As the freestanding emergency care industry continues to expand in Texas, TAFEC wants to ensure that consumers are well aware of the emergency care options available to them, as well as their varying levels of service.

Cost Confusion Between Freestanding Emergency Centers (FECs) and Urgent Care Facilities

FECs in Texas are open 24/7, with emergency trained physicians on-staff at all times. Unlike urgent cares, TAFEC facilities are equipped to handle nearly all medical emergencies, similar to a hospital-based ER.

FECs offer quality emergency care with less wait times, which is one of the benefits of choosing FEC facilities over traditional ERs. Patients can be seen right away, thereby limiting the overall time patients spend at the facility, so patients can get back to their daily lives.

Confusion seems to arise from the physical similarities of urgent care and FEC facilities. So how can you tell whether you’re at an FEC or an urgent care?

• Look for the signage: FEC facilities are legally permitted to advertise for treating medical emergencies. Words like “emergency” and “ER” will be on the signage for every TAFEC facility.

• Billing disclosures: Every TAFEC member provides full disclosure that patients are at an emergency room, and as such, will be billed accordingly. This includes covering the costs associated with state of the art medical equipment and ER-trained physicians around the clock. Just as with a hospital ER, all costs are not always immediately available.

In addition to required signage and billing disclosures, TAFEC is working to educate consumers and boost their medical literacy to ensure there are no billing surprises. TAFEC values transparency and wants to empower consumers to make the right decision in the event of the emergency.

Multiple Bills for ER Visits

Just like traditional hospital ERs, Texas statutes allow FEC billing practices to be enterprise-specific. That means each FEC facility may have different billing processes. For example, some FECs issue multiple bills for different areas of treatment, while others consolidate bills for patients. TAFEC members review their established billing procedures with patients and address specific billing questions to provide clarity.

Patient Out-of-Pocket and the Responsibility of the Insurance Companies

The Texas Department of Insurance states that insurance companies are required to pay emergency facilities “at the insured’s in-network benefit level” for all services.  Additionally, the Patient Protection and Affordable Care Act added numerous patient protections that require health plans covering emergency services to provide such coverage without need for prior authorization, regardless of the participating status of the provider, at the in-network level.

Furthermore, health plans are required to pay for emergency visits for medical situations in which an average layperson believes his or her health is threatened.  The final diagnosis should not influence whether the insurer pays for the emergency room visit, and insurers cannot apply the claim towards the out-of-network benefits.

Despite the aforementioned legislation, some insurance companies fail to make appropriate payments for emergency services and/or honor claims. Although overall cost of the visit is comparable to a traditional hospital ER, the claim is processed differently for FECs. The practice of issuing lower reimbursement rates for FECs is unlawful and must be addressed to provide consistency for emergency care providers.

TAFEC’s Response to Medical Overbilling

It is not uncommon for insurance companies to send patients an EOB (explanation of benefits). This is sometimes confused as a bill from the facility, when in fact it is not a bill at all. These EOBs can sometimes be confusing, and patients may be surprised by unexpected charges and feel they've been treated unfairly.

If patients believe they have been overcharged for medical services, TAFEC recommends the following:

• Patients can contact the facility that rendered treatment before making any payments. Billing errors do occur, as is the case with most medical care providers, and they can easily be corrected.
• Patients can contact their insurance providers before making any payments. It is imperative that insurance companies abide by the law and reimburse claims to the degree specified in patient health plans.
• TAFEC members are sensitive to the out-of-pocket costs passed on to the patient. When necessary, emergency facilities will enlist support from the patient (enrollee) in challenging the insurance company’s decision and help appeal for payment – which is often successful.
• If patients are expected to pay additional charges to the facility, TAFEC members are open to negotiating with patients regarding payment amounts and terms. The goal is to find a positive, reasonable outcome.