Audra Melton for KHN
Frankie Cook remembers last year’s car crash only in glimpses.
She was driving a friend home from high school on a winding road outside Rome, Georgia. He saw standing water from the recent rain. She tried to slow down but lost control of her car on a sharp turn. “The car flipped about three times,” says Frankie. “We turned around and went out the side of that hill. My car was on its side and the rear was smashed into a tree.’
It sounds bad, but Frankie says the airbags deployed and both passengers were wearing seat belts, so she was left with just a headache when her father, Russell Cook, came to pick her up from the scene of the crash.
Frankie, then a high school student, worried that she might have a concussion that might affect her performance on an upcoming Advanced Placement exam, so she and her father decided to stop by an urgent care center near their house. to review it. They didn’t make it through the front desk.
“We don’t accept third-party insurance,” Russell tells the receptionist at the Atrium Health Floyd Urgent Care Rome she told him, though he wasn’t sure what she meant. “She told me three times.”
The problem doesn’t seem to be that the clinic lacks the medical expertise to evaluate Frankie, and the family has good health insurance. But when injuries result from accidents, another insurer, such as an auto or home insurer, 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 appear to have run afoul of a reimbursement policy often used by urgent care centers to avoid waiting on auto insurance payouts.
Russell is told to take Frankie to an emergency room, which by law must admit all patients regardless of such problems. The nearest, of Atrium Health Floyd Medical Centerit was about a mile down the road and owned by the same hospital system as the urgent care center.
There, Russell says, a doctor examined Frankie “in just a few minutes,” did safety scans of her head and body, and sent her home with advice to “take some Tylenol” and rest. She did not have a concussion or serious head injury and was able to take her AP exam on time.
Then came the bill.
The patient: Frankie Cook, 18, now a freshman from Rome, Georgia.
Medical services: Medical examination and two CT scans.
Service Provider: Atrium Health Floyd, a hospital system with urgent care centers in northwest Georgia and northeast Alabama.
Total account: $17,005 for an emergency room visit; it was later adjusted to $11,805 after removing duplicate billing.
What it gives: The Cooks face danger in the health care system after Frankie’s car hits that tree: More and more hospital systems own emergency centers that have restrictions on who they treat – both for financial and medical reasons.
Russell was quite upset after receiving such a large bill, especially when he tried to make a quick and cheap trip to the clinic. He said Frankie’s grandmother was seen at an urgent care center after a recent car accident and walked out with a bill for just a few hundred dollars.
“This is what I expected,” he says. “She just really needed to be checked out.”
So why was Frankie turned away from an urgent care center?
Lou Ellen Horwitz, CEO of the Association of Urgent Care, says it’s pretty standard policy for urgent care centers not to treat car accident injuries, even minor ones. “In general, as a rule, they don’t take care of car accident victims, regardless of the extent of their injuries, because it will go through this auto insurance claims process before the provider gets paid,” she says.
Horwitz says urgent care centers — even those owned by large 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 that “unfortunately” people tend to learn about such policies when they show up expecting care.
Fold inwards the complex relationship between health and auto insurance companies and you have what Barack Richmanprofessor of health policy at Duke University Law School, calls “the incredibly complex world we live in.”
“Each product has its own specifications for where it goes and what it covers. Each one is incredibly difficult and complex to administer,” he says. “And they each introduce errors into the system.”
Atrium Health did not respond to repeated requests for comment on Frankie’s case.
Horvitz rejects the idea that a health care system could drive people in car crashes from urgent care centers to emergency rooms to make more money off them. However, auto insurance typically pays more than health insurance for the same services.
Richman remains skeptical.
“At the risk of sounding too cynical, there are always dollar signs when a healthcare provider sees a patient walk through the door,” says Richman.
Dr. Ateev Mehrotra, a professor of health policy at Harvard Medical School, says it was probably strategic to have the urgent care center right down the street from the emergency room. Part of the strategy makes sense medically, he says, “because if something bad happens, you want to get them to a place with more skills very quickly.”
But he also says urgent care centers are “one of the most effective ways” for the health system to generate new revenue, creating a pool of new patients to visit its hospitals and later see doctors for testing and follow-up .
Mehrotra also says urgent care centers are not bound by the Emergency Medical Care and Labor Act, a federal law known as EMTALA which requires hospitals to stabilize patients regardless of their ability to pay.
At the time of Frankie’s visit, both the urgent care center and the emergency room were owned by the Floyd Health System, which operated several hospitals and clinics in Northwest Georgia and Northeast Alabama. Since then, Floyd has united with Atrium Health — a larger company based in North Carolina that operates dozens of hospitals in the Southeast.
Frankie received a CT scan of her head and body in the emergency room, KHN tests confirmed she was unable to make it to the emergency center — whether the test was medically necessary or just part of protocol for people in car accidents who complain of headache.
Resolution: Sixteen months have passed since Frankie Cook’s visit to the hospital, and Russell has delayed paying the bill until the remaining uncertainties are resolved, following advice he received from a family friend who is a lawyer. After insurance covered its share, Cooks’ share came to $1,042.
Getting to that number was a frustrating process, Russell says. He hears about the original $17,005 bill in a letter from a lawyer representing the hospital—another troubling result of Frankie being in a car accident. The Cooks then had to go through a lengthy appeals process to have the $5,200 duplicate charge removed from the bill.
In the end, Anthem Blue Cross Blue Shield, the Cooks’ health insurance company, paid $4,006 of the claim. In a statement, it said it is “committed to providing access to high-quality medical care for our members. This matter was reviewed in accordance with our clinical guidelines and billed claims were processed accordingly.”
“It’s not going to put us on the street,” Russell says of the $1,042 balance, “but we have expenses like everybody else.”
He added: “I’d love an emergency visit for $200, but that ship has sailed.”
The takeaway: It’s important to remember that urgent care centers are not governed by the same laws as emergency departments and that they can be more selective about who they treat. Sometimes their reasons are financial rather than clinical.
It’s not uncommon for urgent care centers — even those in large health systems — to turn away people who have been in a car accident because of the complications that come with auto insurance settlements.
Although urgent care visits are less expensive than an emergency room visit, clinics often cannot offer the same level of care. And you may have to pay for an emergency visit only to find out you need follow-up care in the emergency room. Then you might end up with two accounts.