emergency doctor visit cost

• An emergency room visit typically is covered by health insurance. For patients covered by health insurance, out-of-pocket cost for an emergency room visit typically consists of a copay, usually $50-$150 or more, which often is waived if the patient is admitted to the hospital. Depending on the plan, costs might include coinsurance of 10% to 50%.
• For patients without health insurance, an emergency room visit typically costs from $150-$3,000 or more, depending on the severity of the condition and what diagnostic tests and treatment are performed. In some cases, especially where critical care is required and/or a procedure or surgery is performed, the cost could reach $20,000 or more. For example, at Park Nicollet Methodist Hospital in Minnesota, a low-level emergency room visit, such as for a minor laceration, a skin rash or a minor viral infection, costs about $150 ; a moderate-level visit, such as for a urinary tract infection with fever or a head injury without neurological symptoms, about $400 ; and a high-level visit, such as for chest pains that require multiple diagnostic tests or treatments, or severe burns or ingestion of a toxic substance, about $1,000, not including the doctor fees. At Dartmouth-Hitchcock Medical Center[ 1 ] , a low-level emergency room visit costs about $220, including hospital charge and doctor fee, with the uninsured discount, while a moderate-level visit costs about $610 and a high-level visit about $1,400 .
• Services, diagnostic tests and laboratory fees add to the final bill. For example, Wooster Community Hospital, in Ohio, charges about $170 for a simple suture, $200 for a complex suture, about $170 for a minor procedure and about $400 for a major procedure, not including doctor fees, medicine or supplies.
• A doctor fee could add hundreds or thousands of dollars to the final cost. For example, at Grand Lake Health System[ 2 ] in Ohio, an emergency room doctor charges about $100 for basic care, such as a wound recheck or simple laceration repair; about $300 for mid-level care, such as treatment of a simple fracture; about $870 for advanced-level care, such as frequent monitoring of vital signs and ordering multiple diagnostic tests, administering sedation or a blood transfusion for a seriously injured or ill patient; and about $1,450 for critical care, such as major trauma care or major burn care that could include chest tube insertion and management of IV medications and ventilator for a patient with a complex, life-threatening condition. At the Kettering Health Network, in Ohio, a low-level visit costs about $350, a high-level visit costs about $2,000 and critical care costs almost $1,700 for the first hour and $460 for each additional half hour; ER procedures or surgeries cost $460-$2,300 .
• According to the U.S. Agency for Healthcare Research and Quality[ 3 ] the average emergency room expense in 2008 was $1,265 .
• According to the U.S. Centers for Disease Control and Prevention, in 2008, about 18%of emergency room patients waited less than 15 minutes to see a doctor, about 37%waited 15 minutes to an hour, about 15% waited one to two hours, about 5% waited two to three hours, about 2% waited three to four hours, and about 1.5% waited four to six hours.
• In some cases, the doctor might recommend the patient be admitted to the hospital. The American College of Emergency Physicians Foundation offers a guide[ 4 ] on what to expect.
• An ambulance ride typically costs $400-$1,200 or more, depending on the location and services performed.
• An urgent care center offers substantial savings for more minor ailments. DukeHealth.org offers a guide[ 5 ] on when to seek urgent care. An urgent care visit typically costs between 20% and 50% of the cost of an emergency room visit. MainStreetMedica.com offers a cost-comparison tool for common ailments.
• Hospitals often offer discounts of up to 50% or more for self-pay/uninsured emergency room patients. For example, Ventura County Medical Center[ 6 ] in California offers ER visits, including the doctor fee and emergency room fee but not including lab tests, X-rays or procedures, for $150 for patients up to 200% of the federal poverty level, for $225 for patients between 200% and 500% of the federal poverty level and $350 for patients from 500% to 700% of the federal poverty level.
• The American College of Emergency Physicians Foundation offers a primer[ 7 ] on when to go to the emergency room.
• In most cases, it is recommended to go to the nearest emergency room. The U.S. Department of Health and Human Services offers a hospital-comparison tool[ 8 ] that lists hospitals near a chosen zip code.
•   patients.dartmouth-hitchcock.org/billing_questions/out_of_pocket_estimator_dhmc.ht...
•   www.grandlakehealth.org/index.php?option=com_content&view=article&id=106&Itemid=60
•   meps.ahrq.gov/mepsweb/data_stats/tables_compendia_hh_interactive.jsp?_SERVICE=MEPS...
•   www.EmergencyCareforYou.org/VitalCareMagazine/ER101/Default.aspx?id=1288
•   www.dukehealth.org/health_library/health_articles/wheretogo
•   resources.vchca.org/documents/SELF%20PAY%20DISCOUNT%20GRID%20-%20BOARD%20LETTER%20...
•   www.EmergencyCareforYou.org/YourHealth/AboutEmergencies/Default.aspx?id=26018
•   www.medicare.gov/hospitalcompare/(S(efntd2saaeir2l5pgarwuvvg))/search.aspx?AspxAut...

Know where to go: How to choose between the doctor’s office, urgent care and the ER

When you’re feeling sick or are injured, there are several places you can go for medical care: a doctor’s office, an urgent care center, a retail health clinic or the emergency room. Here’s a quick guide to help you know where to go, based on the urgency of your ailment and your budget. BCBS members can can visit the Blue Cross Blue Shield Provider Finder  to find in-network providers. This includes doctors, dentists, hospitals, urgent care centers, and more. You can also log into your local BCBS company's site . 

The Doctor’s Office Is Your First Option for Non-Emergencies

Your primary care doctor should be your first call in non-emergency situations. Your doctor knows you and your health history, including what medications you are taking and what chronic conditions might need to be considered in your treatment. Plus, the co-pay for a visit to your doctor’s office will cost far less than a trip to the emergency room. This option can also help you avoid the long wait times typically found in an emergency room. Even if your doctor is unavailable or not an expert in the area of care you need, he or she can refer you to a specialist or another medical professional.

If you don’t have a primary care doctor, take some time to review the options in your network and select one. If you are a BCBS member, you can use the Blue Cross Blue Shield Provider Finder  to help your research. You can also read our  tips on how to choose a doctor that’s right for you .

Urgent Care Centers and Retail Health Clinics Offer Affordable Alternatives

If you can’t reach your doctor or need care outside of regular office hours, urgent care centers and retail health clinics are good options. Retail health clinics are walk-in clinics found in many large pharmacies and retail stores. They are staffed by nurse practitioners and physician assistants and are designed to treat simple conditions, like cold and flu, ear infections and skin conditions. Urgent care centers have physicians on staff and can provide care for a greater range of conditions, including performing x-rays.

In most cases, the out-of-pocket cost for visiting a retail health clinic or urgent care center will cost less than a trip to the emergency room, but it’s always a good idea to check to make sure the location you select is covered by your plan. BCBS members can use the Blue Cross Blue Shield Provider Finder  to locate in-network facilities. You can find a list of the urgent care centers in your network on your Blue Cross Blue Shield (BCBS) company’s website , or by calling the 1-800 number on the back of your member ID card.

24-Hour Nurse Lines Provide Phone Consultations

Many BCBS companies also offer a 24-hour nurse line , which you can call any time with questions about your symptoms, complications from medication or advice on when to go to the doctor or emergency room. Check the back of your member ID card or your local BCBS company’s website for more information.

Emergency Rooms Treat Serious Issues

Emergency rooms are designed to treat urgent, acute and life threatening conditions and aren’t the place for routine care or minor ailments. If you feel you are dealing with a health emergency, call 911 or go to the emergency room right away. Otherwise, one of the above options will save you time and money, and clear the way for patients in need of emergency treatment. BCBS members can use the Blue Cross Blue Shield Provider Finder  to find nearby emergency rooms. 

The Blue Cross Blue Shield Association is an association of 35 independent, locally operated Blue Cross and/or Blue Shield companies.

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Health Care

Why an er visit can cost so much — even for those with health insurance.

Terry Gross

Vox reporter Sarah Kliff spent over a year reading thousands of ER bills and investigating the reasons behind the costs, including hidden fees, overpriced supplies and out-of-network doctors.

TERRY GROSS, HOST:

This is FRESH AIR. I'm Terry Gross. You wouldn't believe what some emergency rooms charge, or maybe you would because you've gotten bills. For example, one hospital charged $76 for Bacitracin antibacterial ointment. One woman who fell and cut her ear and was given an ice pack but no other treatment was billed $5,751. My guest, Sarah Kliff, is a health policy journalist at vox.com who spent over a year investigating why ER bills are so high even with health insurance and why the charges vary so widely from one hospital to the next.

Through crowdsourcing, she collected over a thousand ER bills from around the country. She interviewed many of the patients and the people behind the billing. She's reported her findings in a series of articles on Vox. She's also spent years reporting on the battle over health insurance policy. We'll get some updates on the state of Obamacare a little later in the interview.

Sarah Kliff, welcome back to FRESH AIR. Why did you want to do an investigation into emergency room billing?

SARAH KLIFF: You know, I wanted to do this because the emergency room is such a common place where Americans interact with the health care system. There are about 140 million ER visits each year. It's a place where you can't really shop for health care. You can't make a lot of decisions about where you want to go. So I think that is big-picture what got me interested.

Small picture was actually a bill that someone sent me almost three years ago now, where they took their daughter to the emergency room. A Band-Aid was put on the daughter's finger, and they left. And they got a $629 bill. And they said - you know, they - the parents sent this to me, saying, how could a Band-Aid cost $629? And I said, I don't know, but I'm going to find out. And that kind of opened up the door to this, you know, multi-year project I've been working on right now. It started with trying to figure out why a Band-Aid would cost $629.

GROSS: OK. So let's get to that $629 for treatment that was basically a Band-Aid placed on a finger. You investigated that bill.

KLIFF: Yes.

GROSS: Why'd it cost so much?

KLIFF: So what cost so much was really the facility fee. So this is a charge I hadn't heard about before as a health care reporter. This is a charge that hospitals make for just keeping their doors open, keeping the lights on, the cost of running an emergency room 24/7. So if you look at that particular patient's bill, the Band-Aid - you know, I hesitate to say only - but the Band-Aid only cost $7, which, as anyone who's bought Band-Aids knows, is quite expensive for a single Band-Aid.

But the other $622 of that bill were the hospital's facility fees for just walking in the door and seeking service. And these fees are not made public. They vary wildly from one hospital to another. And usually patients only find out what the facility fee of their hospital is when they receive the bill afterwards, like that patient, you know, that sent me this particular bill.

GROSS: And does the facility fee vary from facility to facility?

KLIFF: It does significantly. You know, I've seen some that are in the low hundreds. I've seen some that are in the high thousands. And it's impossible to know what facility fee you're going to be charged until you actually get the billing documents from your hospital. And if you try and call up a hospital and ask what the facility fee is, usually you won't get very far.

So it's this fee that, from all the ER bills I've read, is usually the biggest line item on the bill. But it's also one that is very, very difficult to get good information about until you've already been charged.

GROSS: So you're paying the facility fee to basically share in the cost of running the emergency room.

KLIFF: Yes, that's how hospital executives would describe the fee.

GROSS: But you don't know that when you're going to the emergency room.

KLIFF: You don't, no. And you don't know how much it'll be. You don't know how it's being split up between different patients. You don't know any of that.

GROSS: So is this also why one bill had $60 for the treatment of ibuprofen and another $238 for the treatment of eyedrops?

KLIFF: Yeah. And, you know, this is something I see all the time reading emergency bills - I've read about 1,500 of them at this point - is that things you could buy in a drugstore often cost significantly more in the emergency room. And the people I talked to who run hospitals will say this is because they have to be open all the time. They have to have so many supplies ready.

But I think one of the things that I find pretty frustrating is, you know, patients aren't usually told, we can give you an ibuprofen here, or you can pick some up at the drugstore if you leave, and the cost will be a fraction of what we would charge you here. That information often isn't conveyed to patients who are well enough, you know, to go to a drugstore on their own. But it's just huge variation for these simple items.

One place I see this a lot is pregnancy tests. If you're a woman who's of childbearing age, you go to the emergency room, they will often want to check if you're pregnant. I've seen pregnancy tests that cost a few dollars in emergency room. The most expensive one I saw was over $400. I believe that was at a hospital in Texas. It's just widespread variation for, you know, some pretty simple pieces of medical equipment.

GROSS: I want to get back to the $60 ibuprofen. Is that - does that include the facility fee? Or is that just for the ibuprofen, and the facility fee is separate?

KLIFF: That's just for the ibuprofen. The facility fee is totally separate.

GROSS: So how do they justify that?

KLIFF: They say they have to stock, like, a wide array of medicine, so they have to have everything on hand from ibuprofen, from, you know, expensive rabies treatments - I've talked to a lot of people who've been to the emergency room for exposure to bats and raccoons - and that they need to have all these things in stock. And, you know, one of the things you pay for at the emergency room is the ability to get any medication at any hour of the day right when you need it. I don't necessarily buy that explanation, to be clear. That's what I've heard from hospital executives.

I think it's pretty telling that ibuprofen has a very, very different price depending on which emergency room you go to. The fact that there's so much widespread price variation suggests to me that it's not just the cost of doing business driving it, that there's also business decisions being made behind ibuprofen that are driving the prices different hospitals are setting.

GROSS: Now, of course, trips to the emergency room aren't always as simple as getting a Band-Aid or ibuprofen or some eyedrops. I want you to describe the case of a young man who was hit by a pole on a city bus in San Francisco.

KLIFF: Yeah. So this patient, his name is Justin. He was a community college student in northern California, was walking down a sidewalk in downtown San Francisco one day. And there was a pole hanging off the back of the bus that wasn't where it's supposed to be. It essentially flew off the back of the bus, hit him in the face and knocked him unconscious.

And the next thing he knows, he's waking up at Zuckerberg San Francisco General, which is the only Level I trauma center in the city. He ends up needing a CT scan to check out some brain injuries. He needs some stitches. And then he's discharged. He ends up with a bill for $27,000.

But, you know, as I began figuring out through my reporting, San Francisco General does not contract with private insurance, and they end up pursuing him for the vast majority of that bill. He has $27,000 outstanding. And somewhat ironically, San Francisco General, it is the city hospital. It is run by the city of San Francisco. So this student is hit by a city bus, taken by an ambulance to the city hospital and ends up with a $27,000 bill as a result.

GROSS: So did he have insurance?

KLIFF: He did. He had insurance through his dad.

GROSS: So why doesn't Zuckerberg San Francisco General Hospital contract with private insurers?

KLIFF: So what they have told me when I've talked to some spokespeople there is that they are a safety net hospital, and that is, you know, definitely true. They generally serve a lower-income, often indigent population in San Francisco that would have trouble getting admitted and seeking care at other hospitals in the city. So they have told me that their focus is on serving those patients and that therefore, you know, they're not going to contract with private insurance companies.

The thing I found a little bit confusing about that, though, is there are lots of public hospitals, say, that, you know, also serve low-income populations. And some of them for their inpatient units, you know, for their scheduled surgeries, they're not going to contract with private insurance because they want to make sure beds are available for the publicly insured folks and people on Medicaid and Medicare.

But when it comes to the emergency room, you know, every other public hospital I was in touch with would contract with private insurers there because people don't decide if they're going to end up in the emergency room. So, you know, that's the justification they offered, that it is a hospital meant to serve those with public insurance. But it is not something you see public hospitals typically doing.

GROSS: Isn't - I think legislation was proposed in California to change that. Did that pass?

KLIFF: It's still pending in the California State Assembly. And the hospital has also promised to reform its billing practices, although we haven't seen what exactly their new plan is yet.

GROSS: So the position that Justin was in is that, like, he's unconscious. He's not asking to be taken anyplace. (Laughter) But he's unconscious. He's taken to the emergency room and ends up getting this $27,000 bill. I mean, that just seems so unfair, especially since he has insurance.

KLIFF: Yeah.

GROSS: Like, it's supposed to cover him for things like that (laughter).

KLIFF: Yeah. You know, there's one other patient who kind of makes this point really well who was also seen at San Francisco General. Her name is Nelly. And she fell off a climbing wall and, somewhat amazingly, you know, turns out she had a concussion. But one of the first things she does is she calls her insurance's nursing hotline to ask, should I go to the ER?

And they say yes. And she says, can I go to Zuckerberg San Francisco General? It's the closest. They say, no, don't go there. It's not in network. Go to another hospital. She gets to the other hospital, but the other hospital won't see her because she's a trauma patient. She fell from a really high height. And San Francisco General is the only trauma center in San Francisco. So she tries to go to an in-network hospital. She's then ambulance-transferred to Zuckerberg San Francisco General, and she ends up with another bill over $20,000 that the hospital was pursuing from her until I started asking questions from it, and the hospital ultimately dropped the bill.

But I think it's just such a frustrating situation for someone like Justin, for someone like Nellie (ph). They're either shopping for this good unconscious, they're really trying to do the right thing, and the health care system is just so stacked against the patient. It's so stacked for the hospital to be able to bill the prices that they want to bill.

GROSS: So apparently, the moral of the story is if you want to challenge your emergency room bill, you should get Sarah Kliff to write about you. (Laughter).

KLIFF: It's - (laughter). That's what some people have said. But there's only one of me, and there's about 2,000 bills in our database. And, you know, we have had over $100,000 in bills reversed as a result of our series. But I don't think it's a great way to run a health care system where we just, you know, the people who get their bills reversed are those who are lucky enough to have a reporter write a story about them.

GROSS: Yes. Agreed. Let me reintroduce you. If you're just joining us, my guest is Sarah Kliff. She's a senior policy correspondent at Vox, where she focuses on health policy. She also hosts the Vox podcast, "The Impact," about how policy actually affects people.

So we're going to take a short break, and then we'll talk more about emergency billing. And then later, we'll talk about what's left of Obamacare, and what the president and Congress and candidates are saying about health care, after this break. This is FRESH AIR.

(SOUNDBITE OF ALEXANDRE DESPLAT'S "SPY MEETING")

GROSS: This is FRESH AIR. And if you're just joining us, my guest is Sarah Kliff. We're talking about emergency room billing and why it's so unpredictable and often so incredibly high. She's a senior policy correspondent at Vox, where she focuses on health policy. She also hosts the Vox podcast, "The Impact," about how policy affects people.

So we were talking about the hidden facility fee, which most people don't know exists, and is responsible for a large chunk of a lot of emergency room bills. There's also, like, a trauma unit fee. It's a similar hidden fee in hospitals that have trauma centers in their emergency rooms. So explain the trauma fee and how that kicks in.

KLIFF: Yeah. This is something I also had never heard of till I started reading a lot of emergency room bills, and this is the fee that trauma centers charge for essentially assembling a trauma team to meet you when you're coming in and those folks out in the field, maybe the EMTs, for example, have determined that you meet certain trauma criteria.

So I've talked to people who have been charged trauma fees who were in serious car accidents. One case was a baby who fell from more than 3 feet, and that's considered to trigger a trauma activation. So this is essentially the price for having a robust trauma team - a surgeon, an anesthesiologist, nurses - all at the ready to receive you when you get to the hospital.

And again, these fees can be pretty hefty. San Francisco General, which, I've done the most reporting on their billing, you know, they can charge up to $18,000 for their trauma activation services. I wrote about one family who was visiting San Francisco from Korea when their young son rolled out of the hotel bed. They were nervous. They didn't know the American health care system well. So they called 911, which sent an ambulance, brought him over to the hospital. Turns out, he was fine. They gave him a bottle of formula. He took a nap and went home.

And then a few months later, they get an $18,000 charge for the trauma team that assembled for when that baby came to the hospital. And these are another, you know, pretty significant fee that, again, you don't really know about. You have no idea that the trauma team is assembling to meet you when you're coming into the hospital. You just find out after the fact. And you also have no say in the decision to assemble trauma. That's really left up to the hospital, not the patient.

GROSS: So I'm going to have you compare two possibilities. You go to an emergency room, and the bill is very high. There's two people who have the same problem who go to the emergency room. One of them has a copay. One of them has a high deductible that they haven't paid off yet. How are they treated differently, in terms of what they're billed for the emergency room visit?

KLIFF: Well, the person with the deductible will likely be billed significantly more. You know, if they're just, let's say, at the start of the year, they are going to essentially have to bear the costs of that emergency room visit up until the point they hit their deductible and the insurance kicks in, whereas the person who has a co-payment, they're just going to have to pay that flat fee and, you know, probably not worry about paying more, but there's often surprise bills lurking in the corner that could affect both of those patients as well.

GROSS: Like what?

KLIFF: So one of the most common things we see is out-of-network doctors working at in-network emergency rooms. So you know, you have an emergency, you look up a hospital, you see their ER is in network, so you go there. It turns out that emergency room is staffed by doctors who aren't in your insurance. There's pretty compelling academic research that suggests 1 in 5 emergency room visits involves a surprise bill like that one.

GROSS: That seems so unfair. How are you to know - if you're choosing a hospital that's in network, how are you to know whether the doctor treating you is in network or not?

KLIFF: You know, you really - there isn't a great way to tell, to be honest. This is - you know, when I had to go to the emergency room over the summer, you know, this is something I worried about. You know, I was seeing a doctor who worked for the hospital, but they were sending off my ultrasound to be read by a radiologist who I was never going to meet. I couldn't ask them if they were in-network. I just kind of had to cross my fingers and hope for the best, and luckily, I didn't get a surprise bill.

But I've talked to multiple patients who, you know, tried to do their research, who thought they were in network, only to get a bill, often for thousands of dollars, after leaving the emergency room, from someone who, you know, never mentioned to them, hey, I'm not in your network like this hospital is.

GROSS: So the bill that you'd get would be for the difference between what you pay when somebody is - when a doctor's in network and what you pay when they're not in network?

KLIFF: Yeah, often it's just what that out-of-network doctor wants to charge. So a good example of this is a patient I wrote about in Texas named Scott (ph), who was attacked in downtown Austin, left on the street unconscious, some bystander called him an ambulance, and he woke up at a hospital. And one of the first things he does, because this is the United States, is he gets on his phone and tries to figure out which hospital he is at, and, you know, is that in his insurance network? And he finds out - good news - it is. And a surgeon comes by, tells him he's going to need emergency jaw surgery because of the attack that happened.

So he says, OK. You know, he's not really in a place to go anywhere. Gets the surgery. Goes home. A few weeks later, he gets an $8,000 bill from that oral surgeon, who the insurance companies paid a smaller amount. The oral surgeon didn't have a contract with the insurance and said, you know, I think my services are worth a lot more, so pursued the balance of the bill from Scott.

GROSS: I have to say, I mean, that does seem unfair to the patient because they haven't been informed. They can't make a choice about it if they don't know. And, like, $8,000 is a lot of money.

KLIFF: Yeah. And I think, you know, even more, let's say he did say he was out of network. It kind of puts the patient in an unfair situation, too. You know, one of the things we talk about a lot in health policy is, what if we had more transparency? What if we let patients know the prices? What if we let patients know who is in and out of network? And that - it would be a good step.

But, you know, I think with someone like Scott, sitting in a hospital with a broken jaw, there's not much you can do with that information. He doesn't have, you know, the ability to go home, like, research, like, make an appointment with a new surgeon. So, you know, it'd be great if he knew that the doctor was out of network. It'd be even better if he had some kind of protections against those type of bills.

GROSS: What kind of protection could there be?

KLIFF: So we're actually seeing a lot of action on this in Congress. There's some pretty strong bipartisan support for tackling this specific issue and essentially holding the patient harmless. When there is a situation like Scott's, for example, where there's this $8,000 bill, that's really a dispute between a health insurance company and a doctor, where the doctor says, I want more money, the insurer says, I want to pay you less money. And what Congress wants to do - what a few states have already done with their laws - is said, you can't go to the patient for that money. You, the hospital, and you, the health insurance company, you have to get down to a table and work things out together.

And some state laws will set certain amounts that are allowed to be charged, other ones will force the insurance company and the hospital into an arbitration process. But the general concept is to take the patient out of this billing situation because, like you said, Terry, they really aren't in a position to negotiate. They aren't in a position to shop. They shouldn't be the ones who are left holding the bag at the end of the day.

GROSS: My guest is Sarah Kliff. She covers health policy for Vox. After a break, we'll talk more about why ER bills can have some unpleasant surprises, and she'll give us an update on Obamacare. And Maureen Corrigan will review two books about forgotten stories from Hollywood. I'm Terry Gross, and this is FRESH AIR.

(SOUNDBITE OF JESSICA WILLIAMS TRIO'S "KRISTEN")

GROSS: This is FRESH AIR. I'm Terry Gross. Let's get back to my interview with journalist Sarah Kliff, who covers health policy and how it affects people for Vox. For the past year and a half, she's been writing about why emergency room visits can be so expensive and the pricing so secretive and mysterious, as well as inconsistent from one hospital to the next. She collected over 1,000 bills and tracked down stories behind the billing. She interviewed many of the patients and the people behind the billing to decipher why ER bills can have some surprise costs.

Here's another surprise that often awaits people who go to emergency rooms - some insurance plans only cover true emergencies, and whether it is a true emergency is sometimes determined after the diagnosis is made. So how are you supposed to know before the diagnosis whether you're going to be categorized as a true emergency or not? Like, if you go to the hospital, you don't know if you have a broken bone or not.

KLIFF: Right.

GROSS: Somebody needs to X-ray it and tell you.

KLIFF: Right. The whole point you go to the emergency room is to help them figure out what the emergency is and what treatment you need. This is a policy that the insurance company Anthem has been pioneering for a few years. It's been in Kentucky. It's been in Georgia - a few other states. And, you know, I wrote about one patient out in Kentucky named Brittany, who - she was having really severe abdominal pain. She called her mom who is a nurse, and the nurse said, that might be appendicitis. You've got to get to the emergency room. Turns out it wasn't appendicitis. It was an ovarian cyst. She got it treated elsewhere later down the line.

And Anthem, you know, sent her a letter saying, we're not going to cover that visit because it was not a true emergency. She appealed it. Her appeal was denied. This is another one where, once I started asking them about it, the bill suddenly disappeared. But - and it seems like as Anthem has gotten more attention for this policy - they haven't announced it publicly, but some pretty compelling data The New York Times got their hands on suggest they've backed off this policy.

But it's just, you know - there are so many traps you can fall into going into an emergency room. It just feels like you're walking into this minefield, and this is kind of one of those mines that's lurking in there.

GROSS: Hospital pricing and emergency room pricing seems to vary so much from hospital to hospital. Are there, like, national guidelines that help determine what a hospital or a hospital emergency room charges for services? I mean, who decides, and why is there such a variation?

KLIFF: So hospital executives get to decide, and I think that is why there is such variation. There aren't really guidelines that they're following. You know, one thing you could do as a hospital executive - you could look at what Medicare charges - those prices are public - and, you know, maybe use that as a benchmark. There are some databases. There's one called FAIR Health, for example, where you could look and see, you know, some information on what local prices typically are. But in terms of, you know, what you want to charge, that's kind of up to you as someone running a hospital.

One of the things that's really, really unique about the United States, compared to our peer countries, is that we don't regulate health care prices. Nearly every other country in the developed world - they see health care something as, you know, akin to a utility that everyone needs, like electricity or water. It's so important that the government is going to step in and regulate the prices. That doesn't happen in the United States. You know, if you're a hospital, you just choose your prices. And, you know, that is, I think, why you see so much variation and why you see some really high prices in American health care.

GROSS: So what advice do you have for people who actually need an emergency room and don't want to get hit with a shocking bill afterwards?

KLIFF: Yeah, this is, you know, one of those questions - it just makes me a little frustrated that - 'cause this is the most common question I get - right? - is, how do I - how do we - how do I prevent a surprise bill? And I find it kind of upsetting that, you know, it has to be on the patient because honestly, there really isn't a great way to do this. I've talked to so many patients who tried so hard to avoid a big medical bill and weren't able to.

You know, there's certain things, yes, you can do. You can look up the network status of your hospital. You can try and badger each doctor you see about whether they are in network. You can try to be a really proactive patient, but I think that's just such a huge burden on people who are in, like, really emergent situations. And some people don't have that opportunity, you know, like Justin Zanders, the guy we were talking about earlier who was taken to a hospital while he was unconscious. I cannot think of anything he could've done to avoid that bill. It just was not possible.

GROSS: So your advice is, good luck.

KLIFF: Short of that, I mean, good luck. You know, I'm actually in the middle of reporting a story right now about people who have successfully negotiated down their bills. And, you know, you can certainly - if you do end up with a surprise bill, you can call up the hospital, see if there's a discount. Sometimes there will be. Sometimes there won't. You can call again. Customer service representatives - different ones - often offer you different discounts, I've learned from interviewing patients. You can ask for a prompt pay discount if you pay right away.

You can - you know, one health attorney who negotiates these a lot on behalf of patients - he says one of his favorite tactics is to choose the amount you want to pay; send a check with that amount; and in the note, write, paid in full; and hope they don't come after you after that. I have no idea if that works or not, but he says it works for his patients. But it's a mixed bag. And at the end of the day, the hospital has all the power. You can ask for discounts. You can ask nicely. You can ask angrily. It's up to the hospital if they want to grant you that or not.

GROSS: So what is the status of Obamacare now? You know, Republicans promised to repeal and replace. That didn't work out. So have Republicans given up on repeal and replace?

KLIFF: For the time, it seems pretty clear that repeal and replace is dead on arrival, especially with Democrats taking control of the House this year. Those proposals aren't being talked about as much. They're not really going anywhere. The one big thing we did see Republicans succeed at is repealing Obamacare's individual mandate, the requirement that all of us carry health insurance. That happened as part of the big tax package that passed at the end of 2017.

So we've seen, you know, President Trump, for example, essentially declare victory, declare that repealing the individual mandate is repealing Obamacare, so we're good on that goal. But, you know, generally, Obamacare is still standing. There are millions of people getting their coverage through the Affordable Care Act still today.

GROSS: So now that there's no individual mandate, conservative attorney generals are challenging Obamacare - the Affordable Care Act - and saying it's no longer constitutional after Congress's repeal of the individual mandate. Could you explain that?

KLIFF: Yeah, so this is a challenge that's come up through the courts in the past few months. Obamacare is constantly being challenged in court. It's been through multiple Supreme Court suits. This one - you know, it's a multiple-part argument, so I'll try my best to walk through it.

KLIFF: So essentially, it starts with the fact that the individual mandate - they weren't quite able to repeal it for boring technical reasons. But what they were able to do is change the fee for not having health insurance from $700 to $0. So it - in all practical terms, it feels like repealing it because there is no fee for not carrying health insurance. The individual mandate was upheld as a tax when the Supreme Court said, yes, this is constitutional. The government has a right to tax people. Now that there is no fee associated with not carrying health insurance, the conservative attorneys general who are bringing this case argue that it's not a tax anymore, and therefore, it is not constitutional. That whole defense that John Roberts wrote in 2012 is moot. So that's the first part of it.

They go even further and say the individual mandate is so core to the Affordable Care Act, it is not severable. And if you, the courts, rule the individual mandate unconstitutional, then you need to rule all of Obamacare unconstitutional. And the first judge who heard this case - he is a, you know, judge in a district court in Texas. He agreed with them. He agreed that - first step - that the individual mandate is no longer constitutional. And second step, that means that the entirety of Obamacare has to fall. This is now being appealed up to the 5th Circuit Court of Appeals.

And I will say there are a lot of critics of this case. There are a lot of people who were parties to previous Supreme Court challenges to Obamacare who think this is a bad legal argument and that it will not succeed. But it is already, you know, gone through the district court level. It's moving up to the appellate court level. It is something that is in the mix that could become a threat to the Affordable Care Act.

GROSS: Well, if it goes to the Supreme Court, it would be very interesting to see what Justice Roberts says since he voted for the ACA, saying that the individual mandate was a tax.

KLIFF: Yeah. You know, and I think where some legal scholars would see it shaking out is that the - someone like John Roberts, he might agree, OK, yeah, the individual mandate is unconstitutional, but would not make the leap to the second half of this, that the rest of the law has to fall.

I think one of the most compelling arguments against this case is that Congress knew what they were doing when they repealed the individual mandate. You know, they had the opportunity to repeal Obamacare. They didn't. They'd specifically took aim at this one specific part. So it feels like it might be a bit of a reach to argue that what Congress really meant to do was repeal all these other parts of the Affordable Care Act. But, you know, the Supreme Court is changing. We have a new justice. You know, we have a lot in the mix. So it's always an open question of how a decision like this could go.

GROSS: So correct me if I'm wrong here - the Department of Justice has sided with the conservative attorneys general who are challenging Obamacare, saying it's no longer constitutional, and I think that the Justice Department is also asking the judge to strike down the ACA's mandatory coverage of pre-existing conditions.

KLIFF: Yeah, that's right. So it's a kind of unusual situation. Usually, it's the Justice Department that is going to defend a federal law in court. But, you know, given the Trump administration's opposition to the Affordable Care Act, they have decided to side with the conservative attorneys general. They have a slightly different argument. They don't think all of Obamacare should fall if the mandate falls, but they do think some big parts, like you mentioned, the protections for pre-existing conditions, should be ruled unconstitutional if the mandate falls.

So this has led to a bit of an unusual situation where you've had this coalition of Democratic attorneys general step in and take over the case, basically saying that the federal government is going - is not going to defend the Affordable Care Act. We are going to defend the Affordable Care Act. So you have this coalition of Democratic attorneys general, led by the attorney general of California, stepping in and, you know, offering a defense as this case works its way up through the court system.

GROSS: Let's take a short break here, and then we'll talk some more. If you're just joining us, my guest is Sarah Kliff. She's senior policy correspondent at Vox, where she focuses on health policy. And she hosts the Vox podcast "The Impact," about how policy actually affects people. We'll be right back. This is FRESH AIR.

(SOUNDBITE OF THE WEE TRIO'S "LOLA")

GROSS: This is FRESH AIR. And if you're just joining us, my guest is Sarah Kliff, senior policy correspondent at Vox, where she focuses on health policy.

Do you think health insurance is shaping up to be a big issue in the 2020 campaign?

KLIFF: I do, and I think it's going to be a big issue both in the primary, where you're already seeing candidates get pressed on, should we still have private health insurance, and giving pretty different answers to that question.

And then I think one of the things you're also going to see is whoever is the Democratic nominee is probably going to run on Obamacare. They are going to point at the fact that President Trump tried to repeal the Affordable Care Act. That's pretty different than, you know, the 2012 election, where Democrats were pretty scared to run on Obamacare. It still wasn't popular. The benefits hadn't rolled out. In this past midterm and now again in the 2020 election, it seems pretty clear that Democrats are pretty excited to point out that Republicans wanted to repeal Obamacare. So I think it really will come up.

GROSS: What are some of the biggest falsehoods you've heard from politicians about health insurance costs or health insurance policy?

KLIFF: You know, one of the ones that's come up a lot is actually around the role of private health insurance. So I've - I don't know if it counts as a falsehood, but I think it's a bit of a misunderstanding of how health insurance often works is, you know, when I talk to single-payer supporters, most of them want to eliminate private insurance completely. They just don't think there is a role for it in the health care system.

And one of the things I think that's actually pretty interesting, when you look at any other country - you look at Canada, you look at the U.K., you look at France, which all have national health care systems - all of them have a private health insurance market, too. There are always some kind of gap in the system that the public insurance can't cover, where the government step - where the private industry steps in and offers coverage. In Canada, for example, their public health plan doesn't cover prescription drugs, so two-thirds of Canadians take out a private plan, often through their employer, like us, to cover prescription drugs, to cover their eyeglasses, to cover their dental. So I think that's a confusion I see a lot in the "Medicare for All" debate coming up right now.

I think the other thing I see a lot of confusion around - and we've talked about this a little bit with emergency room billing - is the role of transparency in health care. I see a lot of, you know, if we just made the prices public, like, that is what we need to do to fix the system, and I think that really misses the fact that, even if the prices were public, health care is so different from everything else we shop for. It might be - I think it is the only thing we purchase when we are unconscious.

GROSS: (Laughter).

KLIFF: And when you're unconscious, you're not really going to be great at price shopping. So I see that as, you know, a halfway solution that I often hear talked about here in Washington that would be great but is not going to suddenly result in, you know, prices dropping because they've been exposed in a spotlight.

GROSS: Is there a country that you think has a good health care model that we could borrow?

KLIFF: Oh, yeah. I've been thinking about this a lot lately actually. So I've gotten very interested in the Australia health care system, which is a little far away. But I think they're a really interesting model because they have a public system, everyone's enrolled in it, but they also really aggressively try and get people to buy a private plan, too, and that private plan will get you sometimes faster access to doctors, maybe a private room at a hospital.

It's really hard for me to see the U.S. creating a health care system, similar to Canada's actually, where you can't buy private insurance, where if you're rich or you're poor, everyone waits in the exact same queue, you can't jump to the front of the line. Because I think wealthier Americans have gotten so used to having really good access to health care that they would be very upset with a system like that.

I think Australia is a kind of interesting hybrid between, you know, where we're at in the U.S. right now and what Canada is like, where it says, yes, we're going to create a public system for everybody, but we're also going to have these private plans that compete against the public system. So I've become increasingly, you know, interested in how Australia's system works. And they have - about 47 percent of Australians are buying a private plan to cover the same benefits that the public plan does.

GROSS: So it's not supplemental. It's instead of.

KLIFF: Right. So it's very different from Canada. So in Canada, you can buy complementary insurance, you know, to cover the benefits the public plan doesn't but the government expressly outlaws supplemental insurance. You know, like, what people buy here to cover the gaps in Medicare, that is not allowed. You cannot buy your way to the front of the line in Canada.

One of my favorite sayings about the Canadian health care system is from a doctor in a book I read about Canadian health care is they said, you know, we're fine waiting in lines for health care in Canada as long as the rich people and the poor people have to wait in the exact same line. Their system is all about equality. And I just don't know that we're at a place as a country where we value the same sort of equality in our health care system.

GROSS: Is there any developed country around the world that has a system similar to ours with all these competing insurance companies and, you know, some government plans and, like, a thousand different bureaucracies that doctors have to deal with and that patients have to deal with?

KLIFF: Absolutely not. There's nothing like it. I mean, our system is so unique. I'd say the closest but it's not even close are a few countries that have national health care systems, but they do it through tightly regulated private health insurance plans. So if you look at, like, Netherlands or Israel, there isn't a government-run plan. Instead, in both countries, you actually have four tightly regulated health insurance plans that compete against each other for the citizens' business. I guess that's the closest, but that is so different from what we have here right now. There's really nothing like it in any developed country.

GROSS: Sarah Kliff, thank you so much for talking with us.

KLIFF: Well, thank you for having me.

GROSS: Sarah Kliff covers health policy for Vox, where you'll find her series about emergency room bills. After we take a short break, Maureen Corrigan will review two books about forgotten stories from Hollywood. This is FRESH AIR.

(SOUNDBITE OF GEORGE FENTON AND PHILHARMONIC ORCHESTRA'S "MISS SHEPHERD'S WALTZ")

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Emergency Room Visit: When to Go, What to Expect, Wait Times, and Cost

Knowing when and why to go for an emergency room visit can help you plan for care in the event of a medical emergency.

How much does it cost to go to an emergency room?

Emergency Room (ER) costs can vary greatly depending on what type of medical care you need. How much you pay for the visit depends on your health insurance plan. Most health plans may require you to pay something out-of-pocket for an emergency room visit. A visit to the ER may cost more if you have a High-Deductible Health Plan (HDHP) and you have not met your plan’s annual deductible. HDHP's typically offer lower monthly premiums and higher deductibles than traditional health plans. Your plan will start paying for eligible medical expenses once you’ve met the plan’s annual deductible. Here are some tips to pay less out of pocket .

When should I go to an emergency room?

Emergency rooms are often very busy because many people don’t know what type of care they need, so they immediately go to the ER when they are sick or hurt. You should make an emergency room visit for any condition that’s considered life-threatening.

Life-threatening conditions include, but are not limited to, things like a serious allergic reaction, trouble breathing or speaking, disorientation, a loss of consciousness, or any physical trauma.

If you need to be treated for problems that are considered non-life threatening, such as an earache, fever and flu symptoms, minor animal bites, mild asthma, or a mild urinary tract infection, consider seeing your doctor or visiting an urgent care center or convenience care clinic.

What is the cost of an emergency room visit without insurance?

Emergency room costs with or without health insurance can be very high. If you have health insurance, review your plan documents for details on the costs associated with your plan, including your plan deductible, coinsurance, and copay requirements.

If you don’t have insurance, you may be required to pay the full cost of your treatment, which can vary by facility and the type of treatment required. Always plan ahead for sudden sickness, injury, or other medical needs, so you know where to go and how much it could cost. If you need medical care, but it’s not life-threatening you may not have to go to the ER—there are other more affordable options:

• Urgent care center: Staffed by doctors, nurses, and other medical staff who can treat things like earaches, urinary tract infections, minor cuts, nausea, vomiting, etc. Wait times may be shorter and using an urgent care center could save you hundreds of dollars when compared to an ER.
• Convenience care clinic: Walk-in clinics are typically located in a pharmacy (CVS, Walgreens, etc.) or supermarket/retail store (Target, Walmart, etc.). These clinics are staffed with physician assistants and nurse practitioners who can provide care for minor cold, fever, flu, rashes and bruises, head lice, allergies, sinus/ear infections, urinary tract infections, even flu and shingles shots. No appointments are needed, wait times are usually minimal, and a convenience care clinic costs much less than an ER.

Plan ahead for when you need medical care. You may not need an emergency room visit and the bill that could come with it.

What are common emergency room wait times?

Emergency room wait times vary according to hospital and location. Patients in the ER are seen based on how serious their condition is. This means that the patients with life-threatening conditions are treated first, and those with non-life threatening conditions have to wait.

To help reduce ER wait times, health care facilities encourage you to plan ahead for care, so when you’re sick or hurt, you know if the ER is right for your medical condition.

An emergency room visit can take up time and money if your problem is not life-threatening. Consider other care options, such as an urgent care center, convenience care clinic, your doctor, or a virtual doctor visit (video chat/telehealth)—all of which could be faster and save you money out of your own pocket if the medical problem is non-life threatening.

If you have health insurance, be sure to check your plan documents to see what types of care options are eligible for coverage under your plan, including whether or not you need to stay in your plan’s network.

Is taking an ambulance to the emergency room free?

An ambulance ride is not free, but your insurance may cover some of the costs for the ride, as well as the emergency room visit. Check your plan benefits to see what out-of-pocket expenses you are responsible for when it comes to an ambulance ride and a visit to the ER.

Plan ahead for times you may need immediate medical care. Review the details of your health plan so you know the costs for an ER visit should you ever need it. Know when it’s best to go to the emergency room and when going somewhere else, like an urgent care center, convenience care clinic, your doctor, or even a virtual doctor visit (video chat/telehealth), is the right option that may save you time and money.

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Urgent care vs. emergency room visit cost

$150 – $250 average urgent care visit cost (without insurance), $1,500 – $3,000 average er visit cost (without insurance).

Emergency room vs. urgent care cost

The average urgent care visit costs $150 to $250 without insurance, while an emergency room visit costs $1,500 to $3,000 for the same service. While you should go to the ER for serious health concerns, visiting an urgent care center is the best choice for most non-life-threatening health issues.

What's the difference between urgent care and the emergency room?

Urgent care centers are meant for illnesses and injuries that are not life-threatening. These same-day clinics also provide other healthcare services, like routine physicals, imaging, and lab tests.

The emergency room is intended for critical, life-threatening situations that need immediate attention, such as a major injury, heart attack, stroke, or uncontrollable bleeding.

Cost comparison for common conditions

Many people go to the ER for health concerns that could be handled at an urgent care center for much cheaper. The cost of an urgent care visit is typically much less than the cost of an emergency room visit to treat the same ailment.

The table below shows the average costs for common conditions treated at an urgent care center or the ER.

If you have health insurance, your urgent care visit copay may be higher than your copay to see a primary care doctor but will likely be less than the out-of-pocket cost for an ER visit.

When to go to urgent care vs. the emergency room

Research shows 30% to 50%+ of emergency room patients could have been treated at an urgent care facility, often at a much lower cost. With healthcare prices constantly increasing, consider your options to make the best decision for your situation.

Call 9-1-1 or go to the ER for any serious, potentially life-threatening symptoms, such as:

Fever that does not resolve with over-the-counter medicine

Major broken bones

Trouble breathing

Serious head injury

Severe allergic reaction

Severe burn

Signs of a heart attack or stroke

Sudden severe pain

Sudden change in vision

Sudden confusion

Suddenly feeling weak or unable to move, speak, or walk

Uncontrollable bleeding

Consider an urgent care facility if you are experiencing a non-critical health issue and your primary doctor's office is closed or cannot fit you into the schedule. Urgent care centers can handle most non-emergency healthcare services, including:

Treatment for minor illnesses and injuries

Physicals needed for sports, school, or employment

Diagnostic lab testing

Medications

Medical equipment

Tips to save on urgent care and ER costs

No matter where you get treated, healthcare bills can add up quickly, even if you have insurance. Here are some guidelines to ensure you don't overpay for your care:

Assess your situation before heading straight to the ER. If your health issue is not life threatening, consider going to an urgent care center instead as the cost for the same services can be much lower.

If you do need emergency care, go to a hospital-based ER when possible. Freestanding ER centers typically cost more than hospital-based emergency rooms.

Call ahead to confirm the current wait time, costs, and payment options. Many urgent care centers require payment at the time of service.

Consider asking the following questions up front to prevent surprises in your bill:

Do you have discounted pricing for uninsured patients?

Do you work with any charitable organizations that could help with my costs?

Will this cost less if I pay with cash?

What will the cost be for my specific issue?

Do you think I will need lab tests or scans, and what will they cost?

How much do you charge for X-rays and imaging?

If I need medication, how much will it cost?

We use our proprietary database of project costs, personally contact industry experts to compile up-to-date pricing and insights, and conduct in-depth research to ensure accuracy in all our guides.

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Emergency department visits exceed affordability threshold for many consumers with private insurance

By Hope Schwartz Twitter ,  Matthew Rae Twitter ,  Gary Claxton ,  Dustin Cotliar,  Krutika Amin , and  Cynthia Cox Twitter

December 16, 2022

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Introduction

The high cost of emergency care may impact patients’ ability to afford treatment , with almost half of US adults reporting they have delayed care due to costs. Almost 1 in 10 Americans have medical debt , and about half of American households do not have the liquid assets to afford an average employer sponsored plan deductible. More than one third of US adults are unable to afford a $400 medical expense without borrowing.

Costs of medical emergencies present an additional financial burden on top of already costly health insurance premiums ranging $1,327 for single coverage and $6,106 for family coverage, on average, for workers with employer sponsored insurance. Variation in emergency department billing may make it difficult to predict the cost of an emergency department visit and subsequent financial liability. Recently, the No Surprises Act legislation aimed to curb unexpected emergency medical costs by prohibiting out-of-network billing for emergency services.

In this analysis, we use 2019 insurance claims data from the Merative MarketScan Commercial Database, which captures privately insured individuals with large employer health plans. We look at the total and out-of-pocket costs of emergency department visits for this group, overall and by diagnosis and severity level. We also look at which services contribute most to the costs of emergency department visits and examine regional variation in emergency department costs. Finally, we look at the demographic profile of consumers who visited the emergency department and the relationship between emergency department spending and annual spending for enrollees.

We find that enrollees spend $646 out-of-pocket, on average, for an emergency department visit. Enrollees with high annual health spending were more likely to visit the emergency department; the majority of enrollees in the top 10% of annual health care spending had at least one emergency department visit during the year. The most expensive components of most emergency department visits include evaluation and management charges, imaging, and laboratory studies, and facility fees make up 80% of the cost of visits. Cost varies by disease, visit complexity, and geographic region.

Large employer plan enrollees’ emergency department visits cost $2,453, on average, with enrollees responsible for $646 in out-of-pocket costs

On average, enrollees in large employer health plans who have an emergency department visit spend $646 out-of-pocket on the visit. There is significant variation in emergency department spending, with 25% of visits costing over $907 out-of-pocket and another quarter costing less than $128 out-of-pocket. These out-of-pocket costs for a single emergency department visit may be more than some people with private insurance can afford and, in some cases, could entirely deplete a consumer’s savings. For example, about 1-in-5 people (21%) with private insurance living in single-person households have less than $1,000 in liquid assets.

Related Content:

The burden of medical debt in the United States

Health Cost and Affordability Policy Issues and Trends to Watch in 2024

These amounts only include out-of-pocket spending required by the insurer. Before the No Surprises Act went into effect in January 2022, privately insured patients who visited the emergency department frequently had out-of-network claims on their visit, putting them at risk of providers sending them surprise balance bills. The No Surprises Act now prohibits most surprise out-of-network billing, but does not apply to ground ambulances . Any balance bill that a patient received from a provider would not appear in claims data and therefore would have been in addition to the out-of-pocket amounts shown here.

In total, enrollees and insurers paid $2,453, on average, per visit, with one quarter of visits costing $970 or less and another quarter costing $3,043 or more. All the costs described in this analysis are for the emergency department visits only, including professional services and facility fees, and do not include any spending on subsequent hospitalizations.

Facility fees contribute significantly more than professional fees to total visit cost

Emergency department bills are categorized as facility fees or professional fees. Professional fees are for services provided by clinicians, and facility fees include bills for services rendered using equipment owned by the facility, including laboratory or imaging studies. These fees are considered “overhead” for emergency departments and help facilities maintain appropriate staffing levels and technical resources. Evaluation and management charges also have a facility fee component for the equipment, staffing, and administrative resources used by the physician in their management. We find that facility fees make up 80% of total visit cost.

Evaluation and management charges make up the largest share of costs

Including both the professional fee and facility fee components of charges, the largest contributor to spending on a typical emergency department visit is the evaluation and management charge, which accounts for almost half (44%) of average visit costs. Evaluation and management charges are bills for the assessment of a patient that are not related to specific procedures or treatments provided; these services cost over $1,100 per visit, on average.

Imaging charges, including radiologist interpretation fees, make up an additional 19% of the average emergency department visit charge and cost $483, on average. The highest cost routinely performed imaging services include x-rays of the chest and CT scans of the head, chest, abdomen, and pelvis. Over half of visits (55%) include a charge for imaging services. About half of patients (49%) are charged for laboratory studies, including blood tests, which cost $230 on average. Other high cost but less common charges include surgical charges for patients with appendicitis and other conditions requiring surgery without inpatient admission, as well as ambulance charges for transport.

Heart attacks and appendicitis among the most expensive common conditions treated in the emergency department

Costs of emergency department visits depend on diagnosis. We selected nine common reasons to visit the emergency department that vary in complexity of management. More severe conditions, or those with more intervention required, are the most expensive. Of the nine specific diagnoses that we evaluated, the lower-cost diagnoses were those that generally do not require imaging or extensive treatment in the emergency department. These included upper respiratory tract infections ($1,535 total, $523 out-of-pocket), skin and soft tissue infections ($2,005 total, $572 out-of-pocket), and urinary tract infections ($2,726 total, $683 out-of-pocket). While these diagnoses can occasionally require admission to the hospital, in otherwise healthy adults they are typically evaluated with basic laboratory studies and discharged with prescriptions.

The most expensive emergency department diagnosis among those we examined is appendicitis, which, on average, costs $9,535 ($1,717 out-of-pocket) per visit. Appendicitis is almost two times as expensive as the next most expensive diagnosis we looked at, heart attack. 11% of enrollees with a diagnosis of appendicitis had surgical charges associated with their emergency department visit. Surgical costs may be included in emergency department outpatient billing because these patients are often discharged after surgery without being admitted to the hospital. In contrast, other emergency department visits requiring surgery are often admitted to the hospital and have surgical charges during their inpatient visit. Enrollees who had surgery had more expensive visits by over $2,000 compared to those who did not; however even without surgery, visits for appendicitis were almost four times as expensive as the average emergency department visit (and more than twice as expensive out-of-pocket).

Enrollees with emergency department visits have variable annual spending depending on diagnosis

In addition to the costs of the emergency department visit itself, enrollees who visit the emergency department at least once during the year have higher annual health care spending. Annual spending includes the cost of all claims for each patient in 2019, either before or after their emergency department visit. Though appendicitis was the most expensive emergency department visit among the diagnoses we analyzed, enrollees with appendicitis in 2019 incurred an average of $24,333 in additional health care spending, which was comparable to lower cost diagnoses. Enrollees with heart attacks had at least two times more annual spending than any other diagnosis ($52,993), while enrollees with upper respiratory tract infections had the lowest annual spending ($13,727).

These differences in annual costs may reflect spending both directly related and unrelated to the emergency department visit. For example, enrollees with heart attack emergency department visits may have high annual spending because of follow-up, medications, or hospitalizations after their heart attacks. However, their high annual spending may also reflect more comorbidities and higher healthcare utilization at baseline. In contrast, appendicitis, the most expensive emergency department visit, is correlated with relatively lower annual costs; unlike heart attacks, appendicitis often occurs in younger, healthier people and requires comparatively little additional post-surgical follow-up or treatment.

The most complex emergency visits are more than 6 times as expensive as the least expensive visits, but insurers pay an increasing share of the visit as complexity increases

Emergency department visits are coded by complexity during the billing process, from 1 (least complex) to 5 (most complex). Each evaluation and management charge is associated with a procedure code ranging from level 1 to level 5 (99281 to 99285), which are generated by hospital coding professionals based on the physicians’ medical note. Criteria are defined by the Centers for Medicare and Medicaid Services ( CMS ) and based on the complexity of documentation and medical decision making. Patients with level 1 complexity codes require straightforward medical decision making, with self-limited or minor presenting problems, such as rashes or medication refills. Patients with level 5 codes require high complexity medical decision making and present with life- or limb-threatening conditions, such as severe infections or cardiac arrests.

The lowest complexity visits cost $592 on average, with enrollees responsible for $205, or about one-third of the total visit cost. As visits increase in complexity, both out-of-pocket costs and costs covered by insurance increase. For the highest complexity visits, the health plan covers $3,015 on average, or eight times the cost of the lowest complexity visits. On average, patients pay $840 out-of-pocket for the highest complexity visits, which is four times their out-of-pocket costs for the lowest complexity visits.

Higher complexity visits are more expensive for multiple reasons. In general, evaluation and management charges are higher cost for more complex patients. Also, patients with more complex medical conditions generally receive more diagnostic tests, medication, and other treatment, which increases the cost of the visit. For the lowest complexity visits, evaluation and management charges account for almost half (47%) of the overall visit cost. In contrast, evaluation and management charges for the highest complexity visits account for about one-fourth (27%) of the total visit cost, with additional services including tests and treatment making up a larger share of the cost.

Emergency department costs vary by geographic region

We analyzed the top 20 metropolitan statistical areas (MSAs) by population, where data are available. Overall, the San Diego, CA area had the most expensive average ED visits ($3,761 on average). San Diego ED visits were more than twice as expensive as Baltimore, MD, the least expensive MSA in our analysis ($1,645 on average). Expensive MSAs were geographically distributed in all regions of the country including the South, West, Northeast, and Midwest. Within each MSA, there was significant variation in visit costa. For example, 25% of visits in Oakland, CA cost less than $1,236 on average, while 25% cost more than $4,436 on average.

Some variation may be based on the distribution of diagnoses in each area, with more serious or complex diagnoses leading to higher cost visits. For example, if a metro area sees higher than average volume of appendicitis, heart attacks, or other high-cost diagnoses, that would drive up regional emergency department costs.

For common diagnoses, Texas and Florida MSAs are among the most expensive

If we examine costs for specific diagnoses, we can minimize some of this variation in reasons for visits and gain a better understanding of how prices and service intensity affect the rankings. We selected two common, moderate-cost reasons for emergency department visits: low back pain and lower respiratory infections. While these visits can range in complexity and treatment required, they usually do not require hospital admission or high-cost treatment. Low back pain includes patients who present with the symptom of low back pain, regardless of diagnosis. Lower respiratory tract infection includes infectious causes of pneumonia and bronchitis. This analysis was limited to MSAs in which there were >500 cases of each diagnosis in 2019.

Visit costs for both diagnoses in Dallas, TX, Houston, TX, Fort Worth, TX, and Orlando, FL are in the top five most expensive MSAs with >500 cases. For low back pain visits, the Orlando, FL, Fort Worth, TX, Dallas, TX, and Houston, TX areas are each more than twice as expensive as the Warren, MI and Detroit, MI areas, on average. This trend is similar for lower respiratory tract infections. Within MSAs, variation in costs exist for both diagnoses. For example, for low back pain visits, there is more than a $3,000 difference between the least expensive and most expensive quarter of visits in Fort Worth, TX, Dallas, TX, and Houston, TX.

12% of large employer group enrollees went to the emergency department in 2019

We find that 12% of large group enrollees under age 65 had at least one emergency department visit in 2019, and of enrollees with emergency department visits, 80% had only one visit. 20% had more than one visit, and 7% had more than two visits. Emergency department visits were associated with higher annual health care spending, with almost half of enrollees in the top 25% of annual spending having at least one emergency department visit during the year.

We find that the average emergency department visit exceeds the threshold that some consumers can pay without borrowing, and even one emergency department visit in a year may create financial hardship for enrollees in large employer plans. For example, one quarter of emergency department visits for large employer enrollees cost over $907 out-of-pocket. Meanwhile, about 1-in-5 people with private insurance do not have $1,000 in liquid assets, and almost half of US adults report that they would not be able to pay a $500 medical bill without going into debt. Emergency department visits range significantly in cost depending on diagnosis, visit complexity, and geographic area. These variations may present challenges for consumers trying to predict the cost of their emergency department visit prior to going to the emergency department.

Several factors contribute to the variability of emergency department charges. First, unlike other forms of outpatient care including primary care or urgent care visits, emergency departments charge facility fees to offset the cost of keeping emergency departments open and staffed 24/7. These fees vary widely and are increasing at a faster rate than overall health care spending. The facility component represented 80% of total emergency department spending in our analysis. Many hospitals and health care providers consider these costs necessary given their mandate to provide emergency triage and treatment to allcomers. A second contributor to variation is that services are often billed at different complexity levels, and visits that are billed as more complex are more expensive . In some cases, even similar services are billed at different prices by different facilities. Notably, surprise out-of-network medical bills from emergency departments have contributed to high emergency costs for consumers, though the cost of any balance bills would be outside the scope of our claims data. The implementation of the No Surprises Act in January 2022 will generally curb surprise medical billing for emergency care.

As seen in non-emergency spending , we find that emergency department costs vary by geographic area. Among the most expensive MSAs in our analysis were MSAs located in Texas, Florida, California, Colorado, and New York. Interestingly, the most expensive regions for ED care do not align with the most expensive regions for overall health care spending. These comparisons suggest that our findings are not solely related to overall high health care prices in these areas and may reflect other factors including the age and medical complexity of the population or differences in local norms and practice patterns. State-level emergency department regulation may also play a role—states with higher numbers of freestanding , non-hospital affiliated emergency departments (which are associated with higher spending on emergency care) were among the most costly in our analysis.

The financial implications of visiting the emergency department vary widely. Not all the variation in total charges is reflected in out-of-pocket costs, since differences in cost by complexity level are smaller after insurance covers its portion of the bill. However, the most complex emergency department visits have four times higher out-of-pocket costs than the least complex visits. Even the least complex visits, some of which could be treated by a primary care office or urgent care center, cost an average of $205 out-of-pocket ($592 total). Given facility fees and relatively high evaluation and management charges in emergency departments, insurers and patients are paying more when receiving care for these conditions at emergency departments than they would using primary or urgent care. These lower complexity visits may represent a substantial avoidable cost to patients and the health care system at large.   

High health care costs are of foremost concern for US adults, leading people to skip recommended medical treatment or delay necessary care. Even in the era of new price transparency regulation , which aims to improve consumer access to prices for elective care, emergency department consumers often do not know what testing or treatment they will need, so it is difficult to assess the costs of a visit upfront. Further, in an emergency situation, patients may not be able to choose their provider or facility if they are brought in by ambulance or otherwise unable to direct their care. Lastly, lack of availability and standardization in data may make it difficult for patients to use price transparency data in real time to make decisions about accepting tests and treatment in an emergency. The high and variable cost of emergency department visits represents an opportunity for future policy changes to protect consumers from unaffordable medical bills.

This analysis is based on data from the Merative MarketScan Commercial Database, which contains claims information provided by a sample of large employer plans. Enrollees in MarketScan claims data were included if they were enrolled for 12 months. This analysis used claims for almost 14 million people representing about 17% of the 85 million people in large group market plans (employers with a thousand or more workers) from 2004-2019. To make MarketScan data representative of large group plans, weights were applied to match counts in the Current Population Survey for enrollees at firms of a thousand or more workers by sex, age, state, and whether the enrollee was a policy holder or dependent.

Emergency department visits were flagged if an enrollee had an emergency department evaluation and management claim in the emergency department or the hospital on a given day. If an enrollee had either an emergency evaluation and management claim or another claim originating in the emergency department on the day prior to or after the flagged day, we added the previous and or following day’s outpatient spending to the visit cost. This was to capture all emergency department services for visits that may have spanned overnight or multiple days. Over half (53%) of the spending in this analysis occurred in the emergency department, with another 42% occurring in the hospital, which may occur when a patient receives a test or procedure in a location outside the emergency department during their visit.

Claims were included if they were above $100 and below the 99.5 th percentile of cost. Selected conditions were generated from a literature review of common emergency department diagnoses and defined using ICD10 codes. Enrollees were considered to have a certain diagnosis if the relevant ICD10 code appeared in the “Diagnosis 1” column in one or more claims on an emergency department visit day. While emergency department claims have up to four diagnoses, diagnoses listed in 2-4 were not used to identify relevant conditions because these diagnoses were most often incidentally found rather than related to the reason for presenting to the emergency department. For specific diagnosis definitions: Heart attack includes acute STEMI and NSTEMI, and excludes complications from prior heart attacks or angina; UTI includes acute cystitis, UTI and pyelonephritis; Kidney stone includes renal calculus in any location and renal colic; Lower respiratory infection includes pneumonia and bronchitis. Surgical charges for acute appendicitis include both open and laparoscopic surgical charges. Annual spending was defined as the total spending for each enrollee in the year 2019, which could occur before and/or after their emergency department visit depending on the time of year of the emergency department visit.

This analysis has some limitations. First, there is a chance that we could incorrectly include non-emergency outpatient care (such as a next-day, follow up primary care appointment) in our estimate of emergency department visit costs. Secondly, when accounting for annual spending, we do not control for health status prior to the emergency department visit. Therefore, the increase in annual health spending for patients who visit the emergency department for certain conditions may be because these patients are sicker and higher healthcare utilizers at baseline, rather than specific follow-up costs incurred for the emergency department visit itself. For selecting relevant diagnoses, we only include claims in which a particular diagnosis occurs as the primary diagnosis. Third, the MarketScan database includes only charges incurred under the enrollees’ plan and do not include balance billing to enrollees which may have occurred. Lastly, our findings only represent enrollees in large group employer sponsored plans and may not be generalizable to other groups.

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Urgent care vs emergency room: What's the difference?

It’s Saturday, and the cold you’ve been nursing for the past few days seems to be getting worse. You’ve vomited once and have a fever. Should you head to a hospital emergency room or an urgent care clinic?

Learn more about our urgent care Learn more about our ER

If you’ve ever wondered whether to go to an ER or an urgent care clinic, you’re not alone. As physicians, we’re often asked by family, friends and patients if their symptoms warrant an ER visit, a trip to an urgent care clinic, a call to their primary care doctor or simply management at home.

If you are experiencing mild symptoms , such as mild aches and pains, a mild cough, etc., that could be caused by the flu, COVID-19, RSV  or hundreds of other viruses, consider “doing what your mom used to tell you” — rest, drink plenty of fluids, take over-the-counter medications like Tylenol, if needed, and monitor your symptoms.

If your symptoms don't improve over time, or if they worsen, calling your primary care physician  may be beneficial. Many primary care physicians are now offering virtual visits and can assess patients by a phone or video call fairly quickly.

However, if your symptoms are more severe and can’t wait for an appointment with your doctor, consider your other options for care.

Urgent Care

Unless a condition is life-threatening, a trip to urgent care is generally a better use of a patient’s time and resources to treat injuries, fevers, infections and other ailments.

Urgent care centers often have far shorter wait times than the ER and cost less than a traditional hospital emergency room visit. And many, like our UChicago Medicine Dearborn Station ,  UChicago Medicine Medical Group - Homewood  and UChicago Medicine River East  urgent care centers, offer convenient benefits such as walk-in appointments and on-site x-ray.

There are a variety of conditions treated at our urgent care centers , but common reasons to visit one include:

• If you are experiencing mild to moderate cold symptoms and not sure whether it is flu, COVID-19 or RSV.  
• If you have a sore throat and are concerned it is viral or strep throat.
• If your virus or cold symptoms developed into infections, like ear infections or pneumonia, and may require antibiotics.

Our urgent care clinics have board-certified physicians on staff who can test for and treat these conditions and much more. We treat both adult and pediatric  patients and are available 7 days a week, from 8 a.m. to 8 p.m. during weekdays and 8 a.m. to 4 p.m. on weekends and holidays.

If necessary, urgent care providers can also connect you with a higher level of care.

Emergency Room

You should call 911 or come right to the emergency room if you’re systemically sick. That’s when an illness affects your entire body, and you have severe pain or sudden onset of severe symptoms, a fever that won’t break, or “something doesn’t work,” like you’re unable to move an arm or leg or breathe normally. This includes:

• If a person has a severe injury or allergic reaction.
• If they pass out or experience any signs of a possible stroke or signs of a heart attack.

While you or the victim may have a hospital of choice, an emergency may warrant going to the nearest emergency location for immediate treatment. With their connection to hospitals for seamless admittance and advanced level of technology, ERs are the best place for actual emergencies.

Should you call 911 or go to the hospital emergency room?

The American College of Emergency Physicians (ACEP) has useful guidance on when to call 911, but common reasons include:

• The condition is life-threatening and requires attention as soon as possible. 
• You are unable to move yourself or the victim without causing harm or further damage.
• You are physically or emotionally unable to drive or be transported to a hospital ER. 

Urgent Aid for Lower-Level Emergencies

If you’re in the Southland, UChicago Medicine Ingalls Memorial offers an additional option to consider before heading to the ER. In our south suburban urgent aid centers , physicians provide ER-level care for lower-level emergencies — injuries, viruses and other illnesses — 24 hours a day, every day in an urgent care-like setting.

If a stable patient needs higher-level imaging such as an ultrasound or CT scan, urgent aids may be a better fit than an urgent care clinic.

The cost of an urgent aid visit is the same as the emergency department of Ingalls Memorial for the same level of care. The co-pay for emergency services will apply to your urgent aid visit, which may be higher than the co-pay for services provided by urgent care centers that are not part of a hospital’s emergency department.

Anwar Isabell, MD, is a UChicago Medicine Medical Group provider. UChicago Medicine Medical Group is comprised of UCM Care Network Medical Group, Inc. and Primary Healthcare Associates, S.C. UChicago Medicine Medical Group providers are not employees or agents of The University of Chicago Medical Center, The University of Chicago, or UChicago Medicine Ingalls Memorial.

Anwar Isabell, MD

Board-certified family medicine physician, Anwar Isabell, MD, specializes in care for the whole family.

Daniel Bickley, MD

Daniel Bickley, MD is the Interim Medical Director of the Adult Emergency Department at the University of Chicago Medicine.

Where Should I Go for Care Today?

You never know when a sudden injury or illness may happen. That's why it's so important to be prepared and know what steps you can take as soon as symptoms appear. Click below to learn more about the best times to visit primary care, urgent care or the emergency department.

When should I contact my primary care doctor?

Your regular doctor is the best person to call for minor health issues because they know your medical history.

When should I go to urgent care?

When you need care right away, but the illness or injury isn’t considered life-threatening, visit an urgent care clinic.

When should I seek emergency care?

If you have severe symptoms that could be life-threatening, call 911 or go to the emergency room right away.

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NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006 Feb-.

Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet].

Statistical brief #268 costs of emergency department visits in the united states, 2017.

Brian J. Moore , Ph.D. and Lan Liang , Ph.D.

Published: December 8, 2020 .

• Introduction

Emergency department (ED) visits have grown in the United States, with the rate of increase from 1996 to 2013 exceeding that for hospital inpatient care. 1 In 2017, 13.3 percent of the U.S. population incurred at least one expense for an ED visit. 2 Furthermore, more than 50 percent of hospital inpatient stays in 2017 included evidence of ED services prior to admission. 3 Trends in ED volume vary significantly by patient and hospital characteristics, but an examination of nationwide costs by these characteristics has not yet been explored in the literature. 4

This Healthcare Cost and Utilization Project (HCUP) Statistical Brief presents statistics on the cost of ED visits in the United States using the 2017 Nationwide Emergency Department Sample (NEDS). Total ED charges were converted to costs using HCUP Cost-to-Charge Ratios based on hospital accounting reports from the Centers for Medicare & Medicaid Services (CMS). ED visits include patients treated and released from the ED, as well as those admitted to the same hospital through the ED. Aggregate costs, average costs, and number of ED visits are presented by patient and hospital characteristics. Because of the large sample size of the NEDS data, small differences can be statistically significant. Thus, only percentage differences greater than or equal to 10 percent are discussed in the text.

• There were 144.8 million total emergency department (ED) visits in 2017 with aggregate ED costs totaling $76.3 billion (B).
• Aggregate ED costs were higher for females ($42.6B, 56 percent) than males ($33.7B, 44 percent); 55 percent of total ED visits were for females.
• Average cost per ED visit increased with age, from $290 for patients aged 17 years and younger to $690 for patients aged 65 years and older.
• As community-level income increased, shares of aggregate ED costs decreased and average cost per visit increased.
• In rural areas, one half of ED visit costs were for patients from the lowest income communities.
• The expected payer with the largest share of aggregate costs was private insurance in large metropolitan areas (31.4 percent of $39.5B) and Medicare in micropolitan (34.0 percent of $7.6B) and rural (37.3 percent of $5.5B) areas.
• Patients aged 18–44 years represented the largest share of aggregate ED costs in large metropolitan, small metropolitan, and micropolitan areas (36.4, 34.2, 32.5 percent, respectively). Patients aged 65 years and older represented the largest share of aggregate ED costs in rural areas (32.5 percent).

Aggregate costs for emergency department (ED) visits by patient sex and age group, 2017

Figure 1 presents aggregate ED visit costs by patient sex and age group in 2017 as well as number of ED visits. Estimates of aggregate cost use the product of the number of cases and the average estimated cost per visit to account for records with missing ED charge information. Aggregate cost decompositions among different descriptive statistics or using multiple levels of aggregation in a single computation could lead to slightly different total cost estimates due to the use of slightly different and more specific estimates of the missing information.

Aggregate ED visit costs by patient sex and age, 2017. Abbreviation: ED, emergency department Notes: Statistics for ED visits with missing or invalid patient characteristics are not presented. Patient age and sex were each missing for <0.1% of (more...)

• Aggregate ED visit costs in 2017 were higher overall for females than for males. Of the $76.3 billion in aggregate ED visit costs in 2017, females accounted for $42.6 billion (55.9 percent) and males accounted for $33.7 billion (44.1 percent). This cost differential was largely driven by a difference in ED visit volume, with females having a larger number of ED visits than males (80.2 vs. 64.6 million visits, or 55.4 vs. 44.6 percent of visits). Females had higher aggregate ED visit costs and more ED visits for all age groups except children. The discrepancy was highest for patients aged 18–44 years, with aggregate ED visit costs for females approximately 50 percent higher than costs for males ($15.9 vs. $10.7 billion), followed by patients aged 65 years and older, for which aggregate ED visit costs were approximately one-third higher for females than for males ($11.5 vs. $8.6 billion).

Costs of ED visits by patient characteristics, 2017

Table 1 presents the aggregate and average costs for ED visits, the number of ED visits, and the distributions of costs and visits, by select patient characteristics in 2017.

Aggregate costs, average costs, and number of ED visits by patient characteristics, 2017.

• In 2017, aggregate ED visit costs totaled $76.3 billion across 144.8 million ED visits, with an average cost per visit of $530. Aggregate ED visit costs totaled $76.3 billion in the United States in 2017, encompassing 144.8 million ED visits with an average cost per visit of $530. Routine discharge was the most frequent disposition from the ED, representing 80.8 percent of aggregate ED costs and a similar share of ED visits. Transfers represented 6.2 percent of aggregate ED costs but just 3.0 percent of ED visit volume because they had the highest average cost of any discharge disposition at $1,100 per ED visit. In contrast, ED visits resulting in an inpatient admission to the same hospital had the lowest average cost of any discharge disposition at $360 per ED visit and represented 9.4 percent of aggregate ED costs and 14.0 percent of ED visits.
• The share of aggregate ED visit costs attributed to patients aged 65 years and older was higher than the share of ED visits for this group, and the average cost per visit was highest among patients aged 65 years and older. Aggregate ED visit costs among patients aged 65 years and older totaled $20.2 billion (26.4 percent of the $76.3 billion total for the entire United States in 2017) despite just 29.2 million ED visits from patients in this age group (20.2 percent of the 144.8 million total). Conversely, the share of aggregate ED costs attributed to patients aged 17 years and younger was substantially lower than this group’s corresponding share of ED visits (10.3 percent of ED costs vs.18.5 percent of ED visits). This differential is due in part to the difference in average cost per visit, which increased with age. The average cost per visit among patients aged 65 years and older was more than twice as high as average costs among patients aged 17 years and younger ($690 vs. $290 per visit).
• Medicaid as the primary expected payer had the lowest average cost per ED visit, more than 50 percent lower than average costs for Medicare and one-third lower than for private insurance. Medicaid as the primary expected payer had an average cost per ED visit that was more than 50 percent lower than average costs per visit for Medicare ($420 vs. $660 per visit) and one-third lower than average costs for private insurance ($420 vs. $560 per visit). Due in part to these differences in average costs by expected payer, Medicare represented 30.1 percent of aggregate ED visit costs but 24.1 percent of total ED visits. In contrast, Medicaid represented 25.0 percent of ED costs but 31.5 percent of ED visits.
• As community-level income increased, the share of aggregate ED visit costs decreased and average cost per ED visit increased. The share of ED visit costs and ED visits decreased as community-level income increased. Patients residing in communities with the lowest income (quartile 1) represented roughly one-third of aggregate ED visit costs and ED visits (31.4 and 34.3 percent, respectively). Patients residing in quartiles 2 and 3 represented approximately one-fourth and one-fifth of aggregate ED visit costs and ED visits, respectively. Patients residing in communities with the highest income (quartile 4) represented less than one-fifth of aggregate ED costs and ED visits (18.1 and 16.0 percent, respectively). In contrast, average cost per ED visit increased as community-level income increased, ranging from $480 in communities with the lowest income (quartile 1) to $600 in communities with the highest income (quartile 4).
• The share of aggregate ED visit costs was highest among patients residing in large metropolitan areas. Aggregate ED visit costs for large metropolitan areas totaled $39.5 billion in 2017, more than half of the $76.3 billion in ED costs for the entire United States. The share of aggregate ED costs in large metropolitan areas was analogous to the overall distribution of ED visits in these areas: 51.8 percent of aggregate ED costs and 50.4 percent of ED visits.

Distribution of aggregate ED visit costs for location of patient residence by patient characteristics, 2017

Figures 2 – 4 present the distribution of aggregate costs for ED visits based on the location of the patient’s residence by age ( Figure 2 ), community-level income ( Figure 3 ), and primary expected payer ( Figure 4 ).

Aggregate ED visit costs by age and patient location, 2017. Abbreviations: B, billion; ED, emergency department; M, million Notes: Statistics for ED visits with missing or invalid patient characteristics are not presented. Patient age and patient location (more...)

Aggregate ED visit costs by primary expected payer and patient location, 2017. Abbreviations: B, billion; ED, emergency department; M, million Notes: Statistics for ED visits with missing or invalid patient characteristics are not presented. Expected (more...)

Aggregate ED visit costs by community-level income and location of patient’s residence, 2017. Abbreviations: B, billion; ED, emergency department; M, million Notes: Statistics for ED visits with missing or invalid patient characteristics are not (more...)

Figure 2 presents the distribution of aggregate costs for ED visits by patient age based on the location of the patient’s residence in 2017.

• Patients aged 18–44 years represented the largest share of aggregate ED visit costs in all locations except rural areas where patients aged 65 years and older represented the largest share. Compared with other age groups, patients aged 18–44 years represented the largest share of aggregate ED visit costs in large metropolitan areas in 2017 (36.4 percent). The share of ED costs attributed to patients aged 18–44 years also was larger than for other age groups in small metropolitan and micropolitan areas (34.2 and 32.5 percent, respectively). Overall, the share of ED costs attributed to patients aged 18–44 years decreased as urbanization decreased, from 36.4 percent in large metropolitan areas to 29.8 percent in rural areas. In rural areas, patients aged 65 years and older accounted for the largest share of aggregate ED visit costs (32.5 percent) compared with other age groups. The share of ED costs attributed to patients aged 65 years and older increased as urbanization decreased, from 24.7 percent in large metropolitan areas to 32.5 percent in rural areas. The share of aggregate ED visit costs attributed to patients aged 45–64 years and those aged 17 years and younger were similar across all patient locations (approximately 28 and 10 percent, respectively).

Figure 3 presents the distribution of aggregate costs for ED visits by quartile of community-level household income in the patient’s ZIP Code based on the location of the patient’s residence in 2017.

• In large metropolitan areas, patients residing in communities with the highest and lowest incomes represented the largest shares of aggregate ED visit costs. For other locations, patients in communities with lower incomes represented the largest share of ED costs. Patients residing in communities with the highest and lowest incomes (quartiles 4 and 1) accounted for 28.1 and 26.6 percent, respectively, of the $39.5 billion in aggregate ED visit costs in large metropolitan areas in 2017. In contrast, patients residing in communities with the two lowest income quartiles represented the largest share of ED costs for other patient locations (small metropolitan, micropolitan, and rural).
• As urbanization decreased, the share of aggregate ED visit costs for patients in the lowest income quartile increased and the share for those in the highest income quartile decreased. The share of aggregate ED visit costs attributed to patients residing in communities in the lowest income quartile (quartile 1) increased as urbanization decreased, from 26.6 percent in large metropolitan areas to 48.8 percent in rural areas. In contrast, the share of ED visit costs attributed to patients residing in communities in the highest income quartile (quartile 4) decreased as urbanization decreased, from 28.1 percent in large metropolitan areas to 1.2 percent in rural areas.

Figure 4 presents the distribution of aggregate costs for ED visits by primary expected payer based on the location of the patient’s residence in 2017.

• Private insurance as the primary expected payer accounted for the largest share of aggregate ED visit costs among patients living in large metropolitan areas. Medicare represented the largest share of ED costs in micropolitan and rural areas. Compared with other primary expected payers, private insurance represented the largest share of aggregate ED visit costs among those living in large metropolitan areas in 2017 (31.4 percent). The share of ED costs attributed to private insurance decreased as urbanization decreased, from 31.4 percent in large metropolitan areas to 27.9 percent in rural areas. More than one-third of ED visit costs were attributed to Medicare as the primary expected payer in micropolitan and rural areas. The share of ED costs attributed to Medicare increased as urbanization decreased, from 28.0 percent in large metropolitan areas to 37.3 percent in rural areas.

Costs of ED visits by hospital characteristics, 2017

Table 2 presents the aggregate and average costs for ED visits, the number of ED visits, and the distributions of costs and visits, by select hospital characteristics in 2017.

Aggregate costs, average costs, and number of ED visits by hospital characteristics, 2017.

• Aggregate ED visit costs were highest for hospitals located in the South in 2017. Aggregate ED visit costs in the South were $27.5 billion in 2017 (36.1 percent of the total $76.3 billion for the United States). The share of ED visit volume for the South was even larger (40.0 percent of the 144.8 million total visits). The distribution of aggregate ED visit costs across other hospital characteristics largely followed the pattern of the number of ED visits. Aggregate ED costs were highest in private, nonprofit hospitals; teaching hospitals; and hospitals not designated as a trauma center (72.0, 64.1, and 52.5 percent of ED costs, respectively). ED visits at private, for-profit hospitals had lower average costs per visit than did visits at either private, nonprofit or public hospitals ($420 vs. $540 and $550 per visit).
• About Statistical Briefs

Healthcare Cost and Utilization Project (HCUP) Statistical Briefs provide basic descriptive statistics on a variety of topics using HCUP administrative healthcare data. Topics include hospital inpatient, ambulatory surgery, and emergency department use and costs, quality of care, access to care, medical conditions, procedures, and patient populations, among other topics. The reports are intended to generate hypotheses that can be further explored in other research; the reports are not designed to answer in-depth research questions using multivariate methods.

• Data Source

The estimates in this Statistical Brief are based upon data from the HCUP 2017 Nationwide Emergency Department Sample (NEDS).

• Definitions

Types of hospitals included in the HCUP Nationwide Emergency Department Sample

The Nationwide Emergency Department Sample (NEDS) is based on emergency department (ED) data from community acute care hospitals, which are defined as short-term, non-Federal, general, and other specialty hospitals available to the public. Included among community hospitals are pediatric institutions and hospitals that are part of academic medical centers. Excluded are long-term care facilities such as rehabilitation, psychiatric, and alcoholism and chemical dependency hospitals. Hospitals included in the NEDS have EDs, and no more than 90 percent of their ED visits result in admission.

Unit of analysis

The unit of analysis is the ED visit, not a person or patient. This means that a person who is seen in the ED multiple times in 1 year will be counted each time as a separate visit in the ED.

Costs and charges

Total ED charges were converted to costs using HCUP Cost-to-Charge Ratios based on hospital accounting reports from the Centers for Medicare & Medicaid Services (CMS). a Costs reflect the actual expenses incurred in the production of hospital services, such as wages, supplies, and utility costs; charges represent the amount a hospital billed for the case. For each hospital, a cost-to-charge ratio constructed specifically for the hospital ED is used. Hospital charges reflect the amount the hospital billed for the entire ED visit and do not include professional (physician) fees.

Total charges were not available on all NEDS records. About 13 percent of all ED visits (weighted) in the 2017 NEDS were missing information about ED charges, and therefore, ED cost could not be estimated. For ED visits that resulted in admission, 24 percent of records were missing ED charges. For ED visits that did not result in admission, 11 percent of records were missing ED charges. The missing information was concentrated in the West (59 percent of records missing ED charges). For this Statistical Brief, the methodology used for aggregate cost estimation was analogous to what is recommended for the estimation of aggregate charges in the Introduction to the HCUP NEDS documentation. b Aggregate costs were estimated as the product of number of visits and average cost per visit in each reporting category. If a stay was missing total charges, average cost was imputed using the average cost for other stays with the same combination of payer characteristics. Therefore, a comparison of aggregate cost estimates across different tables, figures, or characteristics may result in slight discrepancies.

How HCUP estimates of costs differ from National Health Expenditure Accounts

There are a number of differences between the costs cited in this Statistical Brief and spending as measured in the National Health Expenditure Accounts (NHEA), which are produced annually by CMS. c The largest source of difference comes from the HCUP coverage of ED treatment only in contrast to the NHEA inclusion of inpatient and other outpatient costs associated with other hospital-based outpatient clinics and departments as well. The outpatient portion of hospitals’ activities has been growing steadily and may exceed half of all hospital revenue in recent years. On the basis of the American Hospital Association Annual Survey, 2017 outpatient gross revenues (or charges) were about 49 percent of total hospital gross revenues. d

Smaller sources of differences come from the inclusion in the NHEA of hospitals that are excluded from HCUP. These include Federal hospitals (Department of Defense, Veterans Administration, Indian Health Services, and Department of Justice [prison] hospitals) as well as psychiatric, substance abuse, and long-term care hospitals. A third source of difference lies in the HCUP reliance on billed charges from hospitals to payers, adjusted to provide estimates of costs using hospital-wide cost-to-charge ratios, in contrast to the NHEA measurement of spending or revenue. HCUP costs estimate the amount of money required to produce hospital services, including expenses for wages, salaries, and benefits paid to staff as well as utilities, maintenance, and other similar expenses required to run a hospital. NHEA spending or revenue measures the amount of income received by the hospital for treatment and other services provided, including payments by insurers, patients, or government programs. The difference between revenues and costs includes profit for for-profit hospitals or surpluses for nonprofit hospitals.

Location of patients’ residence

Place of residence is based on the urban-rural classification scheme for U.S. counties developed by the National Center for Health Statistics (NCHS) and based on the Office of Management and Budget (OMB) definition of a metropolitan service area as including a city and a population of at least 50,000 residents. For this Statistical Brief, we collapsed the NCHS categories into four groups according to the following:

Large Metropolitan

• Large Central Metropolitan: Counties in a metropolitan area with 1 million or more residents that satisfy at least one of the following criteria: (1) containing the entire population of the largest principal city of the metropolitan statistical area (MSA), (2) having their entire population contained within the largest principal city of the MSA, or (3) containing at least 250,000 residents of any principal city in the MSA
• Large Fringe Metropolitan: Counties in a metropolitan area with 1 million or more residents that do not qualify as large central metropolitan counties

Small Metropolitan

• Medium Metropolitan: Counties in a metropolitan area of 250,000–999,999 residents
• Small Metropolitan: Counties in a metropolitan area of 50,000–249,999 residents

Micropolitan:

• Micropolitan: Counties in a nonmetropolitan area of 10,000–49,999 residents
• Noncore: Counties in a nonmetropolitan and nonmicropolitan area

Community-level income

Community-level income is based on the median household income of the patient’s ZIP Code of residence. Quartiles are defined so that the total U.S. population is evenly distributed. Cut-offs for the quartiles are determined annually using ZIP Code demographic data obtained from Claritas, a vendor that produces population estimates and projections based on data from the U.S. Census Bureau. e The value ranges for the income quartiles vary by year. The income quartile is missing for patients who are homeless or foreign.

Expected payer

• Medicare: includes fee-for-service and managed care Medicare
• Medicaid: includes fee-for-service and managed care Medicaid
• Private insurance: includes commercial nongovernmental payers, regardless of the type of plan (e.g., private health maintenance organizations [HMOs], preferred provider organizations [PPOs])
• Self-pay/No charge: includes self-pay, no charge, charity, and no expected payment
• Other payers: includes other Federal and local government programs (e.g., TRICARE, CHAMPVA, Indian Health Service, Black Lung, Title V) and Workers’ Compensation

ED visits that were expected to be billed to the State Children’s Health Insurance Program (SCHIP) are included under Medicaid.

• Northeast: Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York, New Jersey, and Pennsylvania
• Midwest: Ohio, Indiana, Illinois, Michigan, Wisconsin, Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, and Kansas
• South: Delaware, Maryland, District of Columbia, Virginia, West Virginia, North Carolina, South Carolina, Georgia, Florida, Kentucky, Tennessee, Alabama, Mississippi, Arkansas, Louisiana, Oklahoma, and Texas
• West: Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada, Washington, Oregon, California, Alaska, and Hawaii

Discharge status

Discharge status reflects the disposition of the patient at discharge from the ED and includes the following categories reported in this Statistical Brief: routine (to home); admitted as an inpatient to the same hospital; transfers (transfer to another short-term hospital; other transfers including skilled nursing facility, intermediate care, and another type of facility such as a nursing home); and all other dispositions (home healthcare; against medical advice [AMA]; died in the ED; or destination unknown).

Hospital characteristics

Data on hospital ownership and status as a teaching hospital was obtained from the American Hospital Association (AHA) Annual Survey of Hospitals. Hospital ownership/control includes categories for government nonfederal (public), private not-for-profit (voluntary), and private investor-owned (proprietary). Teaching hospital is defined as having a residency program approved by the American Medical Association, being a member of the Council of Teaching Hospitals, or having a ratio of full-time equivalent interns and residents to beds of 0.25 or higher.

Hospital trauma level

• Level I centers have comprehensive resources, are able to care for the most severely injured, and provide leadership in education and research.
• Level II centers have comprehensive resources and are able to care for the most severely injured, but do not provide leadership in education and research.
• Level III centers provide prompt assessment and resuscitation, emergency surgery, and, if needed, transfer to a level I or II center.
• Level IV/V centers provide trauma support in remote areas in which no higher level of care is available. These centers resuscitate and stabilize patients and arrange transfer to an appropriate trauma facility.

For this Statistical Brief, trauma hospitals were defined as those classified by the ASC/COT as a level I, II, or III trauma center. This is consistent with the classification of trauma centers used in the NEDS. The ACS/COT has a program that verifies hospitals as trauma level I, II, or III. h It is important to note that although all level I, II, and III trauma centers offer a high level of trauma care, there may be differences in the specific services and resources offered by hospitals of different levels. Trauma levels IV and V are designated at the State level (and not by ACS/COT) with varying criteria applied across States.

The Healthcare Cost and Utilization Project (HCUP, pronounced "H-Cup") is a family of healthcare databases and related software tools and products developed through a Federal-State-Industry partnership and sponsored by the Agency for Healthcare Research and Quality (AHRQ). HCUP databases bring together the data collection efforts of State data organizations, hospital associations, and private data organizations (HCUP Partners) and the Federal government to create a national information resource of encounter-level healthcare data. HCUP includes the largest collection of longitudinal hospital care data in the United States, with all-payer, encounter-level information beginning in 1988. These databases enable research on a broad range of health policy issues, including cost and quality of health services, medical practice patterns, access to healthcare programs, and outcomes of treatments at the national, State, and local market levels.

• Alaska Department of Health and Social Services
• Alaska State Hospital and Nursing Home Services Association
• Arizona Department of Health Services
• Arkansas Department of Health
• California Office of Statewide Health Planning and Development
• Colorado Hospital Association
• Connecticut Hospital Association
• Delaware Division of Public Health
• District of Columbia Hospital Association
• Florida Agency for Health Care Administration
• Georgia Hospital Association
• Hawaii Laulima Data Alliance
• Hawaii University of Hawai’i at Hilo
• Illinois Department of Public Health
• Indiana Hospital Association
• Iowa Hospital Association
• Kansas Hospital Association
• Kentucky Cabinet for Health and Family Services
• Louisiana Department of Health
• Maine Health Data Organization
• Maryland Health Services Cost Review Commission
• Massachusetts Center for Health Information and Analysis
• Michigan Health & Hospital Association
• Minnesota Hospital Association
• Mississippi State Department of Health
• Missouri Hospital Industry Data Institute
• Montana Hospital Association
• Nebraska Hospital Association Services
• Nevada Department of Health and Human
• New Hampshire Department of Health & Human
• New Jersey Department of Health
• New Mexico Department of Health
• New York State Department of Health
• North Carolina Department of Health and Human Services
• North Dakota (data provided by the Minnesota Hospital Association)
• Ohio Hospital Association
• Oklahoma State Department of Health
• Oregon Association of Hospitals and Health Systems
• Oregon Office of Health Analytics
• Pennsylvania Health Care Cost Containment Council
• Rhode Island Department of Health
• South Carolina Revenue and Fiscal Affairs Office
• South Dakota Association of Healthcare Organizations
• Tennessee Hospital Association
• Texas Department of State Health Services
• Utah Department of Health
• Vermont Association of Hospitals and Health Systems
• Virginia Health Information
• Washington State Department of Health
• West Virginia Department of Health and Human Resources, West Virginia Health Care Authority
• Wisconsin Department of Health Services
• Wyoming Hospital Association
• About the NEDS

The HCUP Nationwide Emergency Department Sample (NEDS) is a unique and powerful database that yields national estimates of emergency department (ED) visits. The NEDS was constructed using records from both the HCUP State Emergency Department Databases (SEDD) and the State Inpatient Databases (SID). The SEDD capture information on ED visits that do not result in an admission (i.e., patients who were treated in the ED and then released from the ED, or patients who were transferred to another hospital); the SID contain information on patients initially seen in the ED and then admitted to the same hospital. The NEDS was created to enable analyses of ED utilization patterns and support public health professionals, administrators, policymakers, and clinicians in their decision making regarding this critical source of care. The NEDS is produced annually beginning in 2006. Over time, the sampling frame for the NEDS has changed; thus, the number of States contributing to the NEDS varies from year to year. The NEDS is intended for national estimates only; no State-level estimates can be produced. The unweighted sample size for the 2017 NEDS is 33,506,645 (weighted, this represents 144,814,803 ED visits).

• For More Information

For other information on emergency department visits, refer to the HCUP Statistical Briefs located at www.hcup-us.ahrq.gov/reports/statbriefs/sb_ed.jsp .

• HCUP Fast Stats at www.hcup-us.ahrq.gov/faststats/landing.jsp for easy access to the latest HCUP-based statistics for healthcare information topics
• HCUPnet, HCUP’s interactive query system, at www.hcupnet.ahrq.gov/

For more information about HCUP, visit www.hcup-us.ahrq.gov/ .

For a detailed description of HCUP and more information on the design of the Nationwide Emergency Department Sample (NEDS), please refer to the following database documentation:

Agency for Healthcare Research and Quality. Overview of the Nationwide Emergency Department Sample (NEDS). Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality. Updated December 2019. www.hcup-us.ahrq.gov/nedsoverview.jsp . Accessed February 3, 2020.

• Acknowledgments

The authors would like to acknowledge the contributions of Nils Nordstrand of IBM Watson Health.

The HCUP Cost-to-Charge Ratios (CCRs) for NEDS Files were not publicly available at the time of publication, so an internal version was used in this Statistical Brief.

Agency for Healthcare Research and Quality. HCUP Nationwide Emergency Department Sample (NEDS) Database Documentation. Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality. Updated April 27, 2020. www ​.hcup-us.ahrq.gov ​/db/nation/neds/nedsdbdocumentation.jsp . Accessed October 27, 2020.

For additional information about the NHEA, see Centers for Medicare & Medicaid Services (CMS). National Health Expenditure Data. CMS website. Updated December 17, 2019. www ​.cms.gov/Research-Statistics-Data-and-Systems ​/Statistics-Trends-and-Reports ​/NationalHealthExpendData/index ​.html?redirect= ​/NationalHealthExpendData/ . Accessed February 3, 2020.

American Hospital Association. TrendWatch Chartbook, 2019. Table 4.2. Distribution of Inpatient vs. Outpatient Revenues, 1995–2017. www ​.aha.org/system/files ​/media/file/2019 ​/11/TrendwatchChartbook-2019-Appendices ​.pdf . Accessed March 19, 2020.

Claritas. Claritas Demographic Profile by ZIP Code. https://claritas360.claritas.com/mybestsegments/. Accessed February 3, 2020.

American Trauma Society. Trauma Information Exchange Program (TIEP). www ​.amtrauma.org/page/TIEP . Accessed June 11, 2020.

MacKenzie EJ, Hoyt DB, Sacra JC, Jurkovich GJ, Carlini AR, Teitelbaum SD, et al. National inventory of hospital trauma centers. JAMA. 2003;289(12):1515–22. [ PubMed : 12672768 ]

American College of Surgeons Committee on Trauma, Verification, Review, and Consultation Program for Hospitals. Additional details are available at www ​.facs.org/quality-programs/trauma/vrc . Accessed July 17, 2020.

Moore BJ (IBM Watson Health), Liang L (AHRQ). Costs of Emergency Department Visits in the United States, 2017. HCUP Statistical Brief #268. December 2020. Agency for Healthcare Research and Quality, Rockville, MD. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb268-ED-Costs-2017.pdf .

• Cite this Page Moore BJ, Liang L. Costs of Emergency Department Visits in the United States, 2017. 2020 Dec 8. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006 Feb-. Statistical Brief #268.
• PDF version of this page (326K)

In this Page

• Healthcare Cost and Utilization Project (HCUP)
• Nationwide Inpatient Sample (NIS)
• Kids' Inpatient Database (KID)
• Nationwide Emergency Department Sample (NEDS)
• State Inpatient Databases (SID)
• State Ambulatory Surgery Databases (SASD)
• State Emergency Department Databases (SEDD)
• HCUP Overview
• HCUP Fact Sheet
• HCUP Partners
• HCUP User Support

Related information

• PMC PubMed Central citations
• PubMed Links to PubMed

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Urgent Care Visit Cost: Insurance vs. No Insurance

Due to lower costs and convenience, urgent care centers and stand-alone health clinics are becoming more popular. As of 2019, across the United States, there were around 9,616 urgent care centers . But what do they treat at an urgent care clinic ? How much does it cost compared to going to the ER? What if you don’t have insurance? We’ll cover these questions and more, plus offer cost-saving advice.

What is Urgent Care?

Healthcare .gov defines urgent care as “Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe it requires emergency room care.”

In other words, it’s the middle ground between assessing bug bites and performing surgery. Urgent care centers provide relief without the wait or expense of going to your hospital’s emergency department. 

Urgent Care Visit vs. Emergency Room Visit

Hospital emergency rooms are usually busier and always more expensive than urgent care centers . The cost of an ER visit varies, but the average cost is around $1,200. So when you can’t see your primary care physician or normal health care provider , a trip to urgent care is usually the most cost-friendly move.

Typical urgent care services include minor medical treatments that you can get at the doctor’s office such as:

• Urinary tract infections
• Upper respiratory infections
• Sore throat  
• Strep throat
• STD treatment and diagnosis

When should you go to the ER ? 

• Chest pain and other signs of a heart attack
• Problems breathing
• Weakness or numbness on one side
• Slurred speech
• Serious burns
• Head injury
• Broken bones
• Dislocated joints

Types of Procedures Offered at Urgent Care Facilities  

Besides physical exams, urgent care may provide the following procedures: 

• Minor surgical procedures (stitches, mole removal, cauterization, incision and drainage, cyst extraction, fingernail or toenail removal)
• Pap smear testing
• STD testing
• Pregnancy tests
• Blood tests (complete blood count, metabolic panels, enzymes, cholesterol, triglyceride)
• Flu tests and COVID-19 tests

Interested in learning more about procedure costs? Use this price comparison tool to quickly access the costs of these procedures (and lots of others) from providers in your area. 

Compare Procedure Costs Near You

How Much Does a Trip to Urgent Care Cost if You Have Insurance?

All ACA-compliant health insurance plans cover emergency care, though not all insurers define what emergency care is in the same way. So, most insurance plans cover urgent care , and your out-of- pocket costs will likely be cheaper than an ER visit.

Most insurance plan providers encourage the use of urgent care clinics during off-hours, weekends, and holidays — when you can’t see your regular doctor — by charging fees and copays similar to an office visit with a primary care provider. However, some plan providers, like TRICARE, only allow you to visit urgent care clinics that are within your network up to two times each year without prior authorization. 

The typical copay for urgent care is between $25 and $50. Your insurance company sets the rates, and they may vary. 

The average out-of- pocket costs for an urgent care visit if you have insurance breaks down like this: 

Copay and/or coinsurance + deductible (if applicable) = out-of- pocket costs

To find out exactly how much you will have to pay, consult your health insurance plan policy’s explanation of benefits (EOB).

How Much Does Urgent Care Cost for Uninsured Patients ?

In the United States, 5.4 million laid-off workers became uninsured between February and May 2020, an increase that is 39% higher than any other in modern history. 

The average cost of an urgent care visit is $100 to $200, according to American Family Care, the largest urgent care clinic in the United States.

Depending on your medical needs , this could be much higher. Procedures like lab tests and X-rays will increase the amount of your final bill.

Urgent Care Alternatives

Many people go to the ER for simple medical care when they are between paychecks or have a high deductible insurance plan, because an emergency department (unlike urgent care) is obligated to provide care to all patients regardless of their ability to pay. 

If you fall into this category or have no insurance , the following urgent care alternatives may fit your needs:

• Free clinics: Many communities offer free or low-cost health care clinics. The cost of using these clinics usually depends on your income or ability to pay. State and local health departments also offer deeply discounted services similar to urgent care clinics . Additionally, there are around 1,400 charity hospitals and clinics across the United States. 
• Retail health clinics: Chains like CVS and Walgreens, as well as big-box stores like Target and Walmart, offer minor medical care via retail health clinics (RHC). RHCs offer walk-in health care services in select stores across the United States. The average cost for treatment at an RHC is around $100.
• Telehealth: This is one of the most budget-friendly ways to access health care today. According to United Healthcare , the average cost for telehealth, currently around $50, is about 50% less than most urgent care visit costs. You don’t need to have insurance to use telehealth either. CVS offers telehealth visits via the Minute Clinic .

How to Save on Your Urgent Care Visit Cost

If you are covered by insurance, make certain to go to an urgent care clinic that accepts your specific insurance plan . Calling your provider is the best way to avoid the unhappy surprise of unmet urgent care costs. 

If you’re wondering how you can save money on your out-of- pocket costs , you have a few options. For one, many urgent care clinics offer discounted rates of up to 20% off when you pay in cash. And you can always visit Aunt Bertha , the website that connects you with partners in your area. Their mission is to provide community support, including financial help for medical bills, prescriptions, copays , and deductibles . 

Sometimes when you have to go to an urgent care center , you don’t have time to worry about the costs of tests and procedures. But when possible, looking up prices on Compare.com puts you in control of your health care , helping you make better, more informed decisions.  

Disclaimer: Compare.com does not offer medical advice and is in no way a substitute for any medical advice received from health professionals. Compare.com is unable to offer any advice on any medical procedure you may need.

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