Even with insurance, ERs can cost a bundle

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January 4, 2023 – If you’ve been to the emergency room recently, you probably know how much such a visit can cost. A new study by researchers at the Kaiser Family Foundation finds that even for people with private insurance who are employed by large corporations, the average out-of-pocket expense for an emergency room visit can exceed their savings.

In 2019, the study shows, patients enrolled in large corporate health plans paid an average of $646 in copayments and deductibles for each emergency room visit. A quarter of the visits cost more than $907 and another quarter cost less than $128.

About half of households cannot afford to pay the average deductible in an employer-sponsored insurance plan, the report finds. And more than a third of American adults are unable to afford $400 of medical care without borrowing.

Although it is not known how many people do not go to an emergency department because of the expected cost, nearly half of US adults report delaying care because of cost, according to a current Kaiser survey.

A problem people often face when deciding whether to seek emergency care is not knowing how serious their condition is and what emergency care will cost, says Hope Schwartz, lead author of the report.

“If they go to the [ER], they do not always know what their diagnosis is and what their treatment costs will be. What we have highlighted is that these costs can be very high or very low and there is no way to predict that,” she says.

what does it cost so much

Based on the paid claims data used in the study, insurance plans and patients combined paid an average of $2,453 for an emergency room visit. A quarter of the visits cost $970 or less and a quarter cost $3,043 or more.

Claims in the emergency room include professional fees and facility fees. Facility fees, which cover the costs of a hospital that operates a 24-hour emergency department, accounted for 80% of the total cost, including some medical, lab, and imaging fees.

But physicians’ charges for assessment and administrative services accounted for most of the cost, averaging $1,134 per visit. Procedures and treatments average over $1,100 per visit, while the average imaging claim is $483 and the average lab work cost is $230.

More than half of the visits resulted in imaging claims and approximately half of the visits involved lab claims.

The Kaiser Family Foundation report also looked at the costs of several common ER diagnoses. The most expensive diagnosis was appendicitis, which cost almost twice as much as a heart attack, in part because it often led to emergency room surgery. The average appendicitis visit cost $9,535, of which $1,717 was out of pocket.

In addition, researchers investigated lower-cost diagnoses that generally do not require imaging or extensive emergency room treatment. These included upper respiratory tract infections (total $1,535, $523 out of pocket), skin and soft tissue infections (total $2,005, $572 out of pocket), and urinary tract infections (total $2,726, $683 out of pocket).

While these diagnoses can sometimes require hospital admission, in otherwise healthy adults they are usually evaluated with simple laboratory tests and patients are discharged with prescriptions, according to the report.

Complexity of billing

ER visits are given codes to show how complex the task or service was during the billing process. These codes have five levels.

Less complex visits require straightforward medical decision making, such as B. Skin rashes or refilling medication. Patients with Level 5 codes require highly complex decision making and include life or limb threatening conditions such as: B. serious infections or heart attacks.

The less complex visits average $592, with patients being responsible for $205. For the most complex visits, the healthcare plan covered an average of $3,015, or eight times the cost of the lowest code visits.

On average, patients paid $840 out of pocket for the most complex visits — four times the average cost for the less complex visits.

One reason spending on emergency room visits has increased is the nationwide shift to higher-tier billing codes in the emergency room, says Schwartz, a Kaiser Family Foundation public health policy grantee and medical student. “A good job has been done to show this [ER] Visits are increasingly being billed as Tier 4 or 5, whereas in previous years they might have been billed as Tier 3.

“Whether a hospital charges a level 4 or a level 5 code for your visit can make a really big difference in how much you charge. And if you don’t know what services you’re getting, you don’t know if you’re getting a level 3, 4, or 5 code, and the cost goes up pretty quickly,” she says.

The costs vary by region

The report provides an analysis of emergency department costs in the 20 largest metropolitan areas in the United States. Overall, the researchers found, San Diego had the most expensive emergency rooms. San Diego ERs charge, on average, about twice as much per visit as those in Baltimore.

While there were expensive areas across the country, many of the most expensive locations were in Texas, Florida, California, Colorado, and New York. The report found that the most expensive regions for ER care did not match the regions that had the most expensive health care overall.

“These comparisons suggest that our results are not only related to the overall high healthcare costs in these areas and may reflect other factors, including the age and medical complexity of the population, or differences in local norms and practice patterns,” the report said Report.

healthier people

In addition to these geographic differences, the incidence of emergency room visits by employer-insured individuals differed from that of the general population.

During the academic year, the report found, 12% of insured had at least one emergency room visit — a percentage that did not vary for any age group under 65, including children. (Patients over the age of 65 were not included in the study.)

In comparison a government survey shows that in 2019, 21% of all US adults ages 18 to 44 had one or more emergency room visits. Of those aged 45 to 64, 20% made at least one visit to the emergency department.

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Even with insurance, ERs can cost a bundle
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