Urgent care dilemma? Why a visit to an “urgent care” facility could cost you more than you expect

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GREENFIELD (WITI) — Accidents can happen at any time. Parents know a child is just a jump away from a broken arm or needing stitches. If it happens, you'll probably run them to urgent care, but will your insurance cover it?

Theo Karcher plays baseball in the Little League and he's tough, but like most kids, he doesn't always catch the ball.

"He was wearing sunglasses at the time, so when the ball hit him in the face, the glasses got pushed into his face and cut his eyebrow. And then there was a lot of blood," explained Theo's mother Lori Karcher.

Lori and her husband, Greg, knew it was more than a bandage could handle. While Lori took their other kids home — Greg drove Theo to Lakeshore Medical Clinic on Loomis Road.

"We've never been there before. It was just the closest place to our house that we knew that had an urgent care because they had a big sign that said 'urgent care' and they had a neon sign at night that lights up and says 'open — urgent care,'" Lori recalled.

Theo got five stitches and Greg came home with the bill.

"I looked at it and they had charged him $30 for a co-pay. And I said 'why did they only charge you $30? Our co-pay for an urgent care visit is $100,'" Lori said.

Greg didn't know why and when Lori started calling around it was hard for her to get answers. Eventually, she was told something unbelievable.

"I was told that they can't bill it as an urgent care visit because they're not licensed to bill as an urgent care. But they have signage outside their building promoting them as an urgent care," Lori said.

Lori was facing a bill for $1,205 because her visit was seen as going out of network to another primary doctor without prior approval.

According to the Urgent Care Association of America (UCAOA) most states, including  Wisconsin, do not regulate the use of the term "urgent care."

The UCAOA defines an urgent care as a facility that is open after hours, where no appointment is needed and the office can treat medical conditions that need immediate attention. In addition, urgent care is also a billing code for insurance companies.

Lakeshore Medical is owned by Aurora Health Care.

Aurora Health Care Chief Communications Officer Mike Brophy issued this statement to FOX6's Contact 6:

The term ‘urgent care’ sets an expectation that patients will receive unscheduled, acute care for non-emergent cases.  When urgent care services are delivered in clinics, we’re precluded from billing them as urgent care, based on government definitions. We utilize signage at our locations to help clarify billing details.

 We apologize for any inconvenience this creates for some patients.  In rare instances when this is an issue with a patient’s insurance coverage, our customer service team works with individuals to find appropriate solutions.

Lori appealed her billing issue with her insurance company. When she showed up for the appeals hearing, she ran into the right person in the lobby.

"She said 'I'm literally the person who signs the exception,'" Lori recalled.

Lori's bill was taken care of as a one-time exception. It's a tough situation for any parent because most don't think of the bill when their child is injured.

"My husband's walking through the door with my son bleeding from the head who needed five stitches. It wasn't a runny nose. It wasn't something that could have been dealt with a home. He just wanted to get it taken care of," said Lori.

The easiest solution to ensure you don't run into a similar issue is to be prepared and plan ahead.

Before you go to an urgent care center near you, know how your insurance company will handle the billing with that specific office and get pre-approval if you need it.

7 comments

  • Mr. Bob

    The answer lies in the last two sentences in the story:
    The easiest solution to ensure you don’t run into a similar issue is to be prepared and plan ahead.
    Before you go to an urgent care center near you, know how your insurance company will handle the billing with that specific office and get pre-approval if you need it.
    So your child gets hurt and requires 5 stitches, take a deep breath, calm down yourself and THINK!! You know you have insurance and should be familiar with your network. Select a provider in your network and go there. These people must already have a family doctor in a network for their kids or themselves. I am sure this was an extremely drama filled episode for these parents all over 5 stitches. They shouldhave been denied the appeal by the insurance company to teach them how to stay calm in the future when junior suffers his next minor injury……

  • Fox6IgnoresGoodNewsStories

    Well, I gave a news story to FOX6 that really goes hand in hand with this one but they choose to ignore it. The Wheaton-Franciscan group has been taking advantage of a “gray area” of the law (basically a loophole) that allows them to double bill your urgent care visit if you go to the urgent care attached to the hospital. Why? Because they use ER doctors to take care of urgent care patients, so there is a loophole that allows them to charge ER-level charges and charge the room separately (The room charges are way up there in price as well). I went after I fell and they tried to charge me OVER $1000 for 10 minutes of looking at a bruise! They did not do x-rays, they did not do anything that warranted that sort of expense.. no tests.. nothing. They are a SCAM and apparently FOX6 doesn’t care.

  • Rosemary Hassenfeldt

    It’s really not that hard to avoid most of these problems if people think before they act, granted, not always easy to do. Pretty much every doctor these days has some sort of plan in place for even after hours care. Call your primary’s number and they will tell you how to deal with the situation. If you don’t have a primary doctor, call your insurance company’s customer service number. Most have at least a message service for after hours calls. Or better yet, if offered, call their nurse on line service. If they decide it is a problem needing urgent care, they will be able to tell you where to go to get it. Either way, your need for service is documented making it easier to get the bill covered. It’s not fail proof but it does give you another source of proof that you tried to follow the rules if you have to appeal a denial of payment down the line.

  • Peggy Dixon

    I find this hard to believe. My daughter uses urgent care for her children all the time. I’ve used it maybe 2 times and never a problem. So I guess I find this unbelievable.

  • pdixonwi

    Our insurance company is telling us to get our immunizations at the Walgreens or CVS care clinics instead of making an appt with our primary care dr. They said it’scheaper.

  • Kevin Tuvan

    You know, I’m really not surprised at this. I’m doing a bit of research on urgent care facilities now. They are primarily a money making system. I just read here: http://www.nytimes.com-dly.us/2014/07/10/business/race-is-on-to-profit-from-rise-of-urgent-care.html that urgent care facilities are attracting big investors who are mainly interested in profiting. You can bet that they would cut corners when possible and even go so far as to charge extra if they can.

  • DMK

    I am going through a similar situation with an urgent care facility and I am someone who always does their homework. The facility I went to was listed as an in-network urgent care provider by our insurance company, which I found while logged in as myself (aka attached to my specific plan). I had a very general visit for bronchitis. All was well until I received an EOB from my insurance company saying the visit was out of network and would cost $630. For an exam and a rapid strep test. Turns out the provider has 2 federal ID numbers at that address – one for the “urgent care” and one for the actual doctor as a doctors office – and the doctor (the only doctor there mind you) and all of their tests are out of network while the urgent care itself is in-network. So basically they took my $30 co-pay and charged me 100% out of pocket. I am in the process of disputing this but be warned. You made be led to believe an urgent care is in-network only to discover it is not!

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