Freestanding emergency rooms increasingly have developed bad reputations when it comes to patient billing.

Media reports nationwide have featured stories about patients, including those with insurance, visiting a freestanding ER and then receiving unexpected bills months later.

In response, the Colorado Hospital Association worked with state legislators last session on passing Senate Bill 18-146, which requires additional patient notifications at freestanding ERs, according to Cara Welch, director of communication for the association.

“CHA and its member hospitals and health systems have a longstanding commitment to price transparency, and this bill will allow additional information to be shared with patients,” she said via email.

UCHealth and Adeptus Health began a joint venture three years ago to operate 17 freestanding ERs, including four in the Pikes Peak region.

The duo finalized an agreement in early December for UCHealth to become the sole owner and operator of all the locations, said Cary Vogrin, media relations specialist for UCHealth, in an email.

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“These freestanding emergency departments allow patients to receive emergency care close to home, should they need it,” she said. “Our priority is to provide exceptional patient care and an outstanding patient experience, and these locations are an important part of UCHealth’s focus on providing comprehensive care throughout the region.”

Vogrin said UCHealth’s freestanding ERs were implementing more education and transparency initiatives prior to the new legislation requiring it.

However, its facilities will now provide a disclosure: “This is an emergency medical facility that treats emergency medical conditions. This is not an urgent care center or primary care provider.”

Then, after a provider completes an examination and determines that a patient does not have an emergency medical condition or after treatment is provided to stabilize an emergent condition, UCHealth staff will provide patients with a second disclosure, Vogrin said.

That document provides additional insurance information and the prices for the most 25 common services provided by UCHealth’s freestanding ERs.

“UCHealth is committed to ensuring patients understand the most appropriate place to seek care for various injuries or ailments,” Vogrin said. “Emergency care is expensive, and we encourage patients to visit an urgent care facility if they are not experiencing a medical emergency.”

The health care system has five urgent care locations in the Colorado Springs area.

“We actively work to educate the public on when urgent and emergency services should best be utilized,” Vogrin said, adding UCHealth is a supporter of CHA’s Where for Care campaign.

Welch said the campaign attempts to assist consumers plan on where to go for primary care, urgent care and emergency care, in addition to understanding the differences in the various care sites.

“Freestanding ERs are relatively new to Colorado, and as a new care model in the state, we recognize that it’s been confusing for consumers,” she said. “Many believe an ER can only be located near a hospital, and the prevalence of urgent cares across the state has added to that confusion.”

Unfortunately, Welch believes many consumers don’t fully understand the impact of their health insurance coverage until they need to access health care.

“With the increase in high-deductible plans, consumers have more skin in the game and may not realize until after they have accessed care,” she said. “The ER is the most expensive place for health care — and for a reason, as it’s staffed to handle the most severe and life-threatening conditions — and many patients have received significant bills after an ER visit that they did not anticipate.”

Balance billing, or surprise billing, occurs when a consumer receives care from an entity that is not covered by their insurance or is treated by a provider who is not in the their insurance network.

“After the insurance pays whatever part of the claim was in-network and covered, a bill for the remaining balance is sent to the consumer,” Welch said.

Colorado is among 21 states with a limited approach for balance-billing protections for consumers, according to a June 2017 Issue Brief by The Commonwealth Fund, which is a private foundation that aims to promote a “high performing health care system.”

According to Welch, “Those protections hold consumers harmless by shifting payment burden to insurers, but it only applies to plans regulated by the state Division of Insurance, which is about 30 percent of consumers in the market. Unfortunately, this issue often comes from negotiations between providers and insurers, not hospitals. Previous legislative efforts to stop surprise/balance billing have failed because those groups haven’t been able to agree on a default payment for out-of-network charges.”

Only six states have a comprehensive approach to safeguarding consumers against balance billing by an out-of-network provider for care delivered in an emergency department or in-network hospital.

“Because a federal policy solution might prove difficult, states may be better positioned in the short term to protect consumers,” the brief stated.

Vogrin said the board-certified emergency physicians who care for patients at UCHealth’s freestanding ERs in Colorado Springs are all employed by the same emergency physicians group that staffs the emergency departments at Memorial Hospital Central and Memorial Hospital North.

“Because UCHealth now solely owns and operates the freestanding ERs, insurance coverage is very similar for all our locations in Colorado Springs,” she said.

The federal Emergency Medical Treatment and Labor Act prohibits emergency room staff and physicians from discussing cost or insurance before a patient has been evaluated and determined to be stable or not experiencing an emergency.

“Therefore, UCHealth works to educate patients before they ever need emergency services,” Vogrin said. “Last year, UCHealth voluntarily posted self-pay prices for many of the most common emergency services on our website.”

UCHealth also has a guide on its website that helps patients decide whether they need an urgent care or an ER facility.   

“Importantly, details of a patient’s insurance plan drive their out-of-pocket responsibilities,” Vogrin said. “This includes their deductible, copay and coinsurance. Over the past five to 10 years, high-deductible plans have become far more common.”

Those types of plans require a patient pay 100 percent of their bills until their deductible — which can be thousands of dollars — is reached.

“We recommend that anyone who signs up for a high-deductible plan also sign up for a health savings account,” Vogrin said. “This will allow someone to save pre-tax dollars for any out-of-pocket medical expenses.”

Despite the billing confusion, both Vogrin and Welch said freestanding ERs can be beneficial to a city and its residents when utilized appropriately.

“It’s important for patients to have comprehensive care options close to home, including primary care, urgent care and 24-hour emergency services,” Vogrin said. “Primary Care and Urgent Care locations may be the best option, during their operating hours, for those who have non-emergent injuries and illnesses. When patients experience a medical emergency, it is essential that care is available quickly, either by calling 911 or by visiting a nearby emergency room.”

Some health systems are even moving toward a “hub and spoke” model, Welch explained, with the hospital as the hub and clinics and freestanding ERs acting as the spokes that allow patients to access services near their homes.

“Also, prior to the development of freestanding ERs, consumers often faced long wait times at ERs on hospital campuses,” she said. “In addition to other improvements, these facilities have helped most ERs — freestanding and on a hospital campus — to lower those wait times and ensure that people are being seen in a timely manner.”