Audra Melton for KHN
Frankie Cook only remembers last year’s car accident in flashes.
She was driving a friend from high school home on a winding road outside of Rome, Georgia. She noticed standing water from a recent rainstorm. She tried to slow down, but lost control of her car on a large curve. “The car flipped over about three times,” says Frankie. “We spun around and went off the side of this hill. My car was on its side and the back was crushed into a tree.”
It sounds bad, but Frankie says the airbags were deployed and both passengers were wearing seatbelts, so she only had a headache when her father, Russell Cook, came to pick her up from the crash site.
Frankie, then a high school student, was concerned that she might suffer a concussion that could affect her performance on an upcoming Advanced Placement exam, so she and her father decided to stop by an emergency room near their home to to have her checked. They didn’t get past the reception.
“‘We don’t take third-party insurance,'” Russell tells the receptionist at Atrium Health Floyd Urgent Care Rome, though he wasn’t sure what she meant. “She told me three times.”
The problem didn’t seem to be that the clinic didn’t have the medical expertise to evaluate Frankie, and that the family has good health insurance. But when injuries are the result of accidents, another insurer, such as auto or home insurance, may be primarily responsible for the medical bills. Health insurance, if it’s on the hook at all, can kick in after the other insurer pays.
The cooks appeared to be faced with a refund policy often used by emergency centers to avoid waiting for car insurance payments.
Russell was told to take Frankie to an emergency room, which by law must see all patients regardless of such issues. The closest, at Atrium Health Floyd Medical Center, was about a mile away and owned by the same hospital system as the urgent care center.
There, says Russell, a doctor looked at Frankie “for just a few minutes,” took precautionary CT scans of her head and body, and sent her home with the advice to “take some Tylenol” and rest. She had no concussion or serious head injury and was able to pass her AP exam on time.
Then came the bill.
The patient: Frankie Cook, 18, now a freshman from Rome, Ga.
Medical services: A medical evaluation and two CT scans.
Service provider: Atrium Health Floyd, a hospital system with urgent care centers in northwestern Georgia and northeastern Alabama.
Total invoice: $17,005 for an emergency room visit; it was later adjusted to $11,805 after a duplicate charge was removed.
What gives: The Cooks found themselves in health care jeopardy after Frankie’s car hit that tree: More and more hospital systems have urgent care centers, which have restrictions on who they treat – for both financial and medical reasons.
Russell was quite upset after getting such a large bill, especially when he had tried to get to the clinic quickly and cheaply. He said Frankie’s grandmother had been seen in an emergency room after a recent car accident and walked out with a bill of only a few hundred dollars.
“That’s kind of what I expected,” he says. “She just really needed to be looked at.”
So why was Frankie rejected at an emergency room?
Lou Ellen Horwitz, CEO of the Urgent Care Association, says it’s pretty standard policy for urgent care centers not to treat injuries resulting from car accidents, even minor ones. “In general, as a rule, they don’t care for car accident victims regardless of the extent of their injuries because it will go through that car insurance claim process before the provider is paid,” she says.
Horwitz says urgent care centers — even those owned by major health systems — often operate on thin margins and can’t wait months and months for an auto insurance company to pay a claim. She says people “unfortunately” tend to learn about such policies when they show up to expect care.
Add to that the complicated relationship between health care and auto insurance companies, and you have what Barak Richman, professor of health care policy at Duke University Law School, calls “the wildly complex world we live in.”
“Each product has its own specs on where to go and what it covers. Each product is incredibly difficult and complex to manage,” he says. “And each imposes faults on the system.”
Atrium Health did not respond to repeated requests for comment on Frankie’s case.
Horwitz rejects the idea that a health system could push people in wrecked cars from emergency centers to emergency rooms to make more money. Still, car insurance generally pays more than health insurance for the same services.
Richman remains skeptical.
“At the risk of sounding a little too cynical, there are always dollar signs when a healthcare provider sees a patient come through the door,” says Richman.
Dr. Ateev Mehrotra, a professor of health care policy at Harvard Medical School, says it was probably strategically important that the urgent care center was just down the street from the ER. Part of the strategy makes sense medically, he says, “because when something bad happens, you want to get them to a place with more skill real quick.”
But he also says urgent care centers are “one of the most effective ways” for a health system to generate new revenue, creating a pipeline of new patients to visit the hospitals and later go to doctors for testing and follow-up.
Mehrotra also says urgent care centers are not bound by the Emergency Medical Treatment and Labor Act, a federal law known as EMTALA that requires hospitals to stabilize patients regardless of their ability to pay.
At the time of Frankie’s visit, both the urgent care center and emergency room were owned by the Floyd Health System, which operated a handful of hospitals and clinics in northwestern Georgia and northeastern Alabama. Since then, Floyd has merged with Atrium Health – a larger North Carolina-based company that operates dozens of hospitals in the Southeast.
Frankie got a CT scan of her head and body in the ER, tests KHN confirmed she couldn’t have made it to the ER – whether the test was medically necessary or just part of a protocol for people in car wrecks who complain about headache.
Solution: Sixteen months have passed since Frankie Cook’s hospital visit, and Russell has put off paying the bill until the remaining uncertainties are resolved, on the advice of a lawyer friend of the family. After the insurance covered his share, the cooks’ share was $1,042.
Reaching that number has been a frustrating process, says Russell. He learned about the initial $17,005 bill in a letter from a lawyer representing the hospital – another unnerving result of Frankie being in a car accident. The cooks then had to go through a lengthy appeals process to have a $5,200 double charge removed from the bill.
In the end, Anthem Blue Cross paid Blue Shield, the Cooks’ health insurer, $4,006 of the claim. It said in a statement that it is “committed to providing access to quality medical care for our members. This matter was reviewed in accordance with our clinical guidelines and billed claims were processed accordingly.”
“It won’t put us out on the street,” Russell says of the $1,042 balance, “but we have expenses like everyone else.”
He added, “I would have liked a $200 urgent care visit, but that ship has sailed.”
The takeaway meals: It’s important to remember that urgent care centers are not governed by the same laws as emergency rooms and they can be more selective about who they treat. Sometimes their reasons are financial, not clinical.
It’s not uncommon for urgent care centers — even those in major health systems — to turn away people who’ve had car wrecks because of the complications that come with car insurance settlements.
While urgent care visits are cheaper than going to an emergency room, the clinics often cannot provide the same level of care. And you may have to pay the cost of an urgent care visit only to find out you need follow-up care in the emergency room. Then you could end up with two bills.
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