The week after Christmas my youngest child developed an eye infection. When it worsened after a few days we called the doctor and followed the recommendations for home care. When after a few more days there was no improvement but rather a worrisome acceleration of redness and swelling, we called the doctor again. The answer came back: we are booked and can't see you today; you should go to urgent care.
So that's what we did. The urgent care physician diagnosed cellulitis and sent us home with antibiotics. There was no lab work and no other in-office treatment. Just a prescription and an instruction to call if there wasn't rapid improvement. In a few days there was great improvement. We went on with our lives.
Last month we got the bill. Since our health insurance benefits summary lists a $25 copay for either a physician office or urgent care visit with everything else being paid at 100%, we were surprised to see a balance due of $169. I called the insurance company and was initially encouraged that maybe there had been a mistake since the representative on the phone noted that there were two charges for the visit and speculated that maybe one was a duplicate. A follow-up call several days later, however, provided a different explanation. There were in fact two charges: one for $325 for "immediate care" and one for $247 for "professional fees." Per our coverage we are responsible for a $25 copay on the immediate care charge. But after allowing for the preferred provider adjustment on the "professional fees" charge, there is a balance due of $144. That has been applied to our deductible, so the facility is now billing us for it. I argued with the insurance representative to no avail. "But our plan says urgent care is paid at '100% except $25 copay per visit.'" The answer came back: "We can't control how the facility decides to bill. They submitted two charges, a care charge and a facility charge. You will have to take it up with them."
When I go to the doctor I pay a $25 copay. That covers the care and the building in which the care occurs. Why is urgent care different? And why does "100% except $25 copay per visit" not mean "100% except $25 copay per visit"?
Here's what really burns. We thought that by going to urgent care we were doing the responsible thing, saving the health care system unnecessary cost. But guess what? If we had gone to the Emergency Room instead we would have had only a $100 copay. I guess next time we'll just skip urgent care and go straight to the ER.
Something is seriously broken.