February 20, 2025 • 31 mins
Emergency room costs now make up 6% of total healthcare plan spending—why? In this episode, host Stacey Richter welcomes Al Lewis to break down the data behind rising ER expenses, separating fact from fiction.
They discuss whether increased patient acuity or widespread upcoding is driving costs, the impact of the No Surprises Act, and why plan sponsors struggle to negotiate fair ER rates. Plus, Al shares actionable strategies for employers to push back against inflated charges.
If you want to understand the hidden forces behind escalating ER bills, this is a must-listen.
You can find the charts and links mentioned in the show notes in the link below.
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00:00 Introduction
08:32 What is going on in ER visits, and how big of a deal is the total spend?
10:16 Why is the price of ER visits going up when it should be going down?
11:59 What is the major source of unexpected medical debt?
13:27 What is code creep, and why is it happening?
16:26 Why are plan sponsors unable to negotiate emergency room services?
19:22 EP415 with Rob Andrews.
25:53 Why is it imp
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Episode 464.
ER, Emergency Room Visits, Now6 Percent of Total Plan Spend.
Is It Upcoding or What?" Or What Indeed.
Today, I speak with Al Lewis.
(00:22):
American Healthcare Entrepreneurs andExecutives You Want to Know, Talking.
Relentlessly Seeking Value.
Today, I am speaking with the one,the only Al Lewis, and we're gonna
talk about how 6 percent of a lotof plan sponsors total spend is
now going to ER, ED, EmergencyRoom, Emergency Department visits.
(00:45):
That's a lot of spend.
Al digs into this, so I'm just goingto gloss over it all and make my
own points or two along the way,I am sure, here, as the intro.
But the reason why ERs are costing somuch these days is, number one, because ER
volume nationwide is in fact trending up,i. e. more patients are going to the ER.
(01:09):
We had a pandemic in the mix, soit's a little sketchy to track, but
yeah, the volume of ER visits percapita seems to be increasing and it's
increasing faster than the population.
And number two reason, at the same time,the average cost per visit is going up.
So there's a bunch of things that I'mgoing to say today where if you want to
dig in on them, go over to the show notes.
But volume is going up.
Also, the price per visit is going up.
(01:31):
Let's linger a little here on theprice per visit part of the equation.
The average cost per visit went up 15percent in 2023, which is something that
Al brings up in the conversation thatfollows in a little bit greater depth.
Now, in the context of ER visitsbecoming more expensive, here's a
common question that gets posed.
(01:52):
Is this increased cost becauseoption A, ER visits are being
upcoded or option B, are patientsshowing up in the ER actually sicker?
Now I do realize that is aneither or and most of us listening
today and also many who pose thisquestion and certainly Al Lewis.
(02:12):
are fully aware that thereis other stuff going on.
But let's just keep it simplewith this either or binary before
we make it more complicated.
So are ER visits being upcodedor are patients sicker?
There is a right answer to thatquestion, by the way, although
not everyone wants to hear it.
So let us begin with, it is a verifiablefact that visits are being coded at
(02:34):
higher acuities than in the past.
The higher the coding acuity, themore the ER visit is going to cost.
Just to state the obvious, that'swhy there is a financial reason to
up code because the higher codeshave higher associated prices.
Brian Cotter on LinkedIn the other day,sites an ER coding analysis and Al Lewis
sent me a KFF Kaiser Family Foundationslide, basically showing the same thing.
(02:59):
ER visits are beingcoded at higher acuity.
Links in the show notes to both ofthese graphs, but it all boils down to,
as Brian put it in that LinkedIn post.
A notable shift toward higherintensity coding in physician billing.
So codes are upped, but are thepatients actually sicker, thus
warranting the higher acuity codes?
(03:21):
Again, is there an increase in actualpatient acuity or is it just a change
in coding practices jacking thecodes up to higher severity levels?
Let me leave you on the edgeof your seat just a moment here
while I tick through some of theproposed answers to this question.
Whether patients are sicker, thusrequiring higher levels of coding acuity.
(03:41):
You will certainly get some folks,very, very definitely, with three
underlines, talking about their premisethat urgent care has siphoned off most
of the low acuity cases that were goingto ERs in the past, which has left
hospital ERs with higher acuity cases.
So, there is certainly a crew whois firmly in the yes, patients
are actually sicker camp.
(04:01):
Is this actually true?
As per the data, that's sickerpatients are showing up in the ER.
Well, no.
Not that I could find, and ifyou have stats showing otherwise,
certainly send them over.
I did, however, find a KFF HealthNews examination of physician upcoding
which found that minor procedures suchas removing a splinter or treating a
wart are increasingly being billed assurgery, costing hundreds of dollars.
(04:26):
Then I asked Al Lewis whether there'sevidence of higher acuity patients
showing up because urgent caresare dealing with the easy stuff.
And he wrote me back with references.
He said if visits were actuallyhigher acuity, then you would see
a commensurate increase in hospitaladmissions aligned with that acuity.
(04:47):
If, on the other hand, upcoding wasthe cause of more level four and
level five visits, like the KFF HealthNews Examination revealed, then you
would see a reduction in admissionsto the hospital from those codes.
And that is apparently what happenedquite dramatically in California,
where it was actually studied.
Details in the show notes showingway lower hospital admissions
(05:11):
from the way higher acuity codes.
So yeah, upcoding.
And number two reason ERs are costingso much these days, again, ER volume
nationwide is in fact trending up.
And a third issue that Al talksabout for ER total spend becoming
more expensive is just, it's really,really difficult for plan sponsors
(05:31):
to negotiate for ER services.
They are emergencies.
Nobody can navigate.
A fourth factor that Al Lewis talks aboutin the show that follows is some shifts
in what has been going on for in networkpatients since the No Surprises Act.
And again, we take that up inthe conversation that follows.
So four factors underpinning the rise inemergency room spend, but there's kind
(05:54):
of an underlying dynamic here that I wantto bring up, and it's kind of interwoven
through a lot of the conversation.
I want to quote Dr. John Lee, who is,in fact, an emergency room physician.
When I gave him kind of the run ofshow on this episode, Dr. John Lee said
to me, Here's an anecdote from today.
I just saw a young patientwith abdominal pain.
(06:15):
She has had symptoms on and off for monthsand has had little progress getting any
attention from her primary physician.
I could theoretically do some screeningand labs and then have her scheduled
for an office recheck tomorrow.
But I had zero faith thatshe will actually get in
to the office in follow up.
Also, even if she did and somethingbad happened, like appendicitis,
(06:37):
in the interval time period, youknow, we physicians are paranoid.
So, instead, we do the CT scan, we do thelab work, and when nudged by some marginal
other lab results, we did an ultrasound.
We got through weeks worth of workup andbypassed prior auth in one afternoon.
Multiply this same thoughtprocess many, many times over.
I actually saw three patients whowould fit in this general bucket today.
(07:01):
That phenomenon is common.
You can see where the explosion ofacuity and visit volume comes from.
This echoes, by the way, what Dr. MickConnors wrote on LinkedIn the other day.
He wrote, The fact is, primarycare has so few resources these
days, not much can be offered.
There's no xray, lab, procedures,RNs, mental health, etc. And more fees
for quicker services and no penaltyfor sending everyone to the ER.
(07:22):
So it's all built into thefee for service system.
And you see that in thedata, everything above.
There's loads of it that corroboratesthat differences in healthcare access,
principally primary care access,is a huge determinant of the volume
and the average price of ER visits.
It's a little bit ironic that thebigger driver, it seems, is the lack
(07:45):
of urgent care and primary care that'sdriving ER trends, not their existence.
Al Lewis gives advice for what plansponsors can do about these rising
ER charges in the show that follows.
And Al has a bunch of advice here.
Again, towards the end ofthe show on how to do that.
So here's my conversation with AlLewis, who is CEO and founder and
(08:08):
Quizmaster in Chief over at Quizzify.
Contact him for surefor more on any of this.
He says every time he makes an appearanceon Relentless Health Value, lots of people
call him, so you won't be the only one.
My name is Stacey Richter.
This podcast is sponsoredby Aventria Health Group.
Al Lewis, welcome back toRelentless Health Value.
Well, thank you for having me back.
(08:29):
It is a pleasure to haveyou back, my friend.
I'd love to talk with you about whatis going on in emergency departments,
emergency rooms, EDs, ER, becausethis is fast becoming a topic.
How big a deal is this right now?
Well, in terms of total spend per bellybutton, it's about 6%, which may not seem
(08:51):
like a lot, but if you break everythingdown, 6 percent is more than everything
except for, you know, drugs and inpatient.
So 6 percent of total spend or 6percent of like hospital spend?
6 percent of total spend.
For most plan sponsors?
For most plan sponsors, yes.
The rates are now well over 200 visitsper thousand in the commercially
(09:13):
insured population, which means theaverage person under 65, not insured
by Medicaid, is going to the ER onceevery four to five years, which seems
like a lot and yet that's the statistic.
Paradoxically, despite theproliferation of urgent care,
this number has been growing.
And also, despite the factthat the copays are going up.
(09:33):
Okay, so the situation writ largehere for plan sponsors, probably
seeping into Medicare to a certainlevel, but as you said, not Medicaid.
We're taking them off the table now.
But what we've got is the average member,plan member, is going to the ER once
every four to five years, thereforethat results in, if anybody looks across
(09:55):
their membership, you're going to have200 out of a thousand who have showed
up that particular year in the ER,resulting in ER spend being cumulatively
about 6 percent of any plan sponsor'stotal costs in any given plan year.
That's what, that's the summary.
The average plan sponsor in the, yes.
(10:16):
Is this trend increasing?
Like, was it 2 percent a couple ofyears ago and now it's 6 percent
or are we holding steady here?
The volume is going up andthe prices are going up.
It actually, if you take the price forany given visit and the number of visits,
the total went up by 15% in 2023, whenit should have been going down, because
(10:36):
that's after the No Surprises Act, and Ihave to say the data is only public sector
data, that's the only data for governmententities that's been accumulated.
And it's probably also true thatprivate sector has slightly less
than 200 visits a year, whereas thepublic sector has somewhat more.
So I'm averaging it to200 and small change.
So we've got a multivariate increase.
(10:58):
Yes.
Despite the fact that there's urgentcare, which is kind of interesting,
plan members, they're going to theER despite the fact that there are
urgent cares and the prices of thoseemergency room visits are going up.
Yes, and I have a theory for the urgentcare thing and I, unlike everything
else I'll talk to you about, it'snot, it's not data, but I believe
(11:20):
there's some short staffing issues.
So at least in our area, urgent careis ironically not open on weekends.
I've had personally two situations whereI went to urgent care, found it was
closed for something that did not needan ER visit and had to go to the ER.
So it's almost like urgent carehas become primary care because
(11:40):
primary care, there's so many areasof the country where you wait eight
months to get a visit right now.
Yes, and in fact, in fact, that wasthe other theory, Stacey, is that,
is that people simply cannot get notjust urgent care, but primary care.
So that's why the ER visits are going up.
I mean, what's incontrovertibleis that they're going up.
Emergency room volume is goingup as well as the price of
(12:02):
an average visit is going up.
So for plan sponsors, we have a situationthere, but then if you're thinking
about this from a patient finance, froma member finance perspective, at the
same time, we also have medical debt.
Which I understand is increasing anda lot of that is due to ERs as well.
Yes, and in fact, the, the major source ofmedical debt are these unexpected visits.
(12:23):
These things create considerablefinancial hardship, especially for
people who are on high deductible plans.
Uh, even if you have $4,000 inthe bank, one ER visit in network
can cost the whole $4,000.
Other care settings arenot readily available.
Someone winds up in the ER.
It's easy to get a $4,000 bill in the ER.
(12:46):
And 41%, I think was the last stat I saw,41 percent of Americans have medical debt.
So, if you've got 200 out of a thousandin the ED every year, you can kind of
see how those numbers get where they are.
As well as just you know, if you'regoing to the ER every time you have
a diabetes exacerbation, the missionof the emergency room is to make your
(13:09):
emergency not an emergency, not ensurethat you've got continuing disease
management or anything like that.
So why is this happening?
Which is causing theincrease of prices in the ED?
Well, number one would be the up coding.
I have a chart and I'llsend it to whoever wants.
It only goes through 2021, but it showsthere are five codes in the ER from 99281
(13:34):
up to 99285 that over time, the 99284sand 5s that used to be the minority
are now the significant majority.
And I can tell you that mostof that should not be done
and they're not being caught.
There are different codes thatthe emergency room uses, as you
said, from 99281 to 99285, right?
So there's five different severity codesfrom level one visit, which is pretty much
(13:59):
just like something really, really simple,to five, which is gunshot wounds, right?
You had been telling me about arecent ER visit that your wife had.
She suspected she had Lyme'sdisease and ultimately her visit
was coded as a level four, likeshe's one down from a gunshot wound.
So the point is, prices are going upbecause if the ER upcodes the severity
(14:24):
of the reason why the person is inthere and the type of care that they
received, then the dollars start going up.
So if everybody who in the pastwould have been coded as a one
or a two or even a three, now allof a sudden is a four or five.
Yeah, that's not rocket science.
Yes, and I could give youmany examples of that.
My favorite one was once again, justthe other day, another client, the
(14:47):
daughter fell and she did actuallybriefly lose consciousness, so they
went to the ER quite appropriately.
This was at 11 at night.
So the mother and the daughter stayedtill about 7:30 in the morning, at
that point, um, Urgent Care is opening.
So they say, well, we'll justgo to Urgent Care because we
really want this to be seen.
So they leave the ER and go to UrgentCare without being seen in the ER and
(15:08):
they got a bill for $1,000 from the ER.
So it's kind of like a zerolevel code visit and they're
still getting $1,000 back.
Yes.
They said, well, we triaged you.
They said you left, um,against medical advice.
And our argument was, any gooddoctor would tell you to go
get seen somewhere, you know?
So good medical advice would havesaid, yeah, by all means, go get seen.
There is significant codecreep across the country.
(15:29):
If you put that together with theother thing, Stacey, about, about how
people are going to the ER for littlethings because they can't get in to
see their other doctors, there shouldactually be many more ones, twos, and
threes, not more fours and fives..
Okay, so the first reason why we'reseeing this trend up of now ER visits or 6
percent of plan sponsor costs on average,one of them is just this code creep that
(15:54):
even if the volume were remaining thesame, which that's also going up, but even
if it were remaining the same, we wouldhave an increase in spends because the
prices of an average visit are increasing.
So number one, we've got codecreep, upcoding, number two,
volume is actually going up.
Anything else?
Number three is, um,frankly, because they can.
(16:16):
The thing about ER is thereare two things about it.
One is it's very, very difficult, if notimpossible, to negotiate an ER price for
an employer based on volume, because youcan't, you can't direct people to ERs.
You can negotiate a price forjoint replacements or normal
deliveries or that kind of thing.
But, you know, ERs is whatyou, you know, is what you get.
(16:38):
And number two, their ability,the, the provider's ability
to negotiate with the payers.
is paramount.
They're holding all the cardsbecause they, you need them
in their, in their network.
And they also say that unlike in theelectives, in electives, it's common
to get 120 percent of Medicare.
In the ER they're saying, well, wehave to cover all the uninsured people.
(16:59):
So we have to charge you morein order to cover the costs of
people that don't have insurance.
And that creates some, somevery interesting dynamics.
So in Maryland, for example, wherethey have a, uh, uh, every penny
pays the same price, ER visitsare still in the three figures.
It's unbelievable how low they are.
Number two, Massachusetts, whichis known for high healthcare costs,
(17:21):
has like the fifth lowest ER costsbecause everybody is insured.
So the hospitals can't pull that thing.
Meanwhile, on the other end ofthe spectrum, you've got Florida,
where it's literally seven oreight times what Maryland is.
So, the third reason that you'regiving for this, this trend line is ER,
it's like squeezing a balloon, right?
And there's a weak spot in theballoon for ER as you just said.
(17:45):
If it's something that's elective,plan sponsors have an opportunity
to get in there and negotiate.
But if you're talking about anemergency visit, then patient's
going to go to the ER if they feellike they're going to need, they
have, they're having an emergency.
So it's hard to negotiate emergencyroom services as the first
part of the, because they can.
(18:06):
The second part is that there seemsto be a very intuitive reason for a
hospital negotiating for higher ER visits.
Just because it's exactly the samecare setting that all of the uninsured
patients are also winding up.
So you know, you can, in a very clearway, probably pop up a PowerPoint
(18:29):
slide and show that the plansponsors in the area need to cover
the uninsured patients in the area.
And anyone who's community mindedis going to be sympathetic there.
But, you know, plan sponsors,you're paying for all the
uninsured people, uh, allegedly.
At least.
Yeah.
Here's the interesting thingabout that, Stacey, is that in the
old days, you could actually do,they called it a wallet biopsy.
(18:52):
When someone came into the ER, ifyou didn't like their insurance, you
could just send them somewhere else.
And, and the government very wisely,and I might add totally bipartisanly,
uh, put the kibosh on that, you know,at this point, almost 40 years ago.
And that's when the prices startedcreeping up because that's when the
hospital said, we got to cover everybody.
And it's only gotten worse since then.
And I certainly would suggest that anybodywho's kind of thinking about that point
(19:17):
that just got made, that plan sponsorsare very clearly paying for, in a way,
the health of the community to listento the show with Rob Andrews, who really
gets into this, especially relativeto maternity and maternity outcomes.
Okay, so we've talked about three reasonsfor the increase in this growing trend
line for ER spend up to now six percent.
(19:39):
We've got just increased volume.
We've got this code creepthat you talked about.
You've got the because they can.
This is certainly an easy wayfor a hospital who's looking
to increase their revenue to doso without a ton of pushback.
Do we have a number four here?
Yeah, so the No SurprisesAct has worked pretty well.
The headline making ER visits, you know,the $10,000 COVID test, they are all gone.
(20:02):
So, you know, kudos to thebipartisanship behind that.
But it's like the balloon inthat the greatest abuses are
now taking place in network.
And they're not headline makers,they're just every one of these
is higher, you see a lot morescans, and a scan in an emergency
setting costs thousands of dollars.
(20:25):
So it's not only the number of patientsthat are showing up, it's now that when
the patients do show up, beyond thecode creep, which is just the visit
itself gets coded higher, it's alsothat there's now more stuff that's
being done in the ER, like more scans?
It appears, and I cannot give you chapterand verse on this, but it appears that
(20:46):
considerably more scans are being done.
I mean, the United States Hasalways been high in scans.
In fact, we do, and this one I do havethe stats on, we do twice as many scans,
both CAT scans and MRIs as the averagecountry in the Organization for Economic
Cooperation Development, the OECD, withno better outcomes, with worse outcomes.
(21:06):
Now, the thing about the ones in theER is the same scan that would cost
$400 or $500 outpatient is costing$4,000 inpatient, and then it gets
quote unquote discounted by thecarriers negotiation down to $2,500.
So if we're thinking about the numberfour reason for this increased ER
trend since the No Surprises Act, soyou definitely could probably track
(21:30):
it back to some finance person who'slike, wait a second, we're going to
lose the million dollar heart attack.
So how are we going to makethat back one patient at a time?
We, generally speaking, and this,there are exceptions like Walmart and
Caterpillar, but generally speaking,the larger the employer, the less they
connect the dots, basically, and theyjust write a whole bunch of checks.
Yeah, I was talking to a largeplan sponsor the other day who
(21:54):
might have disagreed with you.
I think he would say that it'snot necessarily the size of
the employer that matters.
It's a combination of their philosophyand then also their member mix.
He said something really interesting.
He was like, as a plansponsor, you got to choose.
Do you want to have a well pricedplan and save money, or not.
(22:15):
He's like, that's the first choiceyou have to make, like, pick one.
And if you choose not to, like, maybeyou've got all tech employees who
are making $179,000 a year and whoyou think don't care whether they pay
$4,000 in the ER, they can afford it.
So, you know, I think there's probablya lot of stuff that's going on there.
(22:35):
Okay, so we have, um, we have talkedabout four things here that can
accelerate this trend line with ER.
The last one was stuff going on witha No Surprises Act that increases
in network spending per patient.
Um, so it's not just the volume ofpatients that's going up, it's what's
happening to them once they show up.
(22:57):
Are we capped at four, Al?
If there's a fifth, it would be minor.
So I would say the, I would say thatthat, that the first three are, are, you
know, 80%, the last one is 10, and theneverything else combined would be 10.
So let's get into the advice portionof the pod now, and I'm just gonna
stick in here that one of the reasonsyou can fight and you can win.
(23:18):
Like, because of the, upcoding,there's, there's a precedent that
doesn't want to get set here.
So you can get a write off as aplan sponsor if you take the time
to ask for it and state the facts.
Uh, yeah, but there's a key thing here.
(23:39):
The key thing is you cannot agreeto their consent when you go in.
If you agree to their consentwhen you go in, if you just, they
tell you, you have to sign twice.
Once to get treated, you gotta signthat, and then once I agree to get
paid, I agree to pay whatever you want.
Well, there's a reason for thatsecond thing being, uh, signature
being different from the first isthat you don't have to agree to it.
(24:01):
And according to the EmergencyMedical Treatment Act, they have
to treat you exactly the same,whether you agree to it or not.
Now, if you agree to it, you'veseriously limited your options
and you do have options.
We'll talk about them later.
If you disagree with it and you write inyour own consent or you stick on a sticker
that has a consent or your insurance cardhas a consent that says that you only
(24:23):
agree to appropriate treatment coded atthe correct level at X times Medicare,
like 200 percent of Medicare, you know,in a, if you're a huge organization, maybe
150 percent of Medicare, and they will95 percent of the time just accept it.
They'll have no idea what'sgoing on and they'll accept it.
If they've done that.
You will win and you will get, nowMedicare, you know, people talk about,
(24:48):
you know, good or how bad it is.
One thing they're extremely good atis, is limiting pricing in the ER.
So even if you multiply it by two,um, you're still paying a low price.
So, okay.
So it really is at the member level thatbecause if a member goes in and every time
(25:08):
the iPad gets shoved in their face, theysquiggle their name on the dotted line, if
that is happening, what that patient justdid is financially committed themselves
to basically pay whatever the bill is.
There is some recourse, good recoursefor some people at a certain income
rate, but basically you're limitingyour options very significantly.
(25:29):
Got it.
Okay.
And we did a whole show about this.
I will link to it in the show notes.
So if somebody is interested in a deepdive into the consent form, please go back
and listen to that earlier show becausewe're not going to get into it here.
The one thing I would note, which isdifferent from the earlier show we did
on the consent, is that, uh, there areways of actually automating the consent
so you don't have to rely on the patient,on the employee to put a sticker on or to
(25:53):
remember what to do or anything like that.
It's actually fairly ingenious and youcan do it on your own if you want, you
know, frankly, it's easier if you do itwith us, but you write to the hospital
in advance and you say that anybody whocomes in, uh, under this account number,
here's the consent that we agree to pay.
And, and if they don'tobject, that's what you pay.
(26:16):
And it's not, it's not quite that easy.
And on the card, you have tothen put a little sticker.
The employee doesn't have to do anything.
But on the card it says,see consent on file.
And then there's a QR code thattakes you to this email where
the hospitals agree to this.
Now it's possible the hospital willwrite back and say, we don't agree.
It's extremely unlikely becauseit's, well, number one, it's never
(26:37):
happened, but number two, when yousend this to the hospital, I don't
know if you've noticed this, buthospitals make themselves impossible
to contact electronically because theydon't want to set up audit trails.
So what you need to do is go to ZoomInfoor some other way and find a few
emails from the hospital and send thisthing to them and say, uh, sorry, we
didn't send it right to the ER billingbecause we didn't have their emails,
(26:59):
so please go ahead and forward it.
If they don't forward it, that's onthem because it's well established
in law that you cannot murder bothyour parents and ask the court for
sympathy because you're an orphan.
It's called estoppel.
If they make themselves impossibleto contact, they can't complain that
you didn't contact them correctly.
So part A to this as a plan sponsor is dothe work ahead of time, find the hospitals
(27:21):
that your members are likely to show upat in an emergency and send them all, A,
this is what we consent to in advance.
So that's part A to this.
But then again, part B, as you havementioned, is if there is an egregious
bill, then the member needs to send itto you, plan sponsor, um, so that you can
turn around and say, this is ridiculous.
(27:42):
Right, but let's talk about the situationwhere somebody does not do that for
people who are under $95,000 to somethinglike that, and they do get the bill.
The hospitals have, it's called a501R charity, well they call them
financial assistance or charity care.
That they're not telling you about and werun into these things all the time where
(28:05):
hospitals or doctors have a much betterway of doing something that's much less
expensive that they don't tell you about.
These hospitals have, if they'renon-profit, they have to provide a certain
amount of what they call charity care.
All you got to do is ask for it repeatedlybecause they're not telling you about it.
And we've got all sorts of memos on thiswhere someone is trying to fight our fight
(28:26):
and they say, well, you know, the patientdoes, can get financial assistance,
but they don't offer that up front.
You got to really knowwhat you're asking for.
So as a plan sponsor, that would benumber two, if the plan member or
the plan member themselves, right?
If the plan member is making lessthan $95k a year, then also go back
to the hospital and get their, thecharitable dollars, which are available.
(28:48):
And again, if a hospital that is takingMedicare and Medicaid has been paid
by the federal government, then theyare subject to the 501R rules there.
Yeah, I think it's only non-profits,but it might vary by state.
And the, uh, the cap always also varies byfamily size, but it's always worth looking
into even if you're under $120,000.
(29:10):
So we got one part A and part B,that you have to ensure that your
consent is modified up front.
So there's a proactive bit to this,but then reactively, if a member does
get an egregious bill, then, thenturn around and help them fight it.
I mean, and, and this, if you startthinking about the fact that everybody is
paying a whole lot of money for insurance,and then a plan member finds out the hard
(29:36):
way that they're basically functionallyuninsured and gets I'm going to say taken
advantage of, in the provider setting,then their, their trust in this whole
operation and in their employer planreally diminishes and, and just take to
the social media if you want to see thathappening over and over and over again.
And then Number two, as a nonprofit, thehospital does have to offer charity care.
(29:59):
So if it is available, they generallyspeaking, I'm going to say, and there's
New York Time articles about this.
So, um, generally speaking, thepatient is not necessarily informed
early and often about the fact thatthat charity care is available.
So.
Yeah, let's, let's, let'sbe a little more specific.
They are not informed.
They have to proactively ask for it.
(30:20):
They're not informed.
And, and I do just want to emphasizethe fact that you do no longer have to
rely on the employee for these consents.
You can, there's precedent forsending these to hospital in advance.
So if you do these things, if you, ifyou inform your employees, if you are
willing to fight, if you send the consentin advance, and if you make sure you use
(30:40):
it, there are vendors, not Quizzify, soI can mention them, but, uh, Full Health,
Good Bill, there are probably others.
That will manage this 501R thing for you.
If you do all these things, yourown ER spend should be falling.
And certainly your employees, the lastthing you want them doing is going
bankrupt on your nickel, not just fortheir own sake, but because guess what?
(31:01):
They're not going to beengaged at work anymore.
So you got in your own best interest.
For sure.
Al, if someone's interested in learningmore about the work that you're
doing, where would you direct them?
I would say al@quizzify.comor www.quizzify.com.
We're very easy to find and you know,it doesn't take long to set this up.
(31:22):
You can implement this stuff in an hour.
Al Lewis, thank you so much for comingon Relentless Health Value today.
I'm always glad and thankyou for having me on.
Hi, this is Al Lewis.
So thank you very much to everybodywho listened to the entire podcast.
I hope you learned something useful,as I always do when I work with Stacey.
Episode 464.
ER, Emergency Room Visits, Now6 Percent of Total Plan Spend.
Is It Upcoding or What?" Or What Indeed.
Today, I speak with Al Lewis.
(00:22):
American Healthcare Entrepreneurs andExecutives You Want to Know, Talking.
Relentlessly Seeking Value.
Today, I am speaking with the one,the only Al Lewis, and we're gonna
talk about how 6 percent of a lotof plan sponsors total spend is
now going to ER, ED, EmergencyRoom, Emergency Department visits.
(00:45):
That's a lot of spend.
Al digs into this, so I'm just goingto gloss over it all and make my
own points or two along the way,I am sure, here, as the intro.
But the reason why ERs are costing somuch these days is, number one, because ER
volume nationwide is in fact trending up,i. e. more patients are going to the ER.
(01:09):
We had a pandemic in the mix, soit's a little sketchy to track, but
yeah, the volume of ER visits percapita seems to be increasing and it's
increasing faster than the population.
And number two reason, at the same time,the average cost per visit is going up.
So there's a bunch of things that I'mgoing to say today where if you want to
dig in on them, go over to the show notes.
But volume is going up.
Also, the price per visit is going up.
(01:31):
Let's linger a little here on theprice per visit part of the equation.
The average cost per visit went up 15percent in 2023, which is something that
Al brings up in the conversation thatfollows in a little bit greater depth.
Now, in the context of ER visitsbecoming more expensive, here's a
common question that gets posed.
(01:52):
Is this increased cost becauseoption A, ER visits are being
upcoded or option B, are patientsshowing up in the ER actually sicker?
Now I do realize that is aneither or and most of us listening
today and also many who pose thisquestion and certainly Al Lewis.
(02:12):
are fully aware that thereis other stuff going on.
But let's just keep it simplewith this either or binary before
we make it more complicated.
So are ER visits being upcodedor are patients sicker?
There is a right answer to thatquestion, by the way, although
not everyone wants to hear it.
So let us begin with, it is a verifiablefact that visits are being coded at
(02:34):
higher acuities than in the past.
The higher the coding acuity, themore the ER visit is going to cost.
Just to state the obvious, that'swhy there is a financial reason to
up code because the higher codeshave higher associated prices.
Brian Cotter on LinkedIn the other day,sites an ER coding analysis and Al Lewis
sent me a KFF Kaiser Family Foundationslide, basically showing the same thing.
(02:59):
ER visits are beingcoded at higher acuity.
Links in the show notes to both ofthese graphs, but it all boils down to,
as Brian put it in that LinkedIn post.
A notable shift toward higherintensity coding in physician billing.
So codes are upped, but are thepatients actually sicker, thus
warranting the higher acuity codes?
(03:21):
Again, is there an increase in actualpatient acuity or is it just a change
in coding practices jacking thecodes up to higher severity levels?
Let me leave you on the edgeof your seat just a moment here
while I tick through some of theproposed answers to this question.
Whether patients are sicker, thusrequiring higher levels of coding acuity.
(03:41):
You will certainly get some folks,very, very definitely, with three
underlines, talking about their premisethat urgent care has siphoned off most
of the low acuity cases that were goingto ERs in the past, which has left
hospital ERs with higher acuity cases.
So, there is certainly a crew whois firmly in the yes, patients
are actually sicker camp.
(04:01):
Is this actually true?
As per the data, that's sickerpatients are showing up in the ER.
Well, no.
Not that I could find, and ifyou have stats showing otherwise,
certainly send them over.
I did, however, find a KFF HealthNews examination of physician upcoding
which found that minor procedures suchas removing a splinter or treating a
wart are increasingly being billed assurgery, costing hundreds of dollars.
(04:26):
Then I asked Al Lewis whether there'sevidence of higher acuity patients
showing up because urgent caresare dealing with the easy stuff.
And he wrote me back with references.
He said if visits were actuallyhigher acuity, then you would see
a commensurate increase in hospitaladmissions aligned with that acuity.
(04:47):
If, on the other hand, upcoding wasthe cause of more level four and
level five visits, like the KFF HealthNews Examination revealed, then you
would see a reduction in admissionsto the hospital from those codes.
And that is apparently what happenedquite dramatically in California,
where it was actually studied.
Details in the show notes showingway lower hospital admissions
(05:11):
from the way higher acuity codes.
So yeah, upcoding.
And number two reason ERs are costingso much these days, again, ER volume
nationwide is in fact trending up.
And a third issue that Al talksabout for ER total spend becoming
more expensive is just, it's really,really difficult for plan sponsors
(05:31):
to negotiate for ER services.
They are emergencies.
Nobody can navigate.
A fourth factor that Al Lewis talks aboutin the show that follows is some shifts
in what has been going on for in networkpatients since the No Surprises Act.
And again, we take that up inthe conversation that follows.
So four factors underpinning the rise inemergency room spend, but there's kind
(05:54):
of an underlying dynamic here that I wantto bring up, and it's kind of interwoven
through a lot of the conversation.
I want to quote Dr. John Lee, who is,in fact, an emergency room physician.
When I gave him kind of the run ofshow on this episode, Dr. John Lee said
to me, Here's an anecdote from today.
I just saw a young patientwith abdominal pain.
(06:15):
She has had symptoms on and off for monthsand has had little progress getting any
attention from her primary physician.
I could theoretically do some screeningand labs and then have her scheduled
for an office recheck tomorrow.
But I had zero faith thatshe will actually get in
to the office in follow up.
Also, even if she did and somethingbad happened, like appendicitis,
(06:37):
in the interval time period, youknow, we physicians are paranoid.
So, instead, we do the CT scan, we do thelab work, and when nudged by some marginal
other lab results, we did an ultrasound.
We got through weeks worth of workup andbypassed prior auth in one afternoon.
Multiply this same thoughtprocess many, many times over.
I actually saw three patients whowould fit in this general bucket today.
(07:01):
That phenomenon is common.
You can see where the explosion ofacuity and visit volume comes from.
This echoes, by the way, what Dr. MickConnors wrote on LinkedIn the other day.
He wrote, The fact is, primarycare has so few resources these
days, not much can be offered.
There's no xray, lab, procedures,RNs, mental health, etc. And more fees
for quicker services and no penaltyfor sending everyone to the ER.
(07:22):
So it's all built into thefee for service system.
And you see that in thedata, everything above.
There's loads of it that corroboratesthat differences in healthcare access,
principally primary care access,is a huge determinant of the volume
and the average price of ER visits.
It's a little bit ironic that thebigger driver, it seems, is the lack
(07:45):
of urgent care and primary care that'sdriving ER trends, not their existence.
Al Lewis gives advice for what plansponsors can do about these rising
ER charges in the show that follows.
And Al has a bunch of advice here.
Again, towards the end ofthe show on how to do that.
So here's my conversation with AlLewis, who is CEO and founder and
(08:08):
Quizmaster in Chief over at Quizzify.
Contact him for surefor more on any of this.
He says every time he makes an appearanceon Relentless Health Value, lots of people
call him, so you won't be the only one.
My name is Stacey Richter.
This podcast is sponsoredby Aventria Health Group.
Al Lewis, welcome back toRelentless Health Value.
Well, thank you for having me back.
(08:29):
It is a pleasure to haveyou back, my friend.
I'd love to talk with you about whatis going on in emergency departments,
emergency rooms, EDs, ER, becausethis is fast becoming a topic.
How big a deal is this right now?
Well, in terms of total spend per bellybutton, it's about 6%, which may not seem
(08:51):
like a lot, but if you break everythingdown, 6 percent is more than everything
except for, you know, drugs and inpatient.
So 6 percent of total spend or 6percent of like hospital spend?
6 percent of total spend.
For most plan sponsors?
For most plan sponsors, yes.
The rates are now well over 200 visitsper thousand in the commercially
(09:13):
insured population, which means theaverage person under 65, not insured
by Medicaid, is going to the ER onceevery four to five years, which seems
like a lot and yet that's the statistic.
Paradoxically, despite theproliferation of urgent care,
this number has been growing.
And also, despite the factthat the copays are going up.
(09:33):
Okay, so the situation writ largehere for plan sponsors, probably
seeping into Medicare to a certainlevel, but as you said, not Medicaid.
We're taking them off the table now.
But what we've got is the average member,plan member, is going to the ER once
every four to five years, thereforethat results in, if anybody looks across
(09:55):
their membership, you're going to have200 out of a thousand who have showed
up that particular year in the ER,resulting in ER spend being cumulatively
about 6 percent of any plan sponsor'stotal costs in any given plan year.
That's what, that's the summary.
The average plan sponsor in the, yes.
(10:16):
Is this trend increasing?
Like, was it 2 percent a couple ofyears ago and now it's 6 percent
or are we holding steady here?
The volume is going up andthe prices are going up.
It actually, if you take the price forany given visit and the number of visits,
the total went up by 15% in 2023, whenit should have been going down, because
(10:36):
that's after the No Surprises Act, and Ihave to say the data is only public sector
data, that's the only data for governmententities that's been accumulated.
And it's probably also true thatprivate sector has slightly less
than 200 visits a year, whereas thepublic sector has somewhat more.
So I'm averaging it to200 and small change.
So we've got a multivariate increase.
(10:58):
Yes.
Despite the fact that there's urgentcare, which is kind of interesting,
plan members, they're going to theER despite the fact that there are
urgent cares and the prices of thoseemergency room visits are going up.
Yes, and I have a theory for the urgentcare thing and I, unlike everything
else I'll talk to you about, it'snot, it's not data, but I believe
(11:20):
there's some short staffing issues.
So at least in our area, urgent careis ironically not open on weekends.
I've had personally two situations whereI went to urgent care, found it was
closed for something that did not needan ER visit and had to go to the ER.
So it's almost like urgent carehas become primary care because
(11:40):
primary care, there's so many areasof the country where you wait eight
months to get a visit right now.
Yes, and in fact, in fact, that wasthe other theory, Stacey, is that,
is that people simply cannot get notjust urgent care, but primary care.
So that's why the ER visits are going up.
I mean, what's incontrovertibleis that they're going up.
Emergency room volume is goingup as well as the price of
(12:02):
an average visit is going up.
So for plan sponsors, we have a situationthere, but then if you're thinking
about this from a patient finance, froma member finance perspective, at the
same time, we also have medical debt.
Which I understand is increasing anda lot of that is due to ERs as well.
Yes, and in fact, the, the major source ofmedical debt are these unexpected visits.
(12:23):
These things create considerablefinancial hardship, especially for
people who are on high deductible plans.
Uh, even if you have $4,000 inthe bank, one ER visit in network
can cost the whole $4,000.
Other care settings arenot readily available.
Someone winds up in the ER.
It's easy to get a $4,000 bill in the ER.
(12:46):
And 41%, I think was the last stat I saw,41 percent of Americans have medical debt.
So, if you've got 200 out of a thousandin the ED every year, you can kind of
see how those numbers get where they are.
As well as just you know, if you'regoing to the ER every time you have
a diabetes exacerbation, the missionof the emergency room is to make your
(13:09):
emergency not an emergency, not ensurethat you've got continuing disease
management or anything like that.
So why is this happening?
Which is causing theincrease of prices in the ED?
Well, number one would be the up coding.
I have a chart and I'llsend it to whoever wants.
It only goes through 2021, but it showsthere are five codes in the ER from 99281
(13:34):
up to 99285 that over time, the 99284sand 5s that used to be the minority
are now the significant majority.
And I can tell you that mostof that should not be done
and they're not being caught.
There are different codes thatthe emergency room uses, as you
said, from 99281 to 99285, right?
So there's five different severity codesfrom level one visit, which is pretty much
(13:59):
just like something really, really simple,to five, which is gunshot wounds, right?
You had been telling me about arecent ER visit that your wife had.
She suspected she had Lyme'sdisease and ultimately her visit
was coded as a level four, likeshe's one down from a gunshot wound.
So the point is, prices are going upbecause if the ER upcodes the severity
(14:24):
of the reason why the person is inthere and the type of care that they
received, then the dollars start going up.
So if everybody who in the pastwould have been coded as a one
or a two or even a three, now allof a sudden is a four or five.
Yeah, that's not rocket science.
Yes, and I could give youmany examples of that.
My favorite one was once again, justthe other day, another client, the
(14:47):
daughter fell and she did actuallybriefly lose consciousness, so they
went to the ER quite appropriately.
This was at 11 at night.
So the mother and the daughter stayedtill about 7:30 in the morning, at
that point, um, Urgent Care is opening.
So they say, well, we'll justgo to Urgent Care because we
really want this to be seen.
So they leave the ER and go to UrgentCare without being seen in the ER and
(15:08):
they got a bill for $1,000 from the ER.
So it's kind of like a zerolevel code visit and they're
still getting $1,000 back.
Yes.
They said, well, we triaged you.
They said you left, um,against medical advice.
And our argument was, any gooddoctor would tell you to go
get seen somewhere, you know?
So good medical advice would havesaid, yeah, by all means, go get seen.
There is significant codecreep across the country.
(15:29):
If you put that together with theother thing, Stacey, about, about how
people are going to the ER for littlethings because they can't get in to
see their other doctors, there shouldactually be many more ones, twos, and
threes, not more fours and fives..
Okay, so the first reason why we'reseeing this trend up of now ER visits or 6
percent of plan sponsor costs on average,one of them is just this code creep that
(15:54):
even if the volume were remaining thesame, which that's also going up, but even
if it were remaining the same, we wouldhave an increase in spends because the
prices of an average visit are increasing.
So number one, we've got codecreep, upcoding, number two,
volume is actually going up.
Anything else?
Number three is, um,frankly, because they can.
(16:16):
The thing about ER is thereare two things about it.
One is it's very, very difficult, if notimpossible, to negotiate an ER price for
an employer based on volume, because youcan't, you can't direct people to ERs.
You can negotiate a price forjoint replacements or normal
deliveries or that kind of thing.
But, you know, ERs is whatyou, you know, is what you get.
(16:38):
And number two, their ability,the, the provider's ability
to negotiate with the payers.
is paramount.
They're holding all the cardsbecause they, you need them
in their, in their network.
And they also say that unlike in theelectives, in electives, it's common
to get 120 percent of Medicare.
In the ER they're saying, well, wehave to cover all the uninsured people.
(16:59):
So we have to charge you morein order to cover the costs of
people that don't have insurance.
And that creates some, somevery interesting dynamics.
So in Maryland, for example, wherethey have a, uh, uh, every penny
pays the same price, ER visitsare still in the three figures.
It's unbelievable how low they are.
Number two, Massachusetts, whichis known for high healthcare costs,
(17:21):
has like the fifth lowest ER costsbecause everybody is insured.
So the hospitals can't pull that thing.
Meanwhile, on the other end ofthe spectrum, you've got Florida,
where it's literally seven oreight times what Maryland is.
So, the third reason that you'regiving for this, this trend line is ER,
it's like squeezing a balloon, right?
And there's a weak spot in theballoon for ER as you just said.
(17:45):
If it's something that's elective,plan sponsors have an opportunity
to get in there and negotiate.
But if you're talking about anemergency visit, then patient's
going to go to the ER if they feellike they're going to need, they
have, they're having an emergency.
So it's hard to negotiate emergencyroom services as the first
part of the, because they can.
(18:06):
The second part is that there seemsto be a very intuitive reason for a
hospital negotiating for higher ER visits.
Just because it's exactly the samecare setting that all of the uninsured
patients are also winding up.
So you know, you can, in a very clearway, probably pop up a PowerPoint
(18:29):
slide and show that the plansponsors in the area need to cover
the uninsured patients in the area.
And anyone who's community mindedis going to be sympathetic there.
But, you know, plan sponsors,you're paying for all the
uninsured people, uh, allegedly.
At least.
Yeah.
Here's the interesting thingabout that, Stacey, is that in the
old days, you could actually do,they called it a wallet biopsy.
(18:52):
When someone came into the ER, ifyou didn't like their insurance, you
could just send them somewhere else.
And, and the government very wisely,and I might add totally bipartisanly,
uh, put the kibosh on that, you know,at this point, almost 40 years ago.
And that's when the prices startedcreeping up because that's when the
hospital said, we got to cover everybody.
And it's only gotten worse since then.
And I certainly would suggest that anybodywho's kind of thinking about that point
(19:17):
that just got made, that plan sponsorsare very clearly paying for, in a way,
the health of the community to listento the show with Rob Andrews, who really
gets into this, especially relativeto maternity and maternity outcomes.
Okay, so we've talked about three reasonsfor the increase in this growing trend
line for ER spend up to now six percent.
(19:39):
We've got just increased volume.
We've got this code creepthat you talked about.
You've got the because they can.
This is certainly an easy wayfor a hospital who's looking
to increase their revenue to doso without a ton of pushback.
Do we have a number four here?
Yeah, so the No SurprisesAct has worked pretty well.
The headline making ER visits, you know,the $10,000 COVID test, they are all gone.
(20:02):
So, you know, kudos to thebipartisanship behind that.
But it's like the balloon inthat the greatest abuses are
now taking place in network.
And they're not headline makers,they're just every one of these
is higher, you see a lot morescans, and a scan in an emergency
setting costs thousands of dollars.
(20:25):
So it's not only the number of patientsthat are showing up, it's now that when
the patients do show up, beyond thecode creep, which is just the visit
itself gets coded higher, it's alsothat there's now more stuff that's
being done in the ER, like more scans?
It appears, and I cannot give you chapterand verse on this, but it appears that
(20:46):
considerably more scans are being done.
I mean, the United States Hasalways been high in scans.
In fact, we do, and this one I do havethe stats on, we do twice as many scans,
both CAT scans and MRIs as the averagecountry in the Organization for Economic
Cooperation Development, the OECD, withno better outcomes, with worse outcomes.
(21:06):
Now, the thing about the ones in theER is the same scan that would cost
$400 or $500 outpatient is costing$4,000 inpatient, and then it gets
quote unquote discounted by thecarriers negotiation down to $2,500.
So if we're thinking about the numberfour reason for this increased ER
trend since the No Surprises Act, soyou definitely could probably track
(21:30):
it back to some finance person who'slike, wait a second, we're going to
lose the million dollar heart attack.
So how are we going to makethat back one patient at a time?
We, generally speaking, and this,there are exceptions like Walmart and
Caterpillar, but generally speaking,the larger the employer, the less they
connect the dots, basically, and theyjust write a whole bunch of checks.
Yeah, I was talking to a largeplan sponsor the other day who
(21:54):
might have disagreed with you.
I think he would say that it'snot necessarily the size of
the employer that matters.
It's a combination of their philosophyand then also their member mix.
He said something really interesting.
He was like, as a plansponsor, you got to choose.
Do you want to have a well pricedplan and save money, or not.
(22:15):
He's like, that's the first choiceyou have to make, like, pick one.
And if you choose not to, like, maybeyou've got all tech employees who
are making $179,000 a year and whoyou think don't care whether they pay
$4,000 in the ER, they can afford it.
So, you know, I think there's probablya lot of stuff that's going on there.
(22:35):
Okay, so we have, um, we have talkedabout four things here that can
accelerate this trend line with ER.
The last one was stuff going on witha No Surprises Act that increases
in network spending per patient.
Um, so it's not just the volume ofpatients that's going up, it's what's
happening to them once they show up.
(22:57):
Are we capped at four, Al?
If there's a fifth, it would be minor.
So I would say the, I would say thatthat, that the first three are, are, you
know, 80%, the last one is 10, and theneverything else combined would be 10.
So let's get into the advice portionof the pod now, and I'm just gonna
stick in here that one of the reasonsyou can fight and you can win.
(23:18):
Like, because of the, upcoding,there's, there's a precedent that
doesn't want to get set here.
So you can get a write off as aplan sponsor if you take the time
to ask for it and state the facts.
Uh, yeah, but there's a key thing here.
(23:39):
The key thing is you cannot agreeto their consent when you go in.
If you agree to their consentwhen you go in, if you just, they
tell you, you have to sign twice.
Once to get treated, you gotta signthat, and then once I agree to get
paid, I agree to pay whatever you want.
Well, there's a reason for thatsecond thing being, uh, signature
being different from the first isthat you don't have to agree to it.
(24:01):
And according to the EmergencyMedical Treatment Act, they have
to treat you exactly the same,whether you agree to it or not.
Now, if you agree to it, you'veseriously limited your options
and you do have options.
We'll talk about them later.
If you disagree with it and you write inyour own consent or you stick on a sticker
that has a consent or your insurance cardhas a consent that says that you only
(24:23):
agree to appropriate treatment coded atthe correct level at X times Medicare,
like 200 percent of Medicare, you know,in a, if you're a huge organization, maybe
150 percent of Medicare, and they will95 percent of the time just accept it.
They'll have no idea what'sgoing on and they'll accept it.
If they've done that.
You will win and you will get, nowMedicare, you know, people talk about,
(24:48):
you know, good or how bad it is.
One thing they're extremely good atis, is limiting pricing in the ER.
So even if you multiply it by two,um, you're still paying a low price.
So, okay.
So it really is at the member level thatbecause if a member goes in and every time
(25:08):
the iPad gets shoved in their face, theysquiggle their name on the dotted line, if
that is happening, what that patient justdid is financially committed themselves
to basically pay whatever the bill is.
There is some recourse, good recoursefor some people at a certain income
rate, but basically you're limitingyour options very significantly.
(25:29):
Got it.
Okay.
And we did a whole show about this.
I will link to it in the show notes.
So if somebody is interested in a deepdive into the consent form, please go back
and listen to that earlier show becausewe're not going to get into it here.
The one thing I would note, which isdifferent from the earlier show we did
on the consent, is that, uh, there areways of actually automating the consent
so you don't have to rely on the patient,on the employee to put a sticker on or to
(25:53):
remember what to do or anything like that.
It's actually fairly ingenious and youcan do it on your own if you want, you
know, frankly, it's easier if you do itwith us, but you write to the hospital
in advance and you say that anybody whocomes in, uh, under this account number,
here's the consent that we agree to pay.
And, and if they don'tobject, that's what you pay.
(26:16):
And it's not, it's not quite that easy.
And on the card, you have tothen put a little sticker.
The employee doesn't have to do anything.
But on the card it says,see consent on file.
And then there's a QR code thattakes you to this email where
the hospitals agree to this.
Now it's possible the hospital willwrite back and say, we don't agree.
It's extremely unlikely becauseit's, well, number one, it's never
(26:37):
happened, but number two, when yousend this to the hospital, I don't
know if you've noticed this, buthospitals make themselves impossible
to contact electronically because theydon't want to set up audit trails.
So what you need to do is go to ZoomInfoor some other way and find a few
emails from the hospital and send thisthing to them and say, uh, sorry, we
didn't send it right to the ER billingbecause we didn't have their emails,
(26:59):
so please go ahead and forward it.
If they don't forward it, that's onthem because it's well established
in law that you cannot murder bothyour parents and ask the court for
sympathy because you're an orphan.
It's called estoppel.
If they make themselves impossibleto contact, they can't complain that
you didn't contact them correctly.
So part A to this as a plan sponsor is dothe work ahead of time, find the hospitals
(27:21):
that your members are likely to show upat in an emergency and send them all, A,
this is what we consent to in advance.
So that's part A to this.
But then again, part B, as you havementioned, is if there is an egregious
bill, then the member needs to send itto you, plan sponsor, um, so that you can
turn around and say, this is ridiculous.
(27:42):
Right, but let's talk about the situationwhere somebody does not do that for
people who are under $95,000 to somethinglike that, and they do get the bill.
The hospitals have, it's called a501R charity, well they call them
financial assistance or charity care.
That they're not telling you about and werun into these things all the time where
(28:05):
hospitals or doctors have a much betterway of doing something that's much less
expensive that they don't tell you about.
These hospitals have, if they'renon-profit, they have to provide a certain
amount of what they call charity care.
All you got to do is ask for it repeatedlybecause they're not telling you about it.
And we've got all sorts of memos on thiswhere someone is trying to fight our fight
(28:26):
and they say, well, you know, the patientdoes, can get financial assistance,
but they don't offer that up front.
You got to really knowwhat you're asking for.
So as a plan sponsor, that would benumber two, if the plan member or
the plan member themselves, right?
If the plan member is making lessthan $95k a year, then also go back
to the hospital and get their, thecharitable dollars, which are available.
(28:48):
And again, if a hospital that is takingMedicare and Medicaid has been paid
by the federal government, then theyare subject to the 501R rules there.
Yeah, I think it's only non-profits,but it might vary by state.
And the, uh, the cap always also varies byfamily size, but it's always worth looking
into even if you're under $120,000.
(29:10):
So we got one part A and part B,that you have to ensure that your
consent is modified up front.
So there's a proactive bit to this,but then reactively, if a member does
get an egregious bill, then, thenturn around and help them fight it.
I mean, and, and this, if you startthinking about the fact that everybody is
paying a whole lot of money for insurance,and then a plan member finds out the hard
(29:36):
way that they're basically functionallyuninsured and gets I'm going to say taken
advantage of, in the provider setting,then their, their trust in this whole
operation and in their employer planreally diminishes and, and just take to
the social media if you want to see thathappening over and over and over again.
And then Number two, as a nonprofit, thehospital does have to offer charity care.
(29:59):
So if it is available, they generallyspeaking, I'm going to say, and there's
New York Time articles about this.
So, um, generally speaking, thepatient is not necessarily informed
early and often about the fact thatthat charity care is available.
So.
Yeah, let's, let's, let'sbe a little more specific.
They are not informed.
They have to proactively ask for it.
(30:20):
They're not informed.
And, and I do just want to emphasizethe fact that you do no longer have to
rely on the employee for these consents.
You can, there's precedent forsending these to hospital in advance.
So if you do these things, if you, ifyou inform your employees, if you are
willing to fight, if you send the consentin advance, and if you make sure you use
(30:40):
it, there are vendors, not Quizzify, soI can mention them, but, uh, Full Health,
Good Bill, there are probably others.
That will manage this 501R thing for you.
If you do all these things, yourown ER spend should be falling.
And certainly your employees, the lastthing you want them doing is going
bankrupt on your nickel, not just fortheir own sake, but because guess what?
(31:01):
They're not going to beengaged at work anymore.
So you got in your own best interest.
For sure.
Al, if someone's interested in learningmore about the work that you're
doing, where would you direct them?
I would say al@quizzify.comor www.quizzify.com.
We're very easy to find and you know,it doesn't take long to set this up.
(31:22):
You can implement this stuff in an hour.
Al Lewis, thank you so much for comingon Relentless Health Value today.
I'm always glad and thankyou for having me on.
Hi, this is Al Lewis.
So thank you very much to everybodywho listened to the entire podcast.
I hope you learned something useful,as I always do when I work with Stacey.
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