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A hospital hiked the price of a routine childbirth by calling it an emergency

When Caitlin Wells Salerno and Jon Salernos first son, Hank, was born, his delivery cost the family only $30. Gus bill came in at more than $16,000, all told including the $2,755 ER charge. The family was responsible for about $3,600 of the total.

Originally published on October 27, 2021 9:56 am

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 didnt 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 didnt 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 shed been billed four years earlier for the delivery of her first child, Hank. Shed 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?

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 Hospitalin Fort Collins, Colo., operated by UCHealth, anonprofithealth 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 Salernos eyes pop was the $2,755 charge for Level 5 emergency services included in that total. It didnt 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 Salernos bill include a Level 5 charge?Was it for checking in at the ER desk, as shed been instructed to do? She recalls merely going through security in the ERon her way to labor and delivery, but she seemed to have been charged as though shed 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.

Over the past 20 years, hospitals and doctors have learned theresgreat profit in upcodingvisits. After all, the insurer isnt in the exam room to know what transpired. Aninvestigation by the Center for Public Integrityfound that between 2001 and 2008 the number of Level 4 and 5 visits for patients who were sent homefrom the ER nearly doubled to almost 50% of visits. In Colorado, the Center for Improving Value in Health Care looked at emergency visit billing from 2009 to 2016 and found that the percentage of emergency visits coded as Level 5steadily grew from 23% to 34%for patients who have commercial insurance.

After repeated calls in which she questioned the line item on her bill, Wells Salerno eventually got a voicemail from the billing department, which she shared with us. The person who left the voicemail explained that the emergency room charge is actually the OB triage little area before they take you to the labor and delivery room.

A customer service representative later explained the charge was for services given there when a nurse placed an IV for antibiotics, and her doctor checked her dilation and confirmed her water had broken although none of that was actually performed in the Emergency Department. And those services, performed before every delivery, are traditionally not billed separately and are routine, not emergency, procedures.

Caitlin Wells Salerno was in good enough shape during labor with baby Gus to snap this selfie with husband Jon as she walked to the delivery room. So when the hospital bill included a charge for emergency services, the couple thought it had to be a mistake.

Some hospitals provide that package of services via an obstetrical emergency department. OB-EDs are licensed under the main Emergency Department and typically see patients who are pregnant, for anything from unexplained bleeding to full-term birth. They bill like an ER, even if they arent physically located anywhere near the ER.

TeamHealth a health care staffing company owned by the investment company Blackstone, and known formarking up ER bills to boost profit essentially says an OB-ED can be as simple as a rebranded obstetrical triage area. In awhite paper, the company says an OB-ED is an entrepreneurial approach to strengthening hospital finances, because with little to no structural investment it allows hospitals to collect facility charges that are otherwise lost in the obstetrical triage setting.

The OB Hospitalist Group, which is owned by aprivate equity company, markets a tool to help OB-EDs calculate levels of emergency care. In a case study, OB Hospitalist Group reported that hospitalsleave a lot of money on the tableby billing OB-ED visits as Level 1 and 2 emergencies when they could be considered Level 4 emergencies.

An Arizona facilitysaid its revenue increased$365,000 per quarter after turning its obstetric triage area into an OB-ED. Poudre ValleyHospitals websitedoesnt list OB-ED as part of the facilitys offerings, though UCHealth documents do reference OB-ED beds in other facilities.

KHN spoke with four other women who, after giving birth at Poudre Valley in 2020 and 2021, received ER charges on their bills after healthy births. They had no clue they had received emergency services. One wrote a warning note on Facebook to other moms in the area after getting a whopping charge for the 10 minutes she spent in the triage room, while fully dilated and in active labor.

In Wells Salernos case, UCHealth and her insurer have an agreement that Anthem BCBS pays a lump sum for vaginal delivery, rather than paying for line items individually. Being seen there in OB-ED did not impact this bill whatsoever, says Dan Weaver, a spokesperson with UCHealth.

But in one of the other moms cases, it did make a difference: The hospital received $1,500 from the insurer for that charge, and the mom was on the hook for an additional $375 for coinsurance.

Ge Bai, a professor of accounting and health policy at Johns Hopkins University, says its a questionable billing practice and one that can matter to those who dont have the samekind of insuranceas Wells Salerno and to those who have no insurance at all.

Dr. Mark Simon, chief medical officer with OB Hospitalist Group, says OB-EDs can help women avoid being admitted to the hospital too early in labor, ensuring timelier, more appropriate care.

UCHealths Weaver says such departments can also help pregnant patients with actual emergencies like preterm labor, preeclampsia or vaginal bleeding get quick care from specialists available 24/7 often without having to be admitted to the hospital. But at hospitals like Poudre Valley, healthy women having healthy births also get routine OB-ED treatment, without their knowledge.

Weaver says the only time someone in labor would not go through the OB-ED and therefore the only time they would not receive the emergency charge is if they have a scheduled induction or cesarean section or are directly admitted from a providers office.

Hsia, the UCSF researcher and ER doctor, is unconvinced by Weavers arguments that these sorts of charges benefit patients: If theyre actually going to charge a special fee that you didnt get directly admitted from your physician, thats absolutely ridiculous, Hsia says.

Wells Salernos OB-ED exam was performed by her clinician, but the OB-ED charge still showed up on her bill.

Resolution:Wells Salerno eventually threw in the towel and paid the bill.

I was at a very vulnerable time during pregnancy and immediately postpartum, she says. I just felt like I had kind of been taken advantage of financially at a time when I couldnt muster the energy to fight back.

The fact that two healthy brothers could come into the world with such different overall price tags isnt surprising toDr. Michelle Moniz. There is no clinical reason that we have this level of variation, says Moniz, assistant professor of obstetrics and gynecology at the University of Michigan and its Institute for Healthcare Policy and Innovation. Herresearch showsthat people with private insurance pay anywhere from nothing to $10,000 for childbirth.

You dont get what you pay for, says Wells Salerno, who maintains that despite the price difference in the cost of their deliveries both of her children are equally awesome.

The family expected the bill for Gus birth in April 2020 to be heftier than the $30 they were billed four years earlier for the delivery of his older brother, Hank. They had better insurance back then. But the $2,755 charge for high-level emergency services for a routine delivery seemed outrageous to them.

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 Insuranceshowsthat 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 aprice comparison toolfor 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. Heresa chartthat 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 didnt and doesnt make sense.

Bill of the Month is a crowdsourced investigation byNPRandKaiser Health Newsthat dissects and explains medical bills. Do you have an interesting medical bill you want to share with us?Tell us about it!

SCOTT DETROW, BYLINE: Is the on-time birth of a healthy baby an emergency? Seems pretty straightforward. But that question gets us to the heart of our medical bill of the month. Dr. Elisabeth Rosenthal is the editor-in-chief of our partner, Kaiser Health News. And she is here to discuss this one with us. Welcome back, Elisabeth.

ELISABETH ROSENTHAL: Hi, Scott. Nice to be here again.

DETROW: So who are we hearing from today?

ROSENTHAL: Today were meeting a young family from Fort Collins, Colo. Theres Caitlin Wells Salerno, her husband, Jon, and their two very cute little boys, Hank and Gus.

DETROW: Those are two good names for two little kids, look forward to hearing from them. All right. So your reporter, Rae Ellen Bichell, met the family. Lets listen to her story. And then you and I are going to talk about it afterwards.

RAE ELLEN BICHELL, BYLINE: Caitlin Wells Salerno is a conservation biologist who studies how much animals invest in their babies. An elephant pregnancy lasts almost two years.

CAITLIN WELLS SALERNO: I mean, I dont envy elephants because that is a long time to be pregnant.

BICHELL: She does not envy the golden-mantled ground squirrel that she studies, either. They nurse their babies until the babies collectively weigh twice what the mom does, the equivalent of a human mom breastfeeding a 300-pound child.

C SALERNO: But then theyre done. Then they just send them on their way. And they forage for themselves and disperse.

BICHELL: But humans are stuck with their offspring for decades. And they are the only animal that can spend parental energy playing phone tag with a hospital billing office. The subject of those calls? – Gus, a roly-poly toddler fond of biting things, walking like a drunken sailor and picking not ripe tomatoes.

JON SALERNO: What did you just put in your mouth?

BICHELL: Gus was born in April 2020 in the early weeks of COVID lockdowns. Caitlin and her husband, Jon Salerno, said the experience was a little weird, like how they had to enter through the emergency room because it was the only door open.

J SALERNO: It was totally quiet, empty.

BICHELL: But the birth was quick and smooth.

C SALERNO: Yeah. His birth was great.

BICHELL: Gus arrived right on his due date.

C SALERNO: And he was enormous and healthy. And thats all we wanted.

BICHELL: When the bill came, it showed the hospital wanted more than $16,000. And the family was responsible for 3,600 of it.

C SALERNO: I first saw. And I was just like, whoa (laughter). Thats interesting.

BICHELL: Caitlin and Jons first child, Hank, had a tricky birth. But it was cheap. It cost the family a mere $30, basically the same as what they would have paid at the grocery store for a brick of cheddar cheese the size of Hank. The family knew not to expect that again. They were in a different state with different insurance. Still, what really made their eyeballs pop was a line for a Level 5 emergency department charge for nearly $3,000.

C SALERNO: It seemed like that could have been a mistake and that we went through the ER but it was not an emergency.

BICHELL: So they asked around. An ER doctor relative said that level of emergency is usually for really serious stuff.

C SALERNO: Its gunshots and car accidents is how it was described to us. And I didnt even have a high-risk pregnancy. I was fine.

BICHELL: So they made a bunch of calls to UCHealth, the company that runs the hospital where Caitlin delivered, trying to figure out what this charge was for. No one seemed to know. Finally…

C SALERNO: I got a voicemail that said…

UNIDENTIFIED PERSON: And the emergency room charge is actually the OB triage little area that you go into before they take you to the labor and delivery room. So at this point, we are showing that that charge is correct.

C SALERNO: And at that point, I didnt know what else to do. And I was too tired to do anything else. So we just paid it.

BICHELL: But they wondered, were other families getting these charges, too?

J SALERNO: We complain a lot. But we can pay the hospital bills, you know? So many people cant.

BICHELL: And at the end of the day, they have two awesome kids, even if one did cost 100 times more than the other. Im Rae Ellen Bichell in Fort Collins, Colo.

DETROW: And Dr. Elisabeth Rosenthal, the editor-in-chief of Kaiser Health News, is is still here. Elisabeth, we have been reporting a lot on inflation on this program. But $30 to more than 3,000 is a wild, wild increase. What is going on here?

ROSENTHAL: Oh, in part, its the typical yet irrational variation we see throughout our private health care system. But theres also something relatively new going on. Its a new-fangled billing construct called OB-ED – thats obstetrics emergency department. But the thing is, its more of a concept than a physical place for any emergency medical intervention. I mean, in Caitlins case, thats just the room where a nurse placed an IV and where Caitlins doctor examined her and confirmed she was in active labor. So that line item on the bill was just for the routine care that every woman gets before youre moved into the delivery room.

DETROW: So let me just get this straight. Youre talking about a new concept here. Is this a new room? Is this a new type of service provided in the hospital?

ROSENTHAL: No. It didnt even happen in the emergency room. Its just the OB triage area thats always been there on the labor and delivery floor. This is really just rebranding routine care and charging more for it – a lot more. In fact, we found documents from medical staffing companies that are very transparent. They said hospitals are, quote-unquote, leaving money on the table if they dont charge these ER OB fees and called this an entrepreneurial way of bringing in more money.

DETROW: And what about this way of scaling emergencies? This is a Level 5 emergency and, again, for a pretty straightforward birth.

ROSENTHAL: Yeah. I mean, there was no emergency going on here. Its a huge stretch. As Caitlin said, Level 5 emergencies are the very highest level of charge. Theyre for things like heart attacks, car accidents, not a baby arriving on his due date with zero complications. But this is something we call upcoding. And hospitals have been doing it more and more for decades.

DETROW: So what do you do if you find yourself being upcoded?

ROSENTHAL: Well, first of all, for births, be prepared to ask your hospital, doctor and insurer to estimate what youre going to owe. And see if they have this new-fangled OB-ED charge because thats going to increase your costs. And even in a genuine ER, always look at the level of billing. If you see a Level 4 or 5 charge on the bill but you know nothing very intensive was performed or needed, you should protest. Your insurer doesnt know what happened in that room, but you do, so question it.

DETROW: Well, now Ive learned a new word today, upcoding. Elisabeth Rosenthal, thank you so much for joining us.

ROSENTHAL: Sure. Its a scary word. And I wish it hadnt entered our vocabulary. But its considered fraud. And it will get the billing departments attention.

DETROW: So if you have a confusing or outrageous medical bill or a combination of both, please, go to NPRs Shots blog and tell us about it. Dr. Elisabeth Rosenthal is the editor-in-chief of our partner, Kaiser Health News.

(SOUNDBITE OF DARKSIDES GOLDEN ARROW) Transcript provided by NPR, Copyright NPR.

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