The care was normal. A hospital in Modesto, California treated a 30-year-old man for shoulder and back pain after a car accident. He went home in less than three hours.
The bill was exceptional. The Sutter Health Memorial Medical Center charged $ 44,914, including a $ 8,928 fee for the “trauma alert,” which was billed for calling in the hospital’s top surgical specialists and usually associated with the most serious patients is brought.
The case, buried in the files of a 2017 trial, is a rare example of a judicial challenge to something that billing advisors believe is becoming increasingly common in US hospitals.
Tens of thousands of times a year, hospitals charge enormously expensive trauma alert fees for injuries that are so small that the patient is never admitted.
In Florida alone, where the number of trauma centers has skyrocketed, hospitals charged such fees more than 13,000 times in 2019 despite the patient going home the same day, according to a KHN analysis of state data by Etienne Pracht, an economist at the University of South Florida . These cases accounted for more than a quarter of all trauma team activations in the state that year and were more than twice as many as in 2014, according to a full-payer hospital claims database maintained by the Florida Agency for Health Care Administration.
While false positives are likely, such frequent charges for little or no treatment suggest that some hospitals are viewing the warnings as a clinical emergency tool like a donor, claims advisors say.
“Some hospitals use it as a source of income,” said Tami Rockholt, a registered nurse and medical claims advisor who acted as an expert in Sutter Health’s auto accident process, in an interview. “This is being exploited” and such cases are “much more common” than a few years ago, she said.
Hospitals may charge trauma activation fees when a top group of doctors and nurses gather after an ambulance crew says they are approaching a patient in need of trauma care. The idea is that life-threatening injuries need immediate treatment and that designated trauma centers should be able to cover the cost of providing a team – even if it never goes into action.
These fees, which can exceed $ 50,000 per patient, are billed in addition to hospital fees for emergency medical care.
“We’re seeing quite a lot of unreasonable accident costs – more than five years ago,” said Pat Palmer, co-founder of Beacon Healthcare Costs Illuminated, which analyzes thousands of bills for insurers and patients. Recently, “we saw a charge for trauma activation when the patient walked into the emergency room,” and walked out shortly after, she said.
The percentage of Florida trauma activation cases without admission increased from 22% in 2012 to 27% last year, according to the data. At one Florida facility, Broward Health Medical Center, there were 1,285 cases of non-admission trauma activations in 2019 – almost the number that resulted in admissions.
“Trauma warnings are activated by the emergency services [first responders with emergency medical services], not hospitals, and we respond accordingly when EMS activates a trauma alarm from the field, ”said Jennifer Smith, a spokeswoman for Broward Health.
Florida regulations allow hospitals themselves to declare an “in-hospital trauma alarm” for “patients not identified locally as trauma alarm” according to standards published by the Florida Department of Health.
In some hospitals, few patients whose cases trigger trauma alerts are treated and discharged the same day.
At Regions Hospital, a Level I trauma center in St. Paul, Minnesota, patients who are not admitted after being alerted to the trauma team are “very rare” – 42 of 828 cases last year, or about 5%, said Dr. Michael McGonigal. the center’s director who blogs on “The Trauma Pro”.
“If you charge an activation fee for all of these people going home, it will ultimately be a red flag for Medicare and insurers,” he said.
In the Sutter case in Modesto, the patient sued a driver who had hit his vehicle and demanded compensation from the driver and her insurance company. The patient “looks good,” wrote an emergency doctor in the files that were part of the study evidence. He prescribed Tylenol with hydrocodone for pain.
“If someone doesn’t bleed to death, or their heart doesn’t stop, or they don’t stop breathing in the next 30 minutes, they probably don’t need a trauma team,” Rockholt said in her testimony.
Like other California trauma center designation hospitals, the Sutter Health Memorial Medical Center follows “county-set criteria” to declare activation, Sutter spokeswoman Liz Madison said: “The goal is to be able to deliver trauma cases at all times treat – including those events where it is determined that a patient is healthy enough to be treated and discharged on the same day. “
Trauma centers regularly review and revise their rules for activating trauma teams, said Dr. Martin Schreiber, head of trauma at Oregon Health & Science University and chairman of the board of the Trauma Center Association of America, an industry group.
“I don’t get the impression that trauma centers use activations to make money,” he said. “Unnecessary patient activation is not seen as acceptable in the trauma community.”
Hospitals began billing trauma team fees to insurers of all types in 2008 after being approved by Medicare in 2008 for cases where hospitals are notified of serious injuries before a patient arrives. Instead of leaving the alarms of the trauma team to the paramedics, hospitals often call for trauma activations themselves based on information from the practice, say trauma surgeons.
The reimbursement of trauma activations is complicated. Insurers don’t always pay the hospital trauma fee. According to rules established by Medicare and a committee of insurers and health care providers, emergency rooms after a trauma alarm must provide 30 minutes of critical care in order to be paid to activate the team. For inpatients, the trauma team fee is sometimes pooled with other fees, billing advisors say.
But overall, the increase in the level and frequency of activation fees for trauma teams, including those not admitted, has helped transform trauma surgeries, which used to be a financial burden, into profit centers. In the past few years, hundreds of hospitals have applied for a trauma center designation, which is required for billing a trauma activation fee.
“There must have been a consultant who went around the country and said, ‘Hey hospitals, why don’t you start calculating this because you can,'” said Marc Chapman, founder of Chapman Consulting, the high hospital bills for auto questions insurers and other payers. “In many of these cases, patients are never admitted.”
The national number of Level I and II trauma centers capable of treating the most severely injured patients rose from 305 in 2008 to 567 last year, according to the American College of Surgeons. Hundreds of other hospitals have Level III or IV trauma centers that treat less severe injuries and may also charge for trauma team activation, albeit often at lower prices.
Emergency surgeons say there is a fine line between being too careful and activating a team unnecessarily (known as “overtriage”) and putting patients at risk by failing to call a team when serious injuries are not apparent.
“We often don’t know if patients are seriously injured in the field,” said Dr. Craig Newgard, professor of emergency medicine at Oregon Health & Science University. “The EMS providers use the best information they have.”
Too many seriously injured patients are still not getting the care they need from trauma centers and teams, argues Newgard.
“We’re trying to get the most benefit from a systems perspective for the greatest number of people possible because it’s basically impossible to get the triage right every time,” he said. “They are going to take some patients to large trauma centers who don’t end up with serious injuries. And it gets a little more expensive. But the compromise is to optimize survival. “
At Oregon Health & Science, 24% of patients treated under trauma alerts for 12 months through spring this year were not enrolled, Schreiber said.
“If that number gets much lower, you could put patients who need activation at risk if they aren’t activated,” he said.
On the other hand, the increasing number of trauma centers and fees increase health costs. The levies are borne by higher insurance premiums and expenses not only by the health insurers, but also by the car insurers, who often pay the care of an accident victim first.
Audits are rare and often the system is geared towards paying claims with little or no control, say billing specialists. Legal challenges, as in the Sutter case, are extremely rare.
“Most of these insurers, especially auto insurers, don’t look at the bill,” said Beth Morgan, CEO of Medical Bill Detectives, a consultancy that helps insurers contest hospital charges. “You pay for it automatically.”
And trauma activation charges can also hit patients directly.
“Sometimes the insurance companies don’t pay. So people could get stuck on that bill, ”Morgan said.
A few years ago, the Zuckerberg San Francisco General Hospital charged a family fee of $ 15,666 to a toddler who fell out of a hotel bed. He was fine. Treatment consisted of a bottle of formula and a nap. The hospital waived the fee after KHN and Vox wrote about it.
Trauma alert fatigue can add up to a non-financial cost to the trauma team themselves, McGonigal said.
“Every time that pager goes off, you peel a lot of people off their jobs just to see it [patients] Go home an hour or two later, ”he said.
“Some trauma centers have problems because they have ragged themselves. And there is likely to be unnecessary spending on all of the resources required to evaluate and manage these patients. “
What the levels of the trauma center mean