Patients visiting some doctors' offices and urgent-care clinics are increasingly running into unexpected fees, bills as though they had gone to a hospital. They are becoming victims of the little understood facility fee.
Facility fees are normally generated when a patient visits a hospital or a hospital owned building for medical services. The fees, which can amount to hundreds of dollars, and are billed by hospitals in addition to the physician practices, urgent-care centers and other operations.
Health plans may require consumers to pay emergency-room co-payments even if they didn't understand that an urgent-care visit could count as a trip to the ER because the urgent-care clinic operates in a hospital owned building.
The facility fees are "not about driving revenue," says Sara Larch, a vice president at Inova Health System, a not-for-profit hospital chain based in Fairfax, Va. "It's really just about getting paid for the cost of what we've provided."
Let's examine this fee in a non-medical situation.
It's income tax time. Your appointment with you account is on the 16th floor of Gotham Towers just down the hall from the office of Bruce Wayne.
Two weeks later you get a bill from your accountant for $500 and you pay it.
Three weeks later you get a bill from Gotham Towers and Development LLC for $85.00. Why? You pick up the phone and when you ask why the bill, you are told that you are a client of Mr. Accountant and that the $85 is the facility fee for meeting with your accountant.
It's the same issue. Your accountant pays rent. He pays rent if he has one client or no clients. Why should you be charged anything for providing revenue to your accountant so he can pay the rent.
If you get hit by an unexpected fee, you should first carefully check the bill and your explanation of benefits. If you're still confused, call the provider and your insurer to make sure you understand the charge and confirm that it is allowed by the health plan. If you feel the out-of-pocket amount you're being billed is unfair, you can try to appeal the provider's bill or your insurer's decision. But if the health plan's contract with the provider allows for facility charges, you will likely run into stiff resistance.
When Jim's doctor told him to have an ultrasound, the 34-year-old customer service rep selected what he believed was an independently owned imaging center. The reason, scans at independent centers cost him nothing under his health plan, while hospital charges counted against his deductible. That is there would not be a facility fee.
A month later, Jim got a $773 bill from hospital operator Seton Health, which co-owned the imaging center. "I just feel like I was duped," he says, because there was "absolutely zero" way for him to know he'd be billed as if he'd visited a hospital. Jim says he appealed twice, but was turned down both times by his insurer, Anthem Blue Cross and Blue Shield. Jim, who had a $1,000 deductible in his plan, ended up paying the full bill.
A Seton Health spokeswoman says the imaging center's signs include the Seton name along with the co-owner. She says Seton Health's rates are consistent with its competitors' and it hasn't seen other complaints similar to Mr. Thomson's. Anthem parent WellPoint says it urges members to check on charges and coverage in advance.
There is no OMFS or Official Medical Fee Schedule for facility fees. No CPT codes or CMS guidelines. As the patient who used services, you are left on your own to do battle.
Unfortunately there isn't much you can do about these fees other then be vigilant about the bills you get from medical providers and question the services provided.