How much is this going to cost?

“I’ve reviewed your labs, and based on those and your examination, I’m concerned you might have appendicitis. I’m going to order a CT scan so we can find out.”

“How much is this CT going to cost?”

“I’m sorry, but I don’t know.”

Will my insurance cover it? What will I owe if I get admitted? Is observation cheaper? What if I need to be transferred? I can’t afford the ambulance ride.

These are reasonable questions. Medical care can be expensive, and it is completely reasonable to care about what you may have to pay. Unfortunately, in the ER, the answer is often much more complicated than looking up a price.

“Cost” isn’t one number

When you ask, “How much will this cost?” you’re probably asking a more useful question: “How much am I actually going to have to pay?” Those aren’t necessarily the same thing.

There may be a hospital charge, a cash price, and a price negotiated between the hospital and your insurance company. Then there is your insurance plan, which may include a deductible, copay, and coinsurance. You probably don’t care about most of those numbers individually. You care about the number that eventually comes out of your bank account, and unfortunately, that’s often the hardest number to know ahead of time.

But aren’t hospitals required to publish prices?

Yes. But it’s not that simple.

Federal law requires hospitals to publish a lot of pricing information. Hospitals must also provide information about hundreds of “shoppable” services or offer a qualifying price estimator. The important word there is “shoppable.”

These are services that can usually be planned ahead of time. If you’re scheduling an MRI next month, you may have time to look up the price, check your insurance benefits, compare locations, and get an estimate of what you’ll owe. Emergency care doesn’t work that way. You don’t schedule severe abdominal pain for next Tuesday, and at the beginning of an ER visit, we often don’t know exactly what care you’re going to need.

The ER visit doesn’t exist as a package before you arrive

If you go to a doctor’s office for a planned visit, you usually know who you’re seeing and why you’re going. If your doctor orders a nonurgent lab test or imaging study, you may be able to choose where to have it done and compare costs first.

In the ER, the plan evolves. Abdominal pain may require only an examination. Or you may need blood work, medication, an ultrasound, or a CT scan. Then the CT shows something unexpected, and now you need another test, a specialist, surgery, observation, or admission to the hospital.

The first results often determine the next steps. That’s why it can be nearly impossible to price an entire ER visit at the beginning. Nobody knows the entire course of care yet.

Okay, but how much does the CT cost?

This seems like it should be easier, and sometimes the hospital can give you a price or estimate for the CT itself. But that’s often not the question you’re really asking. You’re asking, “How much will getting this CT add to what I owe?”

That answer may depend on your insurance and on how the hospital and radiologist bill for the study. There may also be contrast, medications, lab work, or other services involved. More importantly, I may know you need the CT. I may not know whether it will be the last test you need.

Suppose the CT shows appendicitis. Now the cost of the visit may include a surgeon, antibiotics, an operation, and a hospital stay. None of that was certain when you first asked what the CT would cost.

Some medical services can’t even be fully described until afterward. Critical care is one example. Billing for critical care depends partly on how much critical-care time was actually needed. A critically ill patient may improve quickly, or may need hours of treatment, repeated evaluation, review of tests, discussions with specialists, and arrangements for transfer. We can’t know all of that when the patient first arrives.

And just to clear up another misconception: you generally aren’t charged according to how many minutes you physically spend sitting in the ER. Critical-care time and your total time in the department are very different things.

Can cost change the medical plan?

Absolutely. Did you expect me to write that?

Doctors shouldn’t ignore cost. If there are several medically reasonable choices, cost can and should be part of the decision. Maybe a nonurgent test can safely be done later as an outpatient. Maybe we can avoid a test that is unlikely to change what we do. Sometimes we order one test first and only order another if the first result points us in that direction.

Prescriptions are another good example. Many electronic medical records can now show us whether your insurance covers a medication while we’re prescribing it. If the medication I picked isn’t covered but another medication should work just as well, I’ll usually switch it and tell you why. That’s not giving you worse care. That’s trying not to make you pay for something unnecessarily.

The same principle works in the other direction. Having excellent insurance doesn’t mean you should get extra tests just because someone else is paying the bill. The goal is medically appropriate care either way.

Cost can help us choose among safe options, but it can’t make an unsafe option safe.

Will my insurance cover this?

Now we’ve reached an even harder question. Your ER clinician usually doesn’t know exactly how your insurance company will process your claim.

“Covered” can mean a lot of things. Maybe the service is covered, but you haven’t met your deductible. Maybe you have a copay. Maybe coinsurance applies. Maybe there are different rules for emergency care. Maybe several different people or groups are involved in your care.

The No Surprises Act gives many patients important protections for emergency care. For health plans covered by the law, emergency services generally cannot require prior authorization simply because the care was out of network. The law also limits certain out-of-network charges and balance billing. But “protected by the No Surprises Act” does not mean “free.” You may still owe your normal in-network deductible, copay, or coinsurance.

So when someone tells you, “Your insurance covers emergency care,” that is not the same as saying, “Your insurance will pay the entire bill.”

What if I don’t have insurance?

This question deserves more than, “Don’t worry about it.” Of course you’re worried about it.

I’ve had uninsured patients ask me whether I’ll still see them, whether they’ll receive the same care, or whether I can limit the testing because they can’t afford a huge bill. I’ve also had patients tell me, “Just order the CT. I have fantastic insurance.” Neither should determine the standard of care.

Being uninsured doesn’t mean you should receive less medically necessary care. Having fantastic insurance doesn’t mean you should receive unnecessary care. The standard should be based on the medical problem.

Let’s use chest pain as an example. You come to the ER with chest pain and tell us you don’t have insurance. You still need an ECG. Depending on your symptoms and risk, you may need blood work and other testing. We need to evaluate the dangerous causes of chest pain whether you have an insurance card or not.

Let’s say the initial tests are reassuring. Great. The workup may stay fairly limited. But what if the ECG or blood work shows a heart attack? Now everything changes. You may need medications, a cardiologist, a heart catheterization, close monitoring, admission, or transfer to another hospital.

I couldn’t have told you what all of that would cost when you walked through the door because I couldn’t tell the future.

That uncertainty is also why the federal good-faith-estimate rules for uninsured or self-pay patients don’t require an estimate during emergency care. An estimate works much better when the care can actually be planned ahead of time.

We should still avoid unnecessary expense, and we should still choose a less expensive option when it is medically appropriate. But we shouldn’t withhold necessary emergency care simply because that care may be expensive. If cost is affecting your decisions, tell us. There may be another medically reasonable option. There also may not be.

Can’t the ER just pause and sort out the insurance first?

Not if doing so delays necessary emergency care.

EMTALA, the Emergency Medical Treatment and Labor Act, requires most hospital emergency departments to provide an appropriate medical screening examination regardless of whether a patient has insurance or can pay. If an emergency medical condition is found, the hospital also has obligations to provide stabilizing treatment or an appropriate transfer.

The hospital can ask about your insurance. What it can’t do is delay the required emergency evaluation or stabilizing treatment while it figures out how you’re going to pay.

That flips the usual way we buy things upside down. Normally, you find out the price and then decide whether to buy. In emergency medicine, we may have to figure out what you medically need before anyone can know what the final price will be.

I’m staying in the hospital. Why am I not “admitted”?

Welcome to observation status, one of the more confusing parts of hospital care.

You can stay overnight in a hospital bed, get IV medications, have repeat blood tests, and be cared for by hospital doctors and nurses while still being considered an outpatient. I know.

Observation is outpatient hospital care used when you need more evaluation or treatment, but it isn’t yet clear that you need an inpatient hospital admission. Observation wasn’t invented by the ER doctor or by someone in the hospital billing office who decided to change your status to save a few dollars. Medicare has long treated observation as outpatient care, and other insurers have their own rules about which hospital stays qualify for inpatient payment.

In 2013, Medicare added what is commonly called the “Two-Midnight Rule” to help clarify when an inpatient admission is generally appropriate for Medicare payment. It did not create observation. Observation was already being used, and long observation stays were actually one of the problems Medicare was trying to address.

Who decides whether I’m observation or inpatient?

There isn’t one person making every part of that decision. Your clinicians decide what medical care you need and enter the appropriate orders. The hospital also has utilization-review staff who look at whether the planned care and documentation support the patient’s status under the applicable rules. Then your insurer applies its own coverage and payment rules.

Those decisions are related, but they aren’t the same decision. Your doctor can tell you why you need to stay in the hospital. Your doctor usually cannot promise exactly how your insurance company will pay for that stay.

Is observation just the cheaper version of admission?

That’s a common explanation, but it’s too simple.

Observation generally applies when a patient needs hospital care but does not meet, or is not expected to meet, the payer’s standard for inpatient care. Hospitals have a financial reason to get that status right. If a hospital bills for an inpatient admission and the insurer decides that inpatient care wasn’t supported, the insurer may not pay the claim as billed.

Yes, hospitals are trying to avoid providing care they won’t be paid for. But matching the billing status to the expected level of care isn’t necessarily bad for the patient either. Billing for a higher level of care does not help you if your insurer later decides that level of care wasn’t covered.

That still does not mean observation will always cost you less. Inpatient and outpatient benefits are different. Your deductible, copays, medications, and other benefits may be handled differently. For some patients, observation can actually result in a higher out-of-pocket cost.

“Observation is a lower billing status” does not necessarily mean “observation will cost me less.”

Can I just stay in the ER instead?

The location of your bed doesn’t determine whether your care is considered observation. Observation services can even be provided while you are physically still in the emergency department. It’s the type of care and your hospital status that matter, not whether you have moved upstairs yet.

Who can tell me what observation will cost?

Probably not your ER doctor. Depending on the hospital, utilization management, case management, financial counselors, billing staff, or your insurance company may be able to help. Even then, they may only be able to give you an estimate while your care is still changing.

Will insurance refuse to pay if I leave against medical advice?

This is a very common belief. There is no evidence that insurance companies routinely deny an ER or hospital claim simply because a patient leaves against medical advice. Medicare generally covers medically necessary care provided before the patient leaves, and research examining this question found no claims denied because the patient left AMA.

That doesn’t mean every claim will be covered. Insurance can deny claims for all sorts of other reasons. But “If you leave AMA, your insurance won’t pay” is not a reason someone should use to scare you into staying.

If cost is the reason you’re thinking about leaving, tell your clinician. There may be a medically reasonable alternative worth discussing.

I can’t afford the ambulance transfer

That’s a legitimate concern. Unfortunately, ambulance billing is another area where the sending doctor usually can’t tell you what you’ll owe.

The price can depend on the ambulance service, distance, level of transport, insurance plan, network status, state law, and how the claim is processed. Ground ambulances are also an important exception to the federal No Surprises Act. In general, ground ambulance services do not have the same federal surprise-billing protections as many other emergency services, although some states have additional protections.

If you receive a large ambulance bill, don’t automatically assume that the amount on the first piece of paper is definitely your final responsibility. Billing and insurance arrangements vary. It may be worth contacting both the ambulance company and your insurer before paying a bill you don’t understand.

But there is another question your emergency physician can help answer: Do I medically need an ambulance?

You may need heart monitoring, oxygen, IV medication, treatment during the trip, or the ability to respond quickly if your condition gets worse. In those situations, riding in a private car is not medically the same thing as being transported by an ambulance.

When we say, “I don’t know what the ambulance will cost,” we are not saying, “I don’t care what the ambulance will cost.” We don’t want to bankrupt people. We also don’t want someone seriously harmed because we pretended two medically different options were equivalent.

Again, cost can be part of the decision. It can’t make an unsafe option safe.

What can the ER actually help me decide?

Your clinician may not be able to tell you exactly what you’ll owe, but that doesn’t mean there is no useful conversation to have. We can usually discuss why a test is being recommended, what we’re looking for, what might happen if the test isn’t done, whether there are medically reasonable alternatives, whether a test can safely wait, whether hospital care is necessary, whether transfer is necessary, whether ambulance transport is medically necessary, and whether cost can reasonably influence the choice among available options.

And it’s okay to tell us that cost matters. If you’re thinking about refusing a medication, CT scan, hospital stay, transfer, or ambulance because you’re worried about the bill, say so. Sometimes there is another safe option. Sometimes there isn’t. But we can’t have that conversation if we don’t know that cost is affecting your decision.

“Is there a less expensive medically reasonable option?” is often a question your doctor can help answer. “Exactly how much is all of this going to cost me?” may not be.

That’s frustrating. Healthcare pricing really is complicated, and our tools for giving patients useful real-time cost information could be much better. You’re completely reasonable for wanting to know what emergency care will cost, but when your clinician says, “I’m sorry, I don’t know,” they aren’t necessarily being evasive. Sometimes we simply don’t know what the rest of your care will be yet.