a five are the most complex cases and then a one which I’ve literally never seen— the ones don’t seem to be— a one would be the easiest.

 

Sarah Kliff: But I started seeing like, some people are being coded at the highest level when their cases. Like to me it seemed like relatively simple. So I’m like wondering like what’s going on with these levels 

 

Dan: To figure THAT out, she needed a bigger pile of data. And she found one, put together by a non-profit group.

 

Saah Kliff: And it turns out they have like millions of emergency room claims. So you can kind of ask this question that I had like, are the ones disappearing? Like are the fives becoming more common? And the answer is yes.

 

Dan: Yes. Yes, the ones are disappearing. Yes, fives are becoming more common. If you were inclined to be suspicious, you might think hospitals were milking this— just declaring a whole bunch of things to be fives.

 

So— back to Tom for a minute. His kid had that earache? : He started reading Sarah’s stuff. He figured out that this mysterious $3,100 was a facility fee.  And it was coded as a level four— the second highest. Medically complex. He asks them why is it a four? Like, what’s a two?

 

They say, a two is an aspirin. And a three is one prescription medication. But you got TWO prescription meds. Antibiotics and the steroid.

 

Dan: Um, and so they’re like, well that’s because it’s, it’s, it’s complex because we gave you two medications and you, it says the risk.

 

Tom: What is it when you walk in with your leg in a bag?

 

Dan: I ask Sarah: Aren’t these fees just BS to begin with? She’s not sure. Hospitals make a case for these fees, and she appreciates the logic behind it.

 

Sarah Kliff: I’m torn. Like I think I can see both sides of this one, like on the one hand, like, yeah, like emergency rooms are a wonderful service that operate all across the country and you can go in there at any time and they’re open 24 hours a day, seven days a week and they see every patient. Um, that’s a really important part of our healthcare infrastructure. Um, so I get that and I get that costs money.  

 

Dan: Yeah OK, but isn’t that why the ER charges me seven bucks for a band-aid? Every single thing that happens in the E.R. is ALREADY marked up. 

 

Isn’t that kind of pricing supposed to be what covers the cost of running the joint?

 

It’s like you’re charging me a big cover charge to get into a bar where there’s no entertainment, just a really fancy selection. And it’s the only bar in town that’s open past 8 p.m. 

 

And then when I order a budweiser, that’s twenty bucks. And if I order a fancy drink, it’s a hundred. So what’s the cover charge for again?

 

I put that question to Sarah, and she starts agreeing with me.

 

Sarah Kliff: Yeah, right. It’s not a. and I think this is, yeah, a key point. It’s not like you have this high facility fee and then you don’t, you don’t see all these itemized charges. Did you have the high facility fee and then you see like a ton of itemized charges for everything else that happened? 

 

Dan: Yeah, I don’t get that. 

 

Sarah Kliff Me neither. Welcome to the American healthcare system

 

Dan: Totally apart from these facility fees. 

 

There’s this whole other problem with emergency room bills.

 

Because: Sometimes the doctors who WORK at the emergency room don’t take your insurance. 

 

Even if the hospital itself does. 

 

Sarah Kliff: Yes, this is becoming more common and more common in a few places. Texas, this is a huge issue in Texas, um, is that you have emergency rooms that are in network that if you go on your insurance website will say yes, you know, emergency racks is in your network, but it turns out a lot of the surgeons, the radiologists, anesthesiologists, that they are not actually in your network

 

And they are going to bill you separately and they do not have a negotiated rate with your insurance company. So they were just going to bill you like what they think is a good price.

 

Dan: So, out of network means one, the price hasn’t been negotiated with your insurance company. So it’s whatever it is. Yes. Two, your insurance company. Maybe like. Yeah, we don’t really reimburse. 

 

Sarah Kliff: We don’t cover that guy. We may not pay anything for him where we may pay a very limited amount for him. Yes. 

 

Dan: And you, there’s a thing called like an out of pocket maximum for a year where there’s like on your insurance plan, there may be a thing where like, the insurance is like, once you hit $10,000 in spending, we got you for the rest of this, but that also doesn’t count when you’re seeing someone’s out of network. So if you happened to walk into an emergency room where the care is actually provided by doctors who aren’t in network, then you, there’s no limit to what you might end up on the hook for.

 

Sarah Kliff: Yes. And you have no insurance companies standing between you and the provider. It’s just like you on your own. Um, and it’s, you know, an emergency rooms that actually, like, what are you going to say? No. I’m like, so this actually happened to me when I was in the emergency room for something, you know, that wasn’t an especially urgent, but basically I needed an ultrasound and this was the only place open to get an ultrasound. So they say go to the emergency room. And they had thought I was gonna be admitted to the hospital from there, but they said, you know, go to the emergency room to get the ultrasound first. Um, and so I go, I’m getting the ultrasound. There’s a radiologist who’s not even at the hospital was like somewhere who’s gonna read my ultrasound and then to say like, here’s what’s going on.

 

Um, I don’t know if this person is a network. I don’t even ask if this person is a network because I’m like, well this doctor says I need this ultrasound. And like who am I at a protest? So I’m like crossing my fingers and hope it’s fine. Like I know I should ask, but like I had like a really fever, like, you know. Yeah, because I was having trouble fever, you know, I have like a two week old baby, like I’m not going to like in my, you know, if I was doing this as a reporter, I’d ask, but like I’m like a person then, you know, I’m not gonna negotiate healthcare prices. Actually I’m going to go shop around for, in network radiologists, like with my hundred degree fever in my, like small baby.

 

No, I’m like totally stuck. 

 

Dan: Lucky for her, she was fine. No giant health crisis AND no big surprises on her ER bill, so she wasn’t going to have a financial crisis. 

 

If all of this makes you kinda anxious, you’re not alone.

 

Sarah Kliff: I personally am much more nervous about going to the emergency room that I would have been a year ago. Wow. How could I not be like, I hear all these stories about, you know, these people like these bills. I know how uncertain it is. Like when I went to the emergency room I was like, well this is kind of a crapshoot and like we’ll see what happens. 

 

I’ve read over a thousand of these bills. I have no skills that would help me avoid a surprise emergency room bill. And Want ot be like here are some smart tips. Like, I wish I had smart tips. 

 

Dan: But there is a little bit of a bright side. Since Sarah’s stories— and others like them— have gotten more and more play, she says some legislators have actually started to respond. 

 

Sarah Kliff: So there’s now two separate bills in Congress, both, um, in the Senate that would end surprise emergency room bills.

 

Dan: Okay. How’s that going? 

 

Sarah Kliff: Better than expected. I mean like look, like nothing moves through Congress fast, but you know, I think it’s interesting that these bills are bipartisan.It’s different than the Affordable Care Act. Like a lot of people are angry about surprise, emergency room bills. I’d say like if you’re in DC, like the smart money is always on. Nothing happening, but it seems like a not crazy area for something possibly happen.

 

Dan: Meanwhile, Tom gave up trying to reason with the folks at his local hospital.

 

Tom: I see where this is going. And they can wait me out because it’s your job to wait me out. 

 

Dan: His insurance had approved the level four facility fee. But it got him a discount. Left him with 15 hundred dollars to pay.  

 

I called the hospital, asked them: Doesn’t Level Four seem kind of high? And by the way, how much less would you have charged for a level two? They didn’t really answer.

 

And I called Tom’s insurance company. Asked them: Why’d you approve this at level four? The spokesman said he’d have to look at the clinical record. And I guess that wasn’t something he was going to do. 

 

But for Tom, that’s water under the bridge.

 

Tom: I paid the bill. I’m very fortunate that my wife and I are relatively frugal and we have a pretty substantial savings account and we own our house, So I could afford it. This is crazy that I can do this. Why is everything so bonkers? 

 

Dan: Everything about the cost of health care is enough to drive us all bonkers. So next time on an Arm and a Leg, we’ll meet Bari Tessler. She makes her living— and she’s a little bit famous— as a financial therapist. 

 

She says, rising health insurance premiums may have made HER a little nuts this year.

 

Bari Tessler: Something in me snapped. And I said that’s it. Or we need to explore other options here.

 

She and her family have stitched together a kind of improvised substitute for health insurance this year. 

 

Bari Tessler: It’s not ideal. And— yeah, it’s not ideal.

 

Dan: Next time on an Arm and a Leg: Bari’s story, the deal she’s pieced together, and what she’s doing next. Also, what my family’s doing for 2019. What some of you are doing.

 

Meanwhile, here’s a voice memo from John in Chicago, age 29, who just spent the morning trying to pick a health-insurance plans for 2019. He says his priorities were finding a policy that could keep him out of bankruptcy if he gets run over by a car— and covers his therapy bills. 

 

John: I found a one with a really expensive either I found ones with like really expensive premiums that um, didn’t really affect the amount of money that I already spend on therapy without insurance. 

 

And, um, when I looked for like, hit by a car plans, um, the, uh, the deductibles were so high that I realized that even if I, even if I got this land and did get hit by a car, I would still like have to pay so much money if I went to the hospital. 

 

Like I would still be screwed. I’ve been talking to my, uh, my therapist works at. And basically her advice for me was to just not get health insurance. I’m not sure that she would say it that way, but that’s kind of what our conversation came down to. She was like, you know what, you’re going to pay the same amount, uh, no matter what type of a health insurance plan you get.

 

And she was like, and you know, if you get hit by a car, hospitals offer financial aid and she told me the story about how she had gone to the hospital with her daughter and gotten financial aid to pay for some really expensive stuff and then wound up paying nothing at all. So yeah, my takeaway was basically just like, well, maybe I just don’t get health insurance and if I get hit by a car, ask for financial aid and cross my fingers because I might as well.

 

Dan: I am so officially NOT offering advice about this. But PLEASE keep these stories coming. Stories at arm-and-a-leg-show, dot com.  

 

More next week.

 

Till then… take care of yourself.

 

This episode was produced by me, Dan Weissmann. Our editor is Whitney Henry-Lester, our consulting producer is Daisy Rosario. Our music is by Dave Winer. Adam Raymonda is our audio wizard.

 

Big thanks this week to Sarah Kliff. We’ll have links to Sarah’s amazing stories about ER bills at arm-and-a-leg-show, dot com, and in our newsletter. 

 

That’s also a place to see a few of the responses we’re getting from you, and other stories we think you might dig.  

 

That’ll ALSO be a great way for us to keep in touch after this season ends next week. You can sign up at arm-and-a-leg-show dot com, slash newsletter.

 

Big thanks also to Tom Karches, for his story and— full disclosure— for supporting this show on Patreon. We’ll thank our latest supporters in a minute, but first: 

 

Here’s one other thing you might enjoy.  The Podcast Brunch Club is like a book club, but for podcasts. Every month there’s a playlist of podcasts to listen to, on a theme— like money, or oceans, or artificial intelligence: Members listen and then get together and talk. There are chapters in 50 cities, you can start one of your own, or you can participate online. It’s kind of cool.

 

ALSO, the website features interviews with folks who make podcasts. Like for instance, this month they interviewed… me. So if you’re curious about how this show gets made, check out podcast brunch club dot com slash arm leg.

 

AND:   

 

Thank you to our new supporters on Patreon!  Big thanks to Tamar Frolichstein-Appel, James Biddle, Jack Reid, Michael White, Jaime Green, Amy Ahlstrom and Brian Chen, Ben Chandler, Allison Akright, Matthew Underwood, Jill Wohl, and Jennifer Lewis 

 

great stories about a mishap at the morgue, the experience of being distracted by technology when caring for a dying patient, and trying to save an important government official on a train in North Korea.

 

For Season 2 we’ve got a bright-eyed medical student wondering how she’ll avoid getting jaded and scarred by the training process, a prison doc who goes to great lengths to make sure that a patient can make it home to die, and a retired military surgeon reflecting on his time caring for wounded children in Vietnam. 

 

We’re taking a break after next week, to get ready for Season Two, and I want to recommend a podcast you might enjoy in the meantime:  It’s called The Nocturnists.  

 

They won’t say this, because they worry about get sued, but I can tell you:  It’s basically like the Moth— except ALL the storytellers are doctors and health care workers. The show’s first season is out now. It includes stories about an… incident at the morgue, and what it’s like to be a doctor and have your 90 year-old patient tell you he wants to die. Like, today. 

 

That’s out right now, wherever you get podcasts. Season Two of The Nocturnists starts in February.