How Hospitals Rip Off Patients With Fraudulent ER Overcharges
This sure seems to be either insurance fraud -- or if patients are paying out of pocket, defrauding of patients themselves.

NPR piece about how hospitals inflate bills, giving the example of a routine childbirth a hospital inflated to code a more costly "emergency" delivery. Rae Ellen Bichell writes:

As a conservation biologist, Caitlin Wells Salerno knows that some mammals -- like the golden-mantled ground squirrels she studies in the Rocky Mountains -- invest an insane amount of resources in their young. That didn't prepare her for the resources she would owe after the birth of her second son.

Wells Salerno went into labor on the eve of her due date, in the early weeks of coronavirus lockdowns in April 2020. She and her husband, Jon Salerno, were instructed to go through the emergency room doors at Poudre Valley Hospital in Fort Collins, Colo., because it was the only entrance open.

Despite the weird vibe of the pandemic era -- the emptiness, the quiet -- everything went smoothly. Wells Salerno felt well enough to decline the help of a nurse who offered to wheel her to the labor and delivery department. She even took a selfie, smiling as she entered the delivery room.

"I was just thrilled that he was here and it was on his due date, so we didn't have to have an induction," she says. "I was doing great."

Gus was born a healthy 10 pounds after about nine hours of labor, and the family went home the next morning.

Wells Salerno expected the bill for Gus' birth to be heftier than the $30 she'd been billed four years earlier for the delivery of her first child, Hank. She'd been a postdoctoral fellow in California, with top-notch insurance, when Hank was born. They were braced to pay more for Gus' delivery -- but how much more?

Then the bill came.

The patient: Caitlin Wells Salerno, a conservation biologist at Colorado State University and a principal investigator at Rocky Mountain Biological Laboratory. She is insured by Anthem Blue Cross Blue Shield through her job.

Medical service: A routine vaginal delivery of a full-term infant.

Total bill: $16,221.26. The Anthem BCBS negotiated rate was $14,550. Insurance paid $10,940.91 and the family paid the remaining $3,609.09 to the hospital.

Service provider: Poudre Valley Hospital in Fort Collins, Colo., operated by UCHealth, a nonprofit health system.

What gives: In a system that has evolved to bill for anything and everything, a quick exam to evaluate labor in a small triage room can generate substantial charges.

The total bill was huge, but what really made Wells Salerno's eyes pop was the $2,755 charge for "Level 5" emergency services included in that total. It didn't make any sense.

Emergency room visits are coded from Level 1 to Level 5, with each higher level garnering more generous reimbursement, in theory commensurate with the work required. Dr. Renee Hsia, a professor of emergency medicine and health policy at the University of California, San Francisco and a practicing ER doctor, says Level 5 charges are supposed to be reserved for serious cases -- "a severe threat to life or very complicated, resource-intense cases" -- not for patients who can walk through a hospital on their own.

So, why did Wells Salerno's bill include a "Level 5" charge? Was it for checking in at the ER desk, as she'd been instructed to do? She recalls merely going through security in the ER on her way to labor and delivery, but she seemed to have been charged as though she'd received care there -- like a patient with a heart attack or someone fresh from a car wreck. That ER charge was the biggest item on the bill, other than the charge for the delivery itself.

...The takeaway: Anything in our health system labeled as an emergency room service likely comes with a big additional charge.

Data from the Colorado Division of Insurance shows that Poudre Valley typically received about $12,000 for similar births in 2020 -- about 43% more than the typical Colorado hospital. So the more than $14,000 Wells Salerno and her insurer paid is very high.

Expectant parents should be aware that OB-EDs are a relatively new feature at some hospitals. Ask whether your hospital has that kind of charge and how it will affect your bill. Ahead of time, ask both the hospital and your insurer how much the birth is expected to cost. In Colorado, the Center for Improving Value in Health Care offers a price comparison tool for common medical procedures, including vaginal delivery.

If you do require a genuine ER encounter, look at your bill to see how it was coded, Levels 1 to 5 -- and protest if your visit was misrepresented. Ask "Has this bill been upcoded?" You are the only one who knows how much time you spent with a medical provider and how much care was given and where. Here's a chart that will help with the proper definition of each level.

Know that victory is possible. At least one mom won the battle and got the emergency charge removed from her Poudre Valley Hospital birth bill. To make that happen she had to put in hours on the phone with UCHealth, have a lot of confidence and had to emphasize to everyone she spoke with that an emergency charge for a routine delivery just didn't -- and doesn't -- make sense.