CORRECTED-YOUR MONEY-How to avoid urgent care sticker shock

Wed Jun 12, 2013 4:58pm EDT

(In the 22nd paragraph, corrects amount to $100 million, not $100,000 million, as previously sent)

By Beth Pinsker

NEW YORK, June 11 (Reuters) - When you walk into any given urgent care center, two things matter: who owns it and what insurance you have.

Urgent care centers are walk-in clinics where you can get care for medical problems you might otherwise go to an emergency room for - like a broken ankle or an asthma attack - but without the long waits and high costs.

Now numbering almost 10,000, there are more urgent care centers in the U.S. than emergency rooms - and that ratio is likely to tip much higher in the next few years as hospitals cut costs: the number of urgent care centers could hit 12,000, according to the research firm IBISWorld.

Even if the back of your insurance card states clearly that an urgent care visit will cost you a fixed-amount co-pay (anywhere from $30 to $100), there could also be charges for individual procedures, facility fees or other add-ons.

Figuring out costs is even more challenging for those with co-insurance, where you pay a percentage of every charge, or high-deductible health plans, where you pay out of pocket until you reach a limit somewhere north of $1,250 for an individual.

When it comes to costs, "it's difficult for patients to do the whole triage thing," says Ateev Mehrotra, a policy analyst at the RAND Corporation, a nonprofit think tank.

INITIAL VISIT COSTS

The reasons prices vary so much is that there is extreme fragmentation in the urgent care business, which produced $14.5 billion in revenue in 2012 and is projected to grow to $18 billion by 2018, according to IBISWorld.

No entity controls more than 1 percent of the market - among the largest, Concentra Inc., now owned by Humana Inc, has 320 locations, NextCare Urgent Care Inc. has 58 and FastMed Inc. has 40.

They all set their own pricing, and have varying rates they've negotiated with insurance companies, a process that will not change with upcoming healthcare reform. (For those who have no insurance at all, there is a different schedule of fees altogether.)

In St. Louis, for example, out-of-pocket fees for an initial visit range from $89 at the three locations of Total Access Urgent Care, owned by Dr. Matt Bruckel, to $277 for one of the four urgent care locations run by St. Anthony's Medical Center (with a 40 percent discount if you pay cash upfront).

At the two locations owned by Dr. Sonny Sugar, Downtown Urgent Care and Eureka Urgent Care, he offers a $67 per month membership.

"The worst thing is the uncertainty about what one's bill will be," Sugar says. Patients at his facilities receive an itemized list of costs before treatment, he says.

Hospitals run about 26 percent of urgent care centers nationwide, but sometimes consumers find out after the fact that their visit was actually billed as an ER visit, or they are charged a "facility fee," which can run in the hundreds of dollars. This results in sticker shock for some patients.

When Chrisi Tainter's son was on a trip and needed stitches, she ended up with a $600 bill for an ER-type facility. As a medical billing manager for Our Urgent Care Centers in St. Louis, she knows exactly what it would have cost with her insurance if he had been treated at her own place of employ: $140.

PROCEDURE CHARGES

For many patients, the initial visit charge will be all that they pay. If prescribed antibiotics for an ear infection, they'll walk out with a slip of paper and the certainty that they won't end up in medical collections.

All other services are a la carte. At urgent care facilities run by Bruckel, it costs $41 for the first procedure (like stitches or setting a fracture) and $30 for subsequent ones, with higher fees for things like a CT scan or vaccinations.

If a patient comes in with suspected pneumonia, gets intravenous fluids, a nebulizer treatment and a $60 x-ray, she could end up with a total bill of $210, Bruckel says, adding that it's less than the $277 at competitors just to see a doctor.

The hospital-run centers, for their part, say they base their charges on insurance rates, and by ability to pay for those who are uninsured.

TOTAL BILLS

Among St. Louis' independently-owned urgent care centers, billing manager Tainter says she has never seen a patient get a bill for over $500. Most bills are under $100, and some are between $100 and $300.

The best way to try to assess your potential costs before you go to an urgent care center is to check with your insurance company. You can also check a cost estimator online or on a mobile app.

The one for UnitedHealth Group Inc allows you to put in a condition, like a sprained ankle, and get an estimate of costs for treatment at all the local options, allowing the customer to compare prices for primary care doctors, urgent care centers and emergency rooms, says Victoria Bogatyrenko, vice president of product innovation for United Healthcare.

In 15 months, the tool has delivered $100 million worth of estimates for care, the company says.

You can also call around to the urgent care centers in your area to ask about pricing - if the situation allows you the time.

Just don't expect them to be able to answer all your questions. "The receptionist will not know, because they won't know what treatment is going to be," Tainter says.

Medical treatment is still personalized - so the specifics of your bill are going to depend on what's wrong with you and what procedures you get. (Follow us @ReutersMoney or here. Editing by Lauren Young and Andrew Hay)

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