As a conservation biologist, Caitlin Wells Salerno knows that some mammals — like the golden-mantled ground squirrels she studies in the Rocky Mountains — invest an insane amount of resources in their young. That didn't prepare her for the resources she would owe after the birth of her second son.
Wells Salerno went into labor on the eve of her due date, in the early weeks of coronavirus lockdowns in April 2020. She and her husband, Jon Salerno, were instructed to go through the emergency room doors at Poudre Valley Hospital in Fort Collins, Colo., because it was the only entrance open.
Despite the weird vibe of the pandemic era — the emptiness, the quiet — everything went smoothly. Wells Salerno felt well enough to decline the help of a nurse who offered to wheel her to the labor and delivery department. She even took a selfie, smiling as she entered the delivery room.
"I was just thrilled that he was here and it was on his due date, so we didn't have to have an induction," she says. "I was doing great."
Gus was born a healthy 10 pounds after about nine hours of labor, and the family went home the next morning.
Wells Salerno expected the bill for Gus' birth to be heftier than the $30 she'd been billed four years earlier for the delivery of her first child, Hank. She'd been a postdoctoral fellow in California, with top-notch insurance, when Hank was born. They were braced to pay more for Gus' delivery — but how much more?
Then the bill came.
The patient: Caitlin Wells Salerno, a conservation biologist at Colorado State University and a principal investigator at Rocky Mountain Biological Laboratory. She is insured by Anthem Blue Cross Blue Shield through her job.
Medical service: A routine vaginal delivery of a full-term infant.
Total bill: $16,221.26. The Anthem BCBS negotiated rate was $14,550. Insurance paid $10,940.91 and the family paid the remaining $3,609.09 to the hospital.
What gives: In a system that has evolved to bill for anything and everything, a quick exam to evaluate labor in a small triage room can generate substantial charges.
The total bill was huge, but what really made Wells Salerno's eyes pop was the $2,755 charge for "Level 5" emergency services included in that total. It didn't make any sense.
Emergency room visits are coded from Level 1 to Level 5, with each higher level garnering more generous reimbursement, in theory commensurate with the work required. Dr. Renee Hsia, a professor of emergency medicine and health policy at the University of California, San Francisco and a practicing ER doctor, says Level 5 charges are supposed to be reserved for serious cases — "a severe threat to life or very complicated, resource-intense cases" — not for patients who can walk through a hospital on their own.
So, why did Wells Salerno's bill include a "Level 5" charge? Was it for checking in at the ER desk, as she'd been instructed to do? She recalls merely going through security in the ER on her way to labor and delivery, but she seemed to have been charged as though she'd received care there — like a patient with a heart attack or someone fresh from a car wreck. That ER charge was the biggest item on the bill, other than the charge for the delivery itself.
Over the past 20 years, hospitals and doctors have learned there's great profit in upcoding visits. After all, the insurer isn't in the exam room to know what transpired. An investigation by the Center for Public Integrity found that between 2001 and 2008 the number of Level 4 and 5 visits for patients who were sent home from the ER nearly doubled to almost 50% of visits. In Colorado, the Center for Improving Value in Health Care looked at emergency visit billing from 2009 to 2016 and found that the percentage of emergency visits coded as Level 5 steadily grew from 23% to 34% for patients who have commercial insurance.
After repeated calls in which she questioned the line item on her bill, Wells Salerno eventually got a voicemail from the billing department, which she shared with us. The person who left the voicemail explained that "the emergency room charge is actually the OB triage little area — before they take you to the labor and delivery room."
A customer service representative later explained the charge was for services given there when a nurse placed an IV for antibiotics, and her doctor checked her dilation and confirmed her water had broken — although none of that was actually performed in the Emergency Department. And those services, performed before every delivery, are traditionally not billed separately — and are routine, not emergency, procedures.
Some hospitals provide that package of services via an "obstetrical emergency department." OB-EDs are licensed under the main Emergency Department and typically see patients who are pregnant, for anything from unexplained bleeding to full-term birth. They bill like an ER, even if they aren't physically located anywhere near the ER.
TeamHealth — a health care staffing company owned by the investment company Blackstone, and known for marking up ER bills to boost profit — essentially says an OB-ED can be as simple as a rebranded obstetrical triage area. In a white paper, the company says an OB-ED is an "entrepreneurial approach to strengthening hospital finances," because with "little to no structural investment" it allows hospitals to "collect facility charges that are otherwise lost in the obstetrical triage setting."
The OB Hospitalist Group, which is owned by a private equity company, markets a tool to help OB-EDs calculate levels of emergency care. In a case study, OB Hospitalist Group reported that hospitals "leave a lot of money on the table" by billing OB-ED visits as Level 1 and 2 emergencies when they could be considered Level 4 emergencies.
An Arizona facility said its revenue increased $365,000 per quarter after turning its obstetric triage area into an OB-ED. Poudre Valley Hospital's website doesn't list "OB-ED" as part of the facility's offerings, though UCHealth documents do reference OB-ED beds in other facilities.
KHN spoke with four other women who, after giving birth at Poudre Valley in 2020 and 2021, received ER charges on their bills after healthy births. They had no clue they had received emergency services. One wrote a warning note on Facebook to other moms in the area after getting a whopping charge — for the 10 minutes she spent in the triage room, while fully dilated and in active labor.
In Wells Salerno's case, UCHealth and her insurer have an agreement that Anthem BCBS pays a lump sum for vaginal delivery, rather than paying for line items individually. "Being seen there in OB-ED did not impact this bill whatsoever," says Dan Weaver, a spokesperson with UCHealth.
But in one of the other moms' cases, it did make a difference: The hospital received $1,500 from the insurer for that charge, and the mom was on the hook for an additional $375 for coinsurance.
Ge Bai, a professor of accounting and health policy at Johns Hopkins University, says it's a "questionable" billing practice and one that can matter to those who don't have the same kind of insurance as Wells Salerno — and to those who have no insurance at all.
Dr. Mark Simon, chief medical officer with OB Hospitalist Group, says OB-EDs can help women avoid being admitted to the hospital too early in labor, ensuring timelier, more appropriate care.
UCHealth's Weaver says such departments can also help pregnant patients with actual emergencies like preterm labor, preeclampsia or vaginal bleeding get quick care from specialists available 24/7 — often without having to be admitted to the hospital. But at hospitals like Poudre Valley, healthy women having healthy births also get routine "OB-ED" treatment, without their knowledge.
Weaver says the only time someone in labor would not go through the OB-ED — and therefore the only time they would not receive the emergency charge — is if they have a scheduled induction or cesarean section or are directly admitted from a provider's office.
Hsia, the UCSF researcher and ER doctor, is unconvinced by Weaver's arguments that these sorts of charges benefit patients: "If they're actually going to charge a special fee that you didn't get directly admitted from your physician, that's absolutely ridiculous," Hsia says.
Wells Salerno's "OB-ED" exam was performed by her clinician, but the OB-ED charge still showed up on her bill.
Resolution: Wells Salerno eventually threw in the towel and paid the bill.
"I was at a very vulnerable time during pregnancy and immediately postpartum," she says. "I just felt like I had kind of been taken advantage of financially at a time when I couldn't muster the energy to fight back."
The fact that two healthy brothers could come into the world with such different overall price tags isn't surprising to Dr. Michelle Moniz. "There is no clinical reason that we have this level of variation," says Moniz, assistant professor of obstetrics and gynecology at the University of Michigan and its Institute for Healthcare Policy and Innovation. Her research shows that people with private insurance pay anywhere from nothing to $10,000 for childbirth.
"You don't get what you pay for," says Wells Salerno, who maintains that — despite the price difference in the cost of their deliveries — both of her children are equally "awesome."
The takeaway: Anything in our health system labeled as an emergency room service likely comes with a big additional charge.
Data from the Colorado Division of Insurance shows that Poudre Valley typically received about $12,000 for similar births in 2020 — about 43% more than the typical Colorado hospital. So the more than $14,000 Wells Salerno and her insurer paid is very high.
Expectant parents should be aware that OB-EDs are a relatively new feature at some hospitals. Ask whether your hospital has that kind of charge and how it will affect your bill. Ahead of time, ask both the hospital and your insurer how much the birth is expected to cost. In Colorado, the Center for Improving Value in Health Care offers a price comparison tool for common medical procedures, including vaginal delivery.
If you do require a genuine ER encounter, look at your bill to see how it was coded, Levels 1 to 5 — and protest if your visit was misrepresented. Ask "Has this bill been upcoded?" You are the only one who knows how much time you spent with a medical provider and how much care was given and where. Here's a chart that will help with the proper definition of each level.
Know that victory is possible. At least one mom won the battle and got the emergency charge removed from her Poudre Valley Hospital birth bill. To make that happen she had to put in hours on the phone with UCHealth, have a lot of confidence and had to emphasize to everyone she spoke with that an emergency charge for a routine delivery just didn't — and doesn't — make sense.
Bill of the Month is a crowdsourced investigation by NPR and Kaiser Health News that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!