Ryan Wettstein Nauman was inconsolable one evening last December. After being put down for bed, the 3-year-old from Peoria, Illinois, just kept crying and crying and crying, and nothing would calm her down.
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Her mother, Maggi Wettstein, remembered fearing it could be a yeast or urinary tract infection, something they had been dealing with during potty training. The urgent care centers around them were closed for the night, so around 10:30 p.m. she decided to take Ryan to the emergency room at Carle Health.
The Medical Procedure
The ER wasnt very busy when they arrived at 10:48 p.m., Wettstein recalled. Medical records indicate they checked in and she explained Ryans symptoms, including an intermittent fever. The toddler was triaged and given a nasal swab test to check for covid-19 and influenza A and B.
Wettstein said they sat down and waited to be called. And they waited.
As Wettstein watched Ryan in the waiting rooms play area, she noticed her daughter had stopped crying.
In fact, she seemed fine.
So Wettstein decided to drive them home. Ryan had preschool the next day, and she figured there was no point keeping her awake for who knew how much longer and getting stuck with a big ER bill. Email Sign-Up
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There was no one at the check-in desk to inform that they were leaving, Wettstein said, so they just headed home to go to bed.
Ryan went to her preschool the next day, and Wettstein said they forgot all about the ER trip for eight months.
Then the bill came.
The Final Bill
$445 for the combined covid and flu test from an ER visit in which the patient never made it beyond the waiting room.
The Billing Problem: A Healthy Hospital Markup and Standard Insurance Rules
Even though Ryan and her mother left without seeing a doctor, the family ended up owing $298.15 after an insurance discount.
At first, Wettstein said, she couldnt recall Ryan being tested at all. It wasnt until she received the bill and requested her daughters medical records that she learned the results. (Ryan tested negative for covid and both types of flu.)
While Wettstein said the bill isnt going to break the bank, it seemed high to her, considering Walgreens sells an at-home covid and flu combination test for $30 and can do higher-quality PCR testing for $145. Maggi Wettstein was charged $445 for the combined covid and flu test from an ER visit in which her daughter never made it beyond the waiting room.(Ron Johnson for KFF Health News)
Under the public health emergency declared in 2020 for the covid pandemic, insurance companies were required to pay for covid tests without copayments or cost sharing for patients.
That requirement ended when the emergency declaration expired in May 2023. Now, it is often patients who foot the bill and ER bills are notoriously high.
Thats a pretty healthy markup the hospital is making on it, Loren Adler, associate director of the Brookings Institution Center on Health Policy, told KFF Health News when contacted about Ryans case.
The rates the insurance companies negotiate with hospitals for various procedures are often based on multipliers of what Medicare pays, Adler said.
Lab tests are one of the few areas in which insurance companies can often pay less than Medicare, he said the exception being when the test is performed by the hospital laboratory, which is often what happens during ER visits.
Medicare pays $142.63 for the joint test that Ryan received, but the family is on the hook for more than twice that amount, and the initial hospital charge was over three times as much.
The hospital is utilizing their market power to make as much money as possible, and the insurance companies are not all that good at pushing back, Adler said. A markup of a few hundred dollars is a drop in the bucket for big insurers. But for the patients who get unexpected bills, it can be a big burden.
Brittany Simon, a public relations manager for Carle Health, did not respond to specific questions but said in a statement, We follow policies that support the safety and wellbeing of our patients, which includes the initial triage of symptomatic patients to the Emergency Department.
While Ryans family would not have had to pay for a covid test during the public health emergency, it was the familys insurer, Cigna, that did not have to pay this time, since the family had not yet met a $3,000 yearly deductible.
A Cigna representative did not respond to requests for comment.
The Resolution
Wettstein said she knew she could just pay the bill and be done with it, but the fact that I never saw a provider, and the fact that it was just for a covid test, is mind-blowing to me.
She contacted the hospitals billing department to make sure the bill was correct. She explained what happened and said the hospital representative was also surprised by the size of the bill and sent it up for further review.
Dont pay this until you hear from me, Wettstein remembered being told.
Soon, though, she received a letter from the hospital explaining that the charge was correct and supported by documentation.
Wettstein thought she was avoiding any charges by taking Ryan home without being seen. Instead, she got a bill that they have verified that I have to pay.
Like I said, its mind-blowing to me. (Ron Johnson for KFF Health News)
The Takeaway
ERs are among the most expensive options for care in the nations health system, and the meter can start running as soon as you check in even if you check out before receiving care.
If your issue isnt life-threatening, consider an urgent care facility, which is often cheaper (and look for posted notices to confirm whether its actually an urgent care clinic). The urgent care centers near Ryans home were closed that evening, but some facilities stay open late or around the clock.
In some ways, Wettstein was lucky. KFF Health News Bill of the Month has received tips from other patients who left an ER after a long wait without seeing a doctor and got slapped with a facility fee of over $1,000.
Making the decision about where to go is tough, especially in a stressful situation such as when the patient is too young to communicate whats wrong. Trying to figure out whats going on physically with a 3-year-old can feel impossible.
If you decide to leave an ER without treatment, dont just walk out. Tell the triage nurse youre leaving. You might get lucky and avoid some charges.
Wettstein wont think twice about taking Ryan to the pediatrician or an urgent care center the next time shes ailing. But, Wettstein said, after getting this bill, Im not going to create a habit out of going to the emergency room.
Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Posts Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!
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