Urgent care billing: Eyebrows raised

An unhealthy discount

My wife was sick a few weekends ago so I took her to the Beth Israel urgent care clinic in Chestnut Hill where they diagnosed her with the flu. Nice modern facility. In network. Convenient parking. You get the idea. Care was good, but slow.

Then a few days ago, I received an Explanation of Benefits (EoB) from my health plan.

One reason to go to urgent care is that it’s more cost effective than the emergency room. In this case BI sent Blue Cross a bill for $1328. Blue Cross marked it down to $365.81, subtracted our co-pay ($35) and deductible ($231.68) and sent BI payment for a whopping $99.13.

In looking at the bill I was most struck by a couple line items. Microbiology/lab was billed at $202.00 and reimbursed at $26.48, or 13%. And Technical Component (maybe for an ultrasound?) was billed at $427.00 and paid at $22.33, or 5%.

Although medical charges (i.e., what’s billed) are known to be detached from reality, I found this EoB particularly galling. How can I explain my visceral reaction, especially to the $427 charge being reimbursed at $22.33?

  • If something is billed for $427 but reimbursed at just $22, it seems that BI is overcharging or Blue Cross is underpaying. Or is it both?
  • What happens to the poor schlub who’s out of network, or worse, lacks insurance? Is the $427 from rare patients like that –who pay 20x what Blue Cross pays– accounting for more than 100% of the center’s profits?
  • Is what I see on the EoB actually the economic reality behind the transaction? Or is BI or my wife’s BI practice being paid a capitated amount for her care and is this bill only meaningful for calculating our cost?
  • What is a patient who’s interested in “transparency” and “cost effectiveness” supposed to think? Did we do the right thing by going to urgent care or not? I think it would have been a lot more useful to see a comparison between the actual urgent care visit cost and a hypothetical visit to the ER or physician office

Ok, I’m feeling a little better now.

Image courtesy of Vlado at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.

4 thoughts on “Urgent care billing: Eyebrows raised”

  1. I think sometimes that the fee schedule teams at BCBS get tanked up on coffee and throw magnetic darts at numbers written on the white board

  2. I learned, when I was a poor schlub with no insurance, to offer to pay 25% over the Medicare reimbursement rate. I would ask for paperwork with all the codes and then do some research and then make an offer. I probably ended up paying more than if I had had insurance, but it sure beat paying the “list price” (chargemaster rate).

  3. I went to urgent care on a Sunday as well in Chestnut Hill at Chestnut Square. The physician covers the emergency department also at Bi. I had an infected foot because there had been a splinter on the bottom of my foot for 4 days. My husband removed the splinter but it looked infected. They took an x ray. I asked if the radiologist was in network. No one knew. The physician injected Novocaine in the bottom of my foot. Spliced it a bit and said there was nothing else inside. A year later my toes are still numb. Never again, but it was a lot cheaper and a lot quicker than the emergency ward and probably just as inept.

  4. Uninsured patients, usually those who can least afford it, get billed the chargemaster rate — its unethical, and borders on criminal. If you have insurance you should simply ignore the charged amount, it means nothing, absolutely nothing, zilch. However, look up the CPT codes for services and make sure your insurance company is being billed for what was really done. Note, the descriptions of CPT codes almost never are printed on the bill — “The better to confuse you.” said the wolf. Even a grocery store prints a receipt with the items listed, but not a hospital.

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