What’s that $100 fee? WSB Forum members ask; Highline explains

Three weeks ago, a WSB Forums member started a discussion there about a $100 fee charged by Highline Medical’s West Seattle Urgent-Care Clinic that was not covered by her insurance. Among discussion participants, much discussion and research followed. The thread was called to our attention, and we sought a response from Highline, as the questions continued to pile up. Today, we have that response from Highline Medical Group’s administrator, confirming that this is a fee charged “for the higher costs of operating an urgent care facility during weekends and evening hours, when there is irregular demand for services,” and saying they are working to get more insurance companies to cover it – with another group coming on board next month, Regence. (Highline is not the only health-care organization with an urgent-care charge, according to one post in the discussion.) Read on for the statement:

As the Administrator of Highline Medical Group, I’d like to answer the questions raised by patients about billing for urgent care services. We do charge a $100 urgent care fee – which is a legal billing code and is covered by some insurance companies. This fee partially compensates us for the higher costs of operating an urgent care facility during weekends and evening hours, when there is irregular demand for services. Our staff and facility are here waiting for you, even when you might not need us.

Like many other healthcare services, the urgent care charge is covered by some insurance carriers and not by others. We have been working with insurance plans to get this fee covered for our patients. If you have the following insurance, you will not be billed personally for the fee:

• First Choice Network PPO
• Regence (effective 4-1-12)
• HMG Medicare Advantage Plans (United/Secure Horizons, Humana, Molina)
• HMG Managed Medicaid (CUP)
• Medicare
• Medicaid

We are still negotiating with other insurance carriers and will update the West Seattle Blog community as we add them.

We do our best to explain to patients that there is an extra fee accompanying treatment at an urgent care clinic. We emphasize that a patient’s insurance company will be billed and it may (or may not) cover the full cost. If the insurance company does not pay, that fee becomes the patient’s responsibility. We ask patients to sign a form acknowledging this because we don’t want them to be surprised by a bill they weren’t expecting. For those who object to the fee, we can offer regularly scheduled appointments during office hours at West Seattle Family Medicine, with no urgent care fee. We are always happy to work with any patient for whom the $100 charge represents financial hardship. Patients can contact us directly at 206.242.8300 if they have questions or would like assistance.

We are sorry there has been so much confusion about this. We take all community input very seriously. Based upon the feedback we have received from the community, we are developing new printed materials that explain the charges in detail and we are working with our staff to assure that they are explaining the charges more thoroughly to each patient.

We are committed to the West Seattle community. I want to assure you that we are doing our best to balance the needs of the community for extended hours with the cost of providing the care.

Susan Pursell
HMG Administrator

Highline opened its Urgent Care clinic in West Seattle last fall east of Jefferson Square, and plans to move later this year to a new location in The Triangle (currently home to Cycle U, which is in turn moving to Harbor Avenue next month).

adamk March 29, 2012 (1:38 pm)

Copying my reply to the forum thread:

Thank you for contacting Highline and getting their side of the story.

I have to point out this one part:
“We ask patients to sign a form acknowledging this because we don’t want them to be surprised by a bill they weren’t expecting.”

This is an outright LIE. If that form is not signed, then they cannot bill the patient without doing something CLEARLY ILLEGAL. There would be no billing surprise if not for the form, because they COULD NOT SEND THE BILL. With the form signed, it’s questionably legal. The form they have you sign is valid for Medicare patients, but it’s not clear whether the law would interpret that as overriding the contract signed for other health care providers. I’m still in contact with a lawyer about this.

Anyway: They’re lying. That form is not an attempt to “clarify the charges you’ll receive”. The form is itself the thing that allows them to balance bill in-network patients.

bob March 29, 2012 (1:40 pm)

Seperate billing for extended care such as night or weekend care should not be done. Reason being, if the clinic is calling itself an URGENT CARE Facility then hours of operation would include weekends and night night time care. Billing amounts for the care given should take this into consideration. Having been in the insurance industry for many years…including Regence, most do not cover an additional billing for “after hours” or weekend treatment. Nice try Highline, this is deceptive billing practices and I would fight it if it were me. Your charges should take all hours into consideration.

Colleen March 29, 2012 (1:43 pm)

Glad to see they are finally saying who is covered with it – the confusion for me was when they make it sound like almost every insurance covers it, when looking at that list its a different story.

DTK March 29, 2012 (1:53 pm)

Gives a whole ‘nother meaning to “bend-over and cough.”

fc43 March 29, 2012 (2:01 pm)

I personally don’t know about the evenings but they have a steady business on the weekends. I had to wait for 3 hours on a Saturday, while the receptionists were turning people away, both on the phone and in person. During my wait, I heard repeatedly that there were already too many people waiting. I feel that they had an opportunity to impose an extra fee and didn’t want to miss it.

homesweethome March 29, 2012 (3:10 pm)

It would make sense if the “urgent care” weren’t taking place in an existing facility that one would assume already covers the expenses based on a 9-5 practice. We do use the urgent care and we do use the same physicians during regular business hours…and the last time I was in the physician (whom I’ve seen for both regular and urgent care) was clear to me that it all about volume and they are paid based on volume. So, it seems like an odd business model to say the least from several angles.

Seattle March 29, 2012 (4:00 pm)

Regardless of the reasoning behind the $100 fee, the way they are going about charging patients (having people sign a waiver) is unethical and maybe even illegal. I don’t understand why we keep skipping over this issue, and instead, constantly focused on the “facility fee.”

The facility fee/charge is NOT the problem. The way they are going about trying to collect this fee IS the problem. When I used their urgent care, no explanation (as they say they are doing) was given to me regarding the extra charge. The front desk was very casual about it and even stated I would be fine as long as I have insurance. I signed the form thinking it was a protection against those who were uninsured or had crappy insurances that don’t cover urgent care services. I did not realize it was a way to deceive me. Furthermore, like others, I was in a great deal of pain at the time and wanted to be seen as soon as possible. I don’t care what they say. What they are doing is deceptive and dishonest. If I had known it would have been cheaper to use the E.R. at the time, I would have done just that.

WSratsinacage March 29, 2012 (4:19 pm)

I think they are the business that put up the billboard ad picture of bumper to bumper traffic on the bridge with the headline, “We feel your pain West Seattle” .. Uh, no, the patients feel Highline’$ pain.
.
Awesome comment DTK.

Karen March 29, 2012 (4:41 pm)

My insurance covered part of the fee and i had to call them three times to get my refund which took about three months

Also they kept faxing my script to the wrong pharmacy–i would not recommend them at all

waterworld March 29, 2012 (4:48 pm)

In addition to the other issues being pointed out here, why does Highline advise patients that the fee “may or may not” be covered when in fact they know which insurers cover it? Highline benefits by keeping that information from patients when they present the form for signature; if they gave the list of insurers posted above to prospective patients when they walked in, more patients might make the decision to go somewhere else.

griffa2 March 29, 2012 (7:37 pm)

You should try Dr. Harrington at West Seattle Convenient Care on Alaska St. He’s open M-TH 4-8pm. He’s saved my family hundreds of dollars and time we might have spent miserably in the ER.

http://www.westseattleconvenientcare.com

Violet04 March 29, 2012 (7:52 pm)

I went last January for a sore throat that wouldn’t go away. I have premera and when I got the EOB back I was shocked. They billed my insurance 650 dollars for a 20 minute office visit and sent me a bill for 100 for the urgent care. Isn’t it illegal that Medicaid pts and other insurances don’t have to pay but some do? I will NEVER go there again and I advise you the same.

adamk March 29, 2012 (8:19 pm)

WSB: When you say this: “(Highline is not the only health-care organization with an urgent-care charge, according to one post in the discussion.)” it’s misleading.
.
The concerns are not about the facility fee so much as the balance-billing that’s occurring. It’s a nuanced issue and I think it’s important that the correct issues get mentioned. The real question that Highline should answer is “Why are you balance-billing your in-network urgent care customers?”.
.
The fact that it’s a facility fee is immaterial. What matters is that they’re charging patients for the difference between what their contract with a health insurance company says they can charge and what they want to charge.

yikes March 29, 2012 (9:38 pm)

@Adamk-
Balance-billing?
Do you mean that the medical bills I get saying charge: $450; allowable amount: $200; amount I owe: $250 are not correct? That I don’t really have to pay beyond what the allowable (or negotiated) amount that the insurance company has paid? So all these years I’ve been paying thousands of dollars, out of pocket, for the special-needs kid’s medical when I didn’t have to?
Wow, I’m going to have a conversation with the billing department!

bob March 29, 2012 (10:26 pm)

YOU GOT ME STARTED>>>>> HAVING PROCESSED MANY A CLAIM, BEWARE. If they are contracted with your insurance, they cannot charge patients for “misc billings” such as after hours care. ONLY actual medical treatments can be billed to insurance. If they try to submit to insurance companies, it will be rejected as inappropriate charges, or commonly known as PROVIDER WRITE OFF. THEY CANNOT BILL THE PATIENT FOR INAPPROPRIATE BILLING AGAIN “IF CONTRACTED”. DO NOT LET THEM COLLECT MONEY UPFRONT YOU WILL NEVER SEE IT AGAIN. GOOD LUCK ON REFUNDS. Only appropriate copays should be collected upfront.
The other side of this, no contracts with your insurance, they can bill what ever they like….beware, once they have your money, good luck getting a refund. I have seen this thousands of times. EITHER THEY OR YOU SHOULD SUBMIT an itemized bill TO your insurance you may have to pay upfront if not contracted do not let this stop you. and if you have any issues beyond this please contact the insurance commissioner Mike Kriedler I can assure you they hate hearing from him.
Ask questions, always get names and phone numbers and please KEEP ALL DOCUMENTATION…EXPLANATION OF BENEFITS (EOB’S) QUESTION DEDUCTIBLES AND WRITE OFFS and COPAYS…LEARN THE TERMS OF INSURANCE. If I could learn it you can. Read your benefits, provider offices hate patients that know more than they do
Best of Luck

M March 29, 2012 (10:34 pm)

Seattle – I was deceived into paying the $100 in just the same way you were. I’t unethical at best.

adamk March 29, 2012 (11:09 pm)

@yikes:
Medical bills are incredibly complicated. I don’t claim to have full knowledge of how these things work – just how my particular interaction with Highline was supposed to work. I deal with computers, not laws and contracts.
.
To know what you owe would require seeing the provisions of your health insurance plan, the EOB for your doctor’s visits, the bill you received from the doctor, knowing how far into your current deductibles you are, how close to a lifetime cap on coverage you are if you have one, etc. There are an incredible number of variables and it’s extremely hard to make generalizations.
.
That said, you should *definitely* talk to your insurance company to find out what’s going on. As is evidenced by what Highline is doing, medical professionals are not immune to lapses of moral judgement, or hell, just plain making billing mistakes.
.
The way things should have worked for me at Highline:
I have a $200 deductible and my insurance pays 90% of urgent care visits once that deductible is met. (yes, I have good insurance.)
Highline’s urgent care is in-network – that means they have a contract with CIGNA to provide certain services for a given price.
I go to see the doctor.
They submit the charges to my insurance company – in this case, they billed $91.35 in doctor’s fees and $100 in a facility fee.
The insurance company, based on their contract, adjusts the charges. In this case they dropped the $91.35 to $54.02, and refused the $100 facility fee outright as it is superseded by the doctor’s charges. This is as per their contract.
The doctor’s office should then bill me the $54.02. That $54.02 goes towards my $200 deductible. If I had already met that deductible, insurance would pay 48.62 and I’d owe $5.40.
.
The way things actually worked was identical until the part where I receive the bill. They billed me $54.02 as far as CIGNA is concerned. Then they added on the $100 to my bill as well. CIGNA knows nothing about this, and it doesn’t go towards my deductible. This is in violation of their contract with CIGNA, and possibly in violation of the law. It’s definitely deceptive. Doctor’s offices which contract with insurance companies do not get to decide how much patients pay: the insurance company does. To do otherwise is called balance billing. It’s often used for out-of-network care, but as far as I can tell is unheard of for in-network care. This situation is so unusual that I can’t find other instances of it happening.

Maggie March 30, 2012 (3:14 am)

Waterworld’s comment is exactly what I was thinking reading the letter above.

Karen March 30, 2012 (7:22 am)

Boycott Highline until they drop the fee!!!!

Kayleigh March 30, 2012 (11:03 am)

I had to pay this fee for an ER visit in another state while on vacation. Even with good insurance, I have recently felt like a cash cow in most ERs. Medical care is getting ridiculous in America.

Bounce March 30, 2012 (2:10 pm)

So…basically, this is a penalty for NOT letting your infection or broken bone fester?

irate March 30, 2012 (4:08 pm)

I rarely post here, but wanted to because Highline Urgent Care is not the only facility in Seattle engaging in this practice.

Some Swedish system facilities do exactly what adamk is calling balance-billing. And, I’m sure other large health care systems do too.

“Facility” fees under most health care plans fall to a different rider of the contract than what covers office visits. The only way to know whether this is going to happen or not is to find out if the office is considered Urgent Care or Hospital-based. If so, it’s pretty likely a fee of $100 (in this example) or of even more ($264 at a Swedish “hospital-based clinic” in my case) can be tacked on and there won’t be much the patient can do about it.

But you probably CAN do SOMETHING. In my case with Swedish, after weeks of phone calls I managed to get my health insurance provider and the billing department attempting to collect the “facility fee” on the phone AT THE SAME TIME to explain all this to me. My insurer explained to the billing department that because of my deductible I was essentially 100% responsible for the “facility fee.” The billing department then agreed to take 35% off of it. Cold comfort after all those phone calls, but it was at least something.

Split billing practices are what cause these unforeseen headaches for patients and it sucks! When we sign those forms acknowledging that we may see more than one bill, I think health care providers ought to tell us specifically what types of fees to expect. Most don’t, which is what leads to these unhappy surprises! If a car mechanic can give us a detailed estimate, why can’t health care clinics or practices do the same?

So now I ask a lot more questions before I make any health care appointments!

Dr Harrington March 30, 2012 (6:01 pm)

I agree that health care has become extremely complex. I have operated the West Seattle Convenient Care for 3 years and have never charged any additional $100 fees. We have served the West Seattle community proudly and in a cost conscious manner. Unfortunately, some of the larger clinics have instituted these fees to help cover their expenses. In the meantime there are alternatives . . .

adamk March 30, 2012 (6:53 pm)

@irate: sorry if I sound like a broken record, but what you’re describing is not what Highline is doing.
Yes, they’re billing a facility fee. Facility fees create incredibly complex situations with insurance regarding deductibles and coverage. It sucks. Many ERs charge facility fees, and more and more urgent care facilities are beginning to charge them. I’m not sure what to do about this except to hope for more stringent regulations to protect patients.
.
As you said, “My insurer explained to the billing department that because of my deductible I was essentially 100% responsible for the “facility fee.””. This was because you had not yet met your deductible. It sounds like your insurance *did* cover the facility fee – just that due to the vagaries of your insurance policy, it would only be paid for if you had already met your deductible.
.
What Highline is doing is getting patients to sign a form that bypasses the insurance company entirely – if insurance does not cover the cost (as in, the contract between the insurance company and Highline says that they cannot bill for that charge), it allows them to bill the patient directly. This is different in the eyes of the law and in the eyes of your insurance contract.
.
As I said up above: my insurance company will not allow Highline to bill an Urgent Care facility fee in addition to the other medical charges. As per RCW 48.44.020 Section 4(a) and 4(b), they cannot a patient for sums owed by the service contractor. (http://apps.leg.wa.gov/rcw/default.aspx?cite=48.44.020)
.
The form they make you sign is an attempt to skirt around this law and open a loophole in their contract that allows them to collect money both from their in-network insurance providers and the patients directly.

m2 March 31, 2012 (9:18 am)

West Seattle Convenient Care does not charge this fee. Plus, Doctor Harrington has been the best doc in WS for a long time (3 patients in our family). Need I say more?

adamk March 31, 2012 (10:54 am)

Because I’m the one raising hell about Highline’s practices I didn’t want to be the first to mention it, but now that he’s here I will. Dr Harrington is awesome, he’s my primary care physician. If you need to see a doctor unscheduled M-Th, definitely go to his clinic from 4-8PM.

irate March 31, 2012 (1:43 pm)

adamk,

I haven’t been to Highline Urgent Care, so I haven’t seen the language they make people sign. The response from the adminstrator above in this blog post sounds almost exactly like the responses I got about the facility fee I got stuck with when talking to their billing people. So, I assumed it was the same thing. Even if it’s not, egads, how ridiculous are these games the insurers and the provider administrators are playing with us?

I took a closer look at the forum thread this morning. That someone can be both stuck with the fee and not have it apply to a deductible does seem pretty sketchy. If that really is what’s happening (balance billing), that *really* ain’t OK.

I still think split billing practices are designed to confuse people who need help at a really vulnerable time. Whatever the case that it seems like more and more we all need to be able to read legalese to understand what going to get a test done or to see a health care provider will cost.

And just to address one of your comments, no my insurance company didn’t have a change of heart about the facility fee, the facility did. The Swedish billing representative subtracted 35% from the bill. My insurance company did nothing. Hence, I’m changing my insurance.

Bob April 5, 2012 (8:25 pm)

I have read everyone’s comments about Highline Urgent Care.
I have just a couple questions.
Has anyone been to the emergency department in the last 3 years?
Was there a facility fee for the emergency department?
What was the facility fee for the emergency department.
My understanding is the ER has a much higher facility fee and this is standard billing practice for any Urgent Care.
I read someone say boycott the Urgent Care.
I prefer their fees over the ER fees anyday.
I prefer my primary care doctor fees over urgent care fees
I mostly prefer to not get ill or injured

Sorry, comment time is over.