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The Murky World of Emergency Room Billing

No matter how you slice it, medical care is expensive—especially in an emergency.

Martha Norbeck shuffles through paperwork as she looks back over her itemized hospital bill from a bike accident five months ago.

“Just to have the guy come to the ER to do my stitches was $460, the six stitches was $846… so that was $140 a stitch or something?” Norbeck muses. 

Because it was a head injury, nurses in the Emergency Room at the University of Iowa Hospitals and Clinics suspected a concussion, and ran a CT-Scan. That wound up as a $4,851 charge, and one Norbeck thinks would have been avoided with an x-ray instead. 

“It’s not about how much I eventually pay. It’s really about this whole concept of bringing down our medical care costs.”  Norbeck said.

Because Norbeck owns her own small business, she’s self-insured with a high deductible. So every time she needs care, she’s thinking about the bill she’ll get afterwards.

“You just close your eyes and pray. And I’m not even praying about my health, I’m praying about the cost,” Norbeck said.


According to an annual poll by Kaiser Health News, 57% of households who have insurance have avoided or delayed some type of care in the past year due to cost. Most often, respondents reported skipping dental checkups or relying on home remedies and over-the-counter drugs instead of seeing a doctor. But in an emergency, you don’t have those choices.

“First, we don’t care what your insurance status is. We’re going to treat you and make sure you’re safe first,” said Dr. Hans House, who works in the Emergency Room at UIHC and is also a professor of Emergency Medicine.

He says ER doctors must first abide by EMTALA—the Emergency Medical Treatment and Active Labor Act, which requires emergency care to be given to anyone needing it, regardless of their ability to pay.

Once a patient is stabilized, House says there are some options for people concerned about their bill. It’s a practice called cost-conscious care, and one House says he teaches his students to keep in mind.

“We might have different options for medical testing. We could do a CT scan or ultrasound, or delay testing, and we’re going to give you those options, based on your financial situation,” House said.

It’s only in the past couple of years that physicians have been able to see the price for every test they order.

“On our electronic medical record, we have reminders that pop up,” House said. “Our menus, when you have to choose tests, they have prices on them, so you can pick and choose and reduce costs that way.”

House says his office is finishing up a study to see whether those notifications have made a difference, but anecdotally, he’s seen the numbers of pricier tests ordered plunge.

But a patient’s ability to pay can be at odds with a doctor’s risk of being sued for malpractice, if they choose not to order a test that would have uncovered a serious condition.

“That element of defensive medicine is really enhanced by the malpractice environment,” House said. “As there’s more frivolous malpractice suits, there’s going to more use of defensive medicine, we see this across the nation.”


Every procedure, consultation, x-ray, lab test… even a couple aspirin tablets taken in the ER… has its own price, and its own billing code in the hospital chargemaster.

The chargemaster is a 100-thousand line menu for everything a patient could need in a hospital. After negotiating rates, insurance companies and Medicare actually pay only a portion of the initial charges, so there’s a markup built into each price. Richard Belloff, a healthcare administration professor at Des Moines University, says the markup varies from item to item and hospital to hospital.

“There’s almost no agreement about how hospital A would build their chargemaster and hospital B,” Belloff explains. “Charges that a hospital would generate are really a recouping of the fixed cost of having the facility there and having it staffed.”

But that markup means people who don’t have insurance can be impacted disproportionately, because they’re left to negotiate the bill on their own.

Belloff says the chargemaster is the tool hospitals have to make sure they don’t lose money.

UIH, for example, received approval last year to increase all their charges by 6-percent, citing rising operating costs for the hospital and a number of construction projects. But Belloff says a hospital’s administration also has to consider how many patients are covered by Medicare and Medicaid, which reimburse at a lower rate than private insurance.

“If I wanted my ER to break even, and my self-pay patients pay 20-cents on the dollar, because they disappear or don’t pay. That’s a similar consideration than if I have a payer that does pay but pays less than others,” Belloff said.

But at the end of the day, does it add up to that much of a difference? Medicare Provider Charge data—which only became public last year as part of the Affordable Care Act, and from the Centers for Medicare and Medicaid Services—shows the University of Iowa Hospitals and Clinics charging $30,774 for treatment of an acute heart attack… over $10,000 more than Mercy Hospital, just across the river.