Victoria freestanding ER closes amid battle with insurers

May 07--Mercer ER, a slick, stand-alone 24-hour emergency center near Home Depot, closed its doors for good last week.

Patty Lutes, a 29-year-old executive assistant in Victoria, said she wasn't surprised it closed, especially after her experience of receiving a surprise bill in the mail.

She remembers the facility had just opened in Victoria -- its signs weren't even up -- when she woke up feeling terrible. There was no time to schedule an appointment with her family doctor before an important work event that night.

"I felt like death," she remembered thinking. She thought she could have strep, a highly contagious infection, and could not risk getting anyone else sick.

She thought she would just run up to Mercer real quick and make sure it wasn't strep. "I was the only person there. In-and-out in 20 minutes," she said. She paid her $250 copay, got a prescription and went on her way.

Later she learned her insurance company paid more than $1,000 for the test and she was being charged the rest of the balance to the tune of more than $500.

She learned later "balance billing" is a national problem that Texas lawmakers have been working on.

Texas legislators passed two bills last year aimed to help protect consumers from surprise bills. The laws, passed in September, state that freestanding emergency rooms must post notice of whether they are part of any insurance networks or risk losing their license and updated a process so that patients can dispute the bill. Not all consumers know that since 2009, they can contact the Texas Insurance Department with complaints or help with mediation.

A former staff member of Mercer said Wednesday that the business closed because Blue Cross Blue Shield and a couple others are not paying their bills.

The next day, Chris Callahan, a spokesman with Blue Cross Blue Shield of Texas, confirmed that Mercer ER was out-of-network but didn't have any other information about working with this specific center.

Accepting all insurances and being in-network are not the same thing, Callahan said. "It's a difference that can cost our members, or a patient, thousands of dollars out of pocket."

"We take very seriously the obligation to pay claims for our members' covered services," he said. "If a member or provider, whether in- or out-of-network, has questions about claims payments, we are here to help."

Some say the problem is that people are confused about what kind of center they are walking into despite the clear "emergency" signs.

A recent study from Rice University's Baker Institute analyzed insurance claims from 2012-2015, finding a huge overlap -- 75 percent of the 20 most common diagnoses at freestanding emergency departments -- were the same as at less-expensive urgent care centers.

In 2015, the average price per visit of a hospital-based ER and freestanding ER were similar at $2,200. The price for urgent care centers was only $168.

In recent years, freestanding ER operators say insurance companies are denying coverage for emergency room visits that the companies say didn't constitute a "true emergency."

Brad Shields, executive director of the Texas Association of Freestanding Emergency Centers, said this isn't good for patients and such policies could cause freestanding ERs to go out of business.

"We continue to grow into different parts of the state, but the challenge that does exist is the ability to be paid for our services," he said.

Shields says insurance companies shouldn't be able to penalize patients who believe they are having an emergency by outright denying or underpaying a claim after the fact.

"We believe this new policy by Blue Cross Blue Shield is against the law and puts people's lives in danger," he said. "Unless the Legislature addresses it, there's a fear that patients are going to be put in a difficult spot."

Last summer, Neighbors Emergency Center on Houston Highway closed before opening for business, citing a saturation of the market. A call to Victoria ER wasn't returned, but the business is still in operation since it opened in 2015.

As for Lutes, next time she'd rather wait for her doctor's office or go to an urgent care center. She said the convenience of a freestanding ER wasn't worth the extra out-of-pocket cost.

"I told them I'm not paying that. That's insane," she said. "They've sent me like two bills since then."

Laura Garcia reports on health and nonprofits for the Victoria Advocate. She may be reached at [email protected] or 361-580-6585.

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