Buyer beware: Freestanding emergency rooms

9Wants To Know spent months looking into the billing practices of so-called freestanding emergency rooms, named because they are not attached to hospitals.

KUSA - They are popping up in places once taken up by Blockbuster Video and Chilis: freestanding emergency rooms.

Supporters say the explosive growth of freestanding ERs is good for consumers. Critics point to people like Jeff Nixon as proof of a costly downside.

Nixon, a deck builder, got a splinter in his thumb in April. Unable to pry it out himself, he went to a First Choice ER near South Kipling Parkway and West Bowles Avenue. In an hour, the splinter was out.

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"Yeah, they were nice enough," Nixon said.

A month later, he opened his bill, and no longer considered the staff "nice enough."

"Yeah, ended up being $3,690 to get a sliver taken out of my thumb," he said.

Technically, after his insurance kicked in, his bill came out to $2,301.60. He complained repeatedly but was told over and over again he would have to pay it.

"I wish it was a joke," he said.

9Wants to Know spent months looking into the billing practices of so-called freestanding emergency rooms, named because they are not attached to hospitals.

What was found is a situation that should be considered a consumer alert.

How much was your free-standing emergency room bill? Send us your bill by using this form: or email

At the start of 2012, Colorado had two freestanding emergency rooms. As of November 2015, there are 24.

MAP: Where are the freestanding ERs and urgent cares in your neighborhood:

According to records and company announcements reviewed by 9Wants to Know, there will be at least 35 by the summer of 2016.

"I think our rural areas set us up to have rules that may have inadvertently played into the business model," Colorado State Senator Irene Aguilar (D-Denver) said.

Sen. Aguilar explained that, historically, Colorado has embraced and hesitated to regulate freestanding ERs because the state didn't want to dissuade any from going into areas that might not have the kind of population to support a hospital. It was not uncommon, for example, for freestanding emergency rooms to open seasonally in ski areas.

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Also in Colorado, there is no requirement for operators to seek what's known as a Certificate of Need. In states where one is required, operators must prove to government regulators of the need for a medical facility in a particular area. The assumption is overbuilding can lead to an unnecessary increase of health-care cost as operators raise prices to justify building and equipment purchases.

Many free-market supporters feel the regulation is unnecessary as it limits competition.

Sen. Aguilar disagrees, and in 2014, she sponsored legislation to make it more difficult to run freestanding ERs.

"I personally think their billing practices are unethical. I think they're taking advantage of a loophole we have in our law," she said.

That "loophole" allows freestanding ERs to charge what's known as a facility fee to every patient who receives care. Hospitals have long charged facility fees to justify the 24-hour nature of ERs as well as the fact that, under federal law, all ERs have to screen patients no matter of their ability to pay.

While that law applies to freestanding emergency rooms as well, critics suggest many freestanding ER owners cherry-pick areas of the state where people are more inclined to have insurance. In addition, the freestanding ERs typically send patients, sometimes via a costly ambulance ride, to hospitals when something like a surgery is required.

Sen. Aguilar tried and failed to convince the legislature to forbid freestanding ERs to charge facility fees in 2014.

9Wants to Know has obtained bills from patients which show the facility charge at the state's largest chain of freestanding ERs to be anywhere from $700 to $6,200. UCHealth ER bought the majority stake in all of the First Choice ERs in Colorado earlier in 2015. It now operates 14 freestanding ERs with plans to build more.

Jennifer Martin went to a First Choice ER in June. Her bill shows a facility charge of $6,237.

She came there with shortness of breath.

"I thought it was an asthma attack or an allergic reaction," she said.

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She said the staff was friendly and ran numerous tests to try to figure out what was going on, but "ultimately they sent me home and told me I needed to relax."

A few weeks later, she opened her bill and nearly fainted.

"I just feel like it was misleading," she said.

Dr. Richard Zane heads UCHealth ER and told 9Wants to Know the bills are in line with industry standards.

"The cost of emergency care is relatively the same whether you go to a freestanding emergency department or a hospital-based emergency department," Dr. Zane said. "And we clearly say we are an emergency department. We are unambiguous about being an emergency department. Each of the UCHealth ERs has a CT scan, X-ray, and board certified emergency room physicians in the building at all hours of the day. There is a cost associated with that level of care."

9Wants To Know asked Dr. Zane if the bill for Nixon's splinter removal seemed a bit excessive.

"I can't tell you specifics about specific patients, but there is a cost associated with health care," he replied.

Currently, the only insurance that is in network with UCHealth ER is Anthem Blue Cross/Blue Shield. Dr. Zane said there are plans to add more insurance companies to "in-network" care soon. In addition, UCHealth ER does not take Medicare, Medicaid or TriCare. Dr. Zane said that should change sometime in 2016.

Over the course of a month-and-a-half, 9Wants to Know visited nine freestanding emergency rooms along the Front Range with undercover cameras.

Each time 9Wants To Know walked in the door, workers greeted us with the same sentence: "Welcome to our emergency room."

Signs noting the buildings were "emergency rooms" were in a number of visible locations.

9Wants To Know went in looking for specifics about billing practices. Each time, it was told roughly the same story: "It depends on the level of care."

"We wouldn't be able to give you a price if that's what you're asking," another said.

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It's the quandary associated with health care in general. It's nearly impossible to know what the cost will be before treatment is received.

The problem exists at a time when many people are signing on or being forced into high-deductible health-insurance plans that put them on the hook for thousands out of their own pockets at first.

Nixon assumed his splinter removal might run him a few hundred dollars.

Doug Linder visited a UCHealth ER in August with a cut finger. He never anticipated his bill for a few stiches would lead to a bill of more than $3,000.

"We had no idea we were going to get slammed with this," his wife Teresa said. "Honestly, it just sucks."

A few employees at UCHealth ER did tell us they try to be honest with patients who might be better served at an urgent care.

"I try to let people know that, because I don't want you to get a $6,000 bill in the mail for your kid having a strep throat," one said.

Another told us of a few urgent-care clinics nearby. Others acknowledged patients remain confused.

"I actually had a patient tell me once, 'Oh, I thought you were just calling yourself an emergency room to be cute,'" another admitted.

Dr. Zane said the UCHealth ERs couldn't be more transparent however. As for ambiguity of cost, he said, it's an issue with health care in general.

"It's probably true for most of health care," Dr. Zane said.

Centura Health, in an effort to bill "based on the level of service," announced it plans on opening four hybrid urgent care/freestanding emergency rooms. The model, conceivably, would allow patients with, for example, splinters in their thumbs to go to the lower cost urgent care for service.

"We are treating the patient at the level they need," Jennifer Wills, spokesperson for Centura, said. "If they need urgent care, they will be seen at the urgent care level."

In other words, a patient with a low-level problem should not be billed at an emergency-room rate.

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Dr. Vivian Ho works at Rice University's Baker Institute for Public Policy and has been a vocal critic of the freestanding emergency room model.

"Under the current model, I think freestanding emergency rooms are relying on an uninformed patient to make the profits they are earning right now," she said. "For most people, I don't think they're good."

Anthem Blue Cross/Blue Shield of Colorado estimates 60 to 70 percent of their customers who go to freestanding emergency rooms have conditions that could be treated in urgent cares. The insurance company also says the average bill from a Colorado urgent care is close to $200. The average bill at a freestanding emergency room is closer to $2,300.

Dr. Ho said, in the end, it's largely up to the patient to know more about his or her health insurance plan.

"The more information we can get to consumers and patients about prices of health-care services, the better they'll be able to choose a doctor or other health care provider," Dr. Ho said.

Dr. Zane said more transparency is coming.

"I think cost transparency is something that's talked about often in medicine, and I think the more transparent we are the better," Dr. Zane said.

(© 2015 KUSA)