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<<   作成日時 : 2010/08/20 20:16   >>

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 6才の子どもが自宅でケガをして、ERで治療を受けた。1/2インチ未満の大きさだったが傷は深く、形成外科医は14針縫合した。数週後請求書には合計5,398ドルとあり、形成外科医から4,950ドル請求されていた。
 ERでは保険の有無にかかわらず患者診療が行われるため、支払い不能の人の分を補うために病院はER治療費を非常に高く設定する。一方で、保険会社との契約医療費はずっと低く設定する。メディケアとメディケイドは病院治療に対して低い医療費を設定している。
 ER料金は治療の複雑さに応じて5つのレベルがあり、こうした縫合ではレベル2の治療と考えられ、488ドルである。外部の医師を呼んだ場合は直接医師からまたは保険会社から請求を受けることになる。
 最終的に現金支払いは最初の1/3となり、一見良さそうに見えるが、それでもまだ1,579ドルだった。
 緊急でない場合はERを受診しないことである。2007年のER受診理由のトップ3は、捻挫・外傷・上気道炎である。まず、保険会社のナース・トリアージ・ホットラインに電話すべきである。骨折していてX線検査が必要かどうかなどに答えてもらえる。
 ERの代案として、緊急治療センターurgent care centerが全国至る所8,700カ所にある。ERより速く安く捻挫や傷の治療をしてくれる。
 病院の不当な請求と思われたら電話をするように。医療費についての質問をおそれる必要はない。ほとんどの病院は値引きをする。保険に加入していても交渉はできる。
 病院にとっては全く支払われないより一部でも支払われる方がよい。病院と分割払いの交渉も可能であり、医師とも医療費の交渉は可能である。

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Demystifying, and Maybe Decreasing, the Emergency Room Bill
By LESLEY ALDERMAN
Published: August 6, 2010
http://www.nytimes.com/2010/08/07/health/07patients.html

画像DURING a snowstorm last winter, my 6-year-old son fell and cut his chin ― not outside on the ice, but inside on the tile bathroom floor. My husband walked our son, Charlie, through the knee-high snow to the local emergency room.

“Never be afraid to ask questions about your bill,” said Michelle Leone of Continuum Health Partners.
Ruth Fremson/The New York Times

Charlie’s gash was small, less than half an inch long, but deep. The hospital called in a plastic surgeon, who put 14 tiny stitches into his chin.

Charlie called the incident “the worst day of my life” ― mostly because he had to spend hours in a hospital instead of throwing snowballs. Weeks later, when the bills arrived, we had our own bad day.

The total charges for his minor spill came to $5,398. The largest single charge was a shocking $4,950 from the plastic surgeon.

Emergency room bills are notoriously high and perplexing; patients often are left feeling like captives who have few alternatives. It is impossible to know how much the services will cost when you walk in the door. The hospital bill, which arrives weeks later, may include seemingly inflated charges for things like Tylenol or an M.R.I. Doctors who treated you may send their own separate bills, further complicating the payment process.

The first step toward managing this expense is understanding what goes on in the hospital’s billing department.

NOBODY PAYS RETAIL The majority of hospitals are required by law to treat any person who walks into an emergency room whether that person has insurance or not. To make up for those who cannot or will not pay, a hospital sets its so-called gross charges very high.

At the same time, hospitals negotiate contracts with managed care and commercial insurance carriers that specify prices much lower than the gross charges. Medicare and Medicaid dictate lower rates for medical services to hospitals. In virtually every instance, “we get paid a lot less than we bill,” said Michelle Leone, senior vice president for revenue cycle operations at Continuum Health Partners in New York City.

You may receive a statement that shows your E.R. visit totaled $3,000, for example, but your insurer may agree to pay just $500, which the hospital will accept. Depending on your plan, you owe either a portion of that $500 ― say, 20 percent, after a deductible ― or a co-payment.

People without insurance end up with bills that are much higher than those for covered patients, because the uninsured are charged the hospital’s gross rates.

“People don’t realize that the prices on the bill are just a starting point,” said Dr. Jesse M. Pines, an associate professor of emergency medicine and health policy at the Center for Health Care Quality at George Washington University. “Prices listed on the bill often don’t represent what the insurer or the patient will ultimately pay.”

The prices ultimately paid to a hospital can vary considerably for treatment of similar medical problems. “It’s kind of like the airline industry,” Dr. Pines said. “It’s rare that two people on a plane will have paid the same amount for their seats.”

THE SURPRISES Besides being charged for each service you receive, you will be charged an emergency room fee corresponding to the complexity of treatment that your injury required.

Normally there are five levels of care ― Level 1 is for minor problems like an earache. Level 5 is for more severe problems like a broken bone. (There are higher levels of care reserved for critically ill patients.) Charlie’s stitches, for instance, were considered Level 2 care, and the emergency room fee was $488.

When an outside doctor is called in, you will receive a bill directly from the doctor or from your insurance company. The fee will be high, but your insurer probably will pay for most of it, depending on your plan and whether you have met your deductible.

In the end, our final out-of-pocket costs for the entire emergency were less than a third of the original charges. That sounds good, but the bill was still $1,579.

Some insurance plans require that you get preauthorization before receiving emergency care, said Gordon Wheeler, associate executive director for public affairs at the American College of Emergency Physicians.

The new health reform law, though, stipulates that a patient may not be penalized for receiving out-of-network care in the case of an emergency, and that a patient does not need to seek preapproval. The final regulations on this issue are to be released at the end of this month.

Whether you have insurance or not, here are some strategies for avoiding high emergency room bills and steps to take when the amount you owe seems unreasonably high.

DON’T GO THERE If your situation is not dire ― you twisted your ankle or have a persistent sore throat, say, or your child receives a small burn ― call your doctor first and ask for advice.

While this might sound obvious, many people routinely head to the E.R. for nonurgent problems. The top three reasons for emergency room visits in 2007 were for sprains and strains, superficial injuries and contusions, and upper respiratory infections, according to Ryan Mutter, a senior economist at the federal Agency for Healthcare Research and Quality.

Call your insurer’s nurse triage hot line. A trained nurse can help you determine whether a swollen ankle is broken and should be immediately X-rayed, for instance, or whether a burn requires a doctor’s attention or just judicious at-home treatment.

Another good alternative to the E.R. is an urgent care center. There are now 8,700 of them across the country. They are typically faster and cheaper than E.R.’s. Urgent care centers specialize in treating mild injuries like sprains, broken toes and fingers and mild cuts. To find a nearby urgent care center, call your insurer or go to iTriagehealth.com.

SCRUTINIZE THE BILL If a charge looks wrong or the amount seems unreasonably high, call the hospital’s billing department. Hospitals and insurers process thousands of claims a day, and mistakes do happen. If you received two stitches in your finger, but were billed $700 for Level 3 care, ask why this is so.

“Never be afraid to ask questions about your bill,” Ms. Leone said.

MAKE AN OFFER If the final bill is beyond your means, it will pay to bargain ― particularly if you do not have insurance.

“The majority of hospitals will discount private paying patients’ bills,” Ms. Leone said. “Most hospitals are generous in their discounts.”

You can negotiate even when you have insurance. Two years ago Lisa Cullen’s father, Thomas Reilly, became very ill and made three trips to the emergency room. Each visit cost about $15,000. Mr. Reilly’s insurer contested some of the charges, and the family ultimately was left owing the hospital $11,000.

The hospital was able to reduce the bill to $5,000. “I was surprised to learn hospitals would rather receive partial payment than no money at all,” Ms. Cullen, a writer in Leonia, N.J., said. Often you can work out a payment plan with the hospital whereby you pay your bill in installments rather than all at once.

Negotiate with doctors, too, over their individual bills.

ACT QUICKLY Unpaid hospital bills are usually forwarded to collection agencies that report uncollectible accounts to credit agencies. When faced with exorbitant bills, don’t hesitate to contact the hospital’s billing department and start a dialogue.

“By the time your bill lands at the collection agency, your credit score will have taken a serious hit,” Dr. Pines warned, “and it might be hard to borrow money in the future.” If that happens, a trip to the emergency room will feel like the beginning, not the end, of your troubles.


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