quote:

Originally posted by Pipe Smoker:
I got the first of two Shingrix shingles shots at my pharmacy several weeks ago. My UHC Plan N insurance covered the full cost. It’ll cover the second shot too. Without insurance, both shots are expensive.

Oddly, my GP recommended getting it at a pharmacy, rather than at the clinic – dunno why…

Same exact thing for my wife and I last week - both of us fully covered by insurance. Will have second shot within 6 months. BTW, shot hurts a little when it is given and both of us had very sore shoulders for several days. Far, FAR preferred over getting shingles!

Ugh, I had chickenpox and also had the fun of getting shingles when I was like 22. Now I weigh waiting until I'm eligible for the shingrix shot under insurance or just getting it done early and paying out of pocket...

Medical billing 'in la-la land': UMMC changes policy amid probe into expensive ER visit
Anna Wolfe, Clarion Ledger


Amy McIntosh knew it wasn't going to be cheap, but going to the emergency room seemed like her only choice.

Her 10-month-old daughter Macy was already on antibiotics for an ear infection and had woken up Dec. 23 with a concerning knot at the base of her skull.

McIntosh didn't want to ignore the bump, but it was a Saturday, and her pediatrician's after-hours clinic was booked for the day. No other pediatric or urgent care clinics she called were able to see Macy.

McIntosh is one of multiple parents who visited the ER at Batson Children's Hospital in recent months and were then unreasonably charged thousands of dollars — much more than the level of care warranted. During a probe by this newspaper, officials announced changes to the hospital's billing procedures.

'Something had to be wrong'
The emergency department physicians at Batson spent a total of five minutes face-to-face with the family, confirmed the knots were swollen lymph nodes, and sent them on their way with no new treatment plan or medication.

Then came the $4,661 medical bill, of which McIntosh was responsible for $875.

"We asked for detailed bill; something had to be wrong," McIntosh said.

The bulk of the bill was categorized as one $4,328 facility fee titled, "emergency room – general classification." Though Macy's care amounted to a check-up with no treatment, the family was charged for the second-highest level of severity for emergency room visits, partly because Macy was under 1 year old.


The family complained for weeks, but hospital billing employees repeatedly told them the bill was correct and directed them to get on a payment plan.

Now, Batson's Chief Executive Officer Guy Giesecke says the hospital's method for determining the severity "level" of an ER visit is in error. On Tuesday, Giesecke told the Clarion Ledger that Batson is changing its scoring criteria for facility fees to better reflect the level of care delivered.

How ER visits are priced
University of Mississippi Medical Center, home of the children's hospital, prices emergency room visits based on their designated "level," depending on the complexity of the medical need and the services rendered. Charges start at $468 for Level 1, shoot up to $2,048 for Level 3 and top out at $4,913 for Level 5, according to the UMMC website.

McIntosh was charged for a Level 4 visit from the facility, according to UMMC officials.

It didn't seem right. Their medical complaint wasn't urgent; doctors didn't even see Macy until they'd been in the emergency room for an hour.

One physician looked at Macy's ears and listened to her chest. Another gave Macy a flu test, which was negative but added $250 to the bill. They were discharged.

An analysis by Vox and the Health Care Cost Institute published in December found that surprisingly high emergency room bills often resulted from hospitals classifying visits as more severe.

They found that hospitals are increasingly billing under the Level 4 and 5 facility charges, "typically reserved for the most complex visits."

"There are no federal guidelines on how to code even the exact same visit," Vox reported. "This is left up to a hospital's billing staff, meaning that if two patients receive identical care in different emergency rooms, one may be coded as a level 3 and another as a level 4."

While the hospital billed the McIntosh's for a Level 4 visit, the physician they saw billed for the much less urgent Level 1 visit. The physician charged $83, all but $9 covered by the insurance plan. A UMMC spokesperson said this seeming discrepancy is not uncommon.

"No services/treatment provided or documented in Macy's medical records justify a Level 4 ER visit," McIntosh wrote in an April 13 letter to Giesecke. "In our view, we are being billed excessively simply for having the perceived ability to pay."

After weeks of prodding, McIntosh learned UMMC designated Macy's care Level 4 based on a point system. Macy received 25 points total, 10 because she was under 1 year old.

UMMC changing its billing policy
In response to this story, Giescke released a statement that said: "One change that will become effective immediately: adjusting the policy that infants under one year old are automatically classified at a higher severity level because of their inherent status as high-acuity patients. This designation will now be limited to patients six months old and younger."

UMMC officials told the Clarion Ledger it predicts the change in policy, which changes Macy's visit to Level 3, will cut McIntosh's bill in half.

Still, this means the facility cost of an ER visit for a 5-month-old and the same service for a 6-month-old can differ by $2,000.

For Macy's visit, five points were added because the physician, to determine Macy's level of consciousness, did a Glasgow coma test, which is usually reserved for people with head trauma. It may have been necessary because of her age. The rest of the points came from Macy having her initial vital signs checked (5) and the discharge (5), two things virtually guaranteed in an ER.

"We knew going to the ER was going to be more expensive, but we never expected this type of billing," McIntosh said.

According to a letter McIntosh received from UMMC's Office of Patient Experience, a visit that earns between 21 and 35 points is considered Level 4.

UMMC would not provide the Clarion Ledger the corresponding points for the other levels, arguing the information is proprietary. But without this information, the hospital's transparency efforts — listing ER visit prices on its website — become opaque.

Without knowing how many points each service is worth and the cutoffs for each visit level, it's impossible to know what's in the bill.

Macy's experience suggests any patient who visits the ER would be given at least 10 points, assuming every patient has their vitals checked and is eventually discharged.

Under the new policy, Macy's visit is given 15 points and designated Level 3, which begs the question: Up to how many points is still considered Level 1, and is it even possible to receive the less severe $468 facility charge?

Giescke indicated in his statement that other changes to the scoring criteria may be coming.

"During this year's busier-than-usual influenza season, after a number of families expressed concerns about the charges they received for their child's visit, we identified a few cases in which there was a mismatch between the actual severity of the patient's condition and the visit level prescribed by our policies that determine charges," Giescke's statement read. "Based on these concerns, including those expressed by Amy McIntosh, a team of medical and billing leaders have proposed a number of evidence-based changes to our policies to better reflect the level of care and hospital resources a patient receives during their time in the ED."

When asked for the email or memo from the administration expressing the policy change to employees in the ER or billing departments, a UMMC spokesperson said no communication had been made and no changes had yet been implemented. By Thursday, McIntosh said she had not been told how the policy change would affect her bill.

'Taking us seriously'
To fight the bill, McIntosh sought help from the Mississippi Health Advocacy Program, which provides resources and assists patients through the grievance process.

McIntosh detailed 11 calls between her family and the hospital in February, none of which resulted in answers for why McIntosh was billed nearly $5,000. She was told at least three times, by three different employees, that her bill was correct, but only learned weeks later how her bill was actually calculated.

"Nobody was taking us seriously," McIntosh said.

Tracye Trest is another mom who took her 2-week-old to the Batson emergency room on a Saturday in December and also received a $5,000 bill for minimal services. Her baby was diagnosed with the common rash known as cradle cap.

Trest, a former UMMC nurse, has been trying unsuccessfully for weeks to get an explanation on her bill. Clarion Ledger analyzed her bill to determine she was also charged for a Level 4 visit from the facility, but a Level 1 visit from the physician.

"I've called them three times and asked for an itemized bill. They said if I wanted to dispute any of the charges I had to write a letter to the billing department. I can't do that though, because I don't have an itemized bill," Trest said. "Being the nurse I am, I am 100 percent certain that the rash was nowhere near severe. I would expect around $500. But it's ridiculous for the amount I was charged. That's not fair to me or anyone else."

Trest said she's not paying the owed $1,342 until she gets an answer on her bill.

In response to her official grievance, McIntosh received a letter from UMMC March 13 saying the bill was reviewed for accuracy and is correct. Only then was she told about the point system on which the charge was based.

'La-la land'
The hospital's billing "is out in la-la land," McIntosh said. "It in no way corresponds to the level of care you receive."

McIntosh said she cannot afford the $865.60 bill for which she was responsible. Had she been able to go to a pediatric clinic, she said the bill would have been $20 or less.

For Macy's visit, UMMC charged roughly 12 times what Medicare would have paid, $355, for the same service, according to UMMC. Medicare's reimbursement rates are set by the government based on cost of services and are often used as a baseline for insurance companies determining what they'll pay.

Hospitals nationally charge for emergency room visits at an average of 4.4 times what Medicare allows, according to a Johns Hopkins School of Medicine study published in the Journal of the American Medical Association Internal Medicine in 2017. The researchers found these "overcharges" totaled more than $3 billion a year nationally.

In her letter, McIntosh referenced the theme of Batson Children's Hospital: "the children of Mississippi deserve all that we can give them." She said she agrees.

"However, first and foremost the children of Mississippi deserve access to comprehensive healthcare along with fair billing practices above anything else and they are not receiving this at Batson Children's Hospital," McIntosh wrote in her letter. "I ask that you strongly consider reviewing your Emergency Department facility billing practices to at least correlate the level of service provided by facility and physician to the level of billing for each as well."

Giescke pointed out that Batson is the only dedicated pediatric emergency department in the state, which offers subspecialty care — and that's expensive.

"Although our charges have to reflect these costs, they must also be fair, and we appreciate the input we have received from families to help us achieve this aim," he said in his statement.

Have your own health care story? We want to tell it. Contact Anna Wolfe at 601-961-7326 or awolfe@gannett.com. Follow her on Twitter.

The cash price for the shingles shot at my store is just under $200 each shot. I don’t think Publix would be able to sell it for less than 1/3 of my cost. I would be mad too though if a doctor didn’t tell me the cost before giving me the shot.