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.