One evening last December, Tieqiao Zhang felt severe pain in her stomach.
After he calmed down later that night, he thought it might be food poisoning. When the pain returned the next morning, Zhang realized the source of his pain might not be as “simple as bad food.”
He didn’t want to wait for an appointment with his regular doctor, but he also wasn’t sure if the pain required urgent care, he said.
Zhang, 50, chose to visit Parkland Health’s Urgent Care Center, a clinic near his Dallas home where he had been treated in the past. It’s on the campus of Parkland, the city’s largest public hospital, which has a dedicated emergency room.
He believed the clinic was an urgent care center, he said.
A CT scan revealed Zhang had a kidney stone. A doctor told him it would go away naturally in a few days, and Zhang was sent home with a prescription for painkillers, he said.
Five days later, Zhang’s stomach pain worsened. Worried and unable to get an immediate appointment with a urologist, Zhang visited the Urgent Care Center once again and was again advised to wait and see, he said.
Two weeks later, Zhang passed the kidney stone.
Then came the bills.
Patient: Tieqiao Zhang, 50, who is insured by BlueCross and BlueShield of Texas through his employer.
Medical services: Two diagnostic visits, including lab tests and CT scans.
Service provider: Parkland Health and Hospital System. The hospital is part of the Dallas County Hospital District.
Total invoices: The in-network hospital charged $19,543 for the two visits. BlueCross and BlueShield of Texas paid $13,070.96. Zhang owed $1,000 to Parkland — a $500 emergency room copay for each of his two visits.
What it gives: Parkland Urgent Care Emergency Center is what is called a freestanding emergency department.
The number of freestanding emergency rooms in the United States increased tenfold from 2001 to 2016, drawing attention for sending unsavory bills to patients. Most states allow them to operate, either with or without regulation. Some states, including Texas, have taken steps to regulate centers, such as requiring posted notices identifying the facility as a freestanding emergency department.
Urgent care centers are a more popular option for many patients. Research shows that, on average, urgent care visits can be about 10 times cheaper than a low-acuity — or less severe — visit to an ER.
But the difference between an urgent care clinic and a freestanding emergency room can be difficult to distinguish.
In general, to bill as an emergency department, facilities must meet specific requirements, such as maintaining designated staff, not turning away patients, and being open around the clock.
Parkland’s freestanding emergency department is 40 yards from its main emergency room and operates under the same license, according to Michael Malaise, Parkland Health spokesman. It is closed at night and on Sundays.
(Parkland President and CEO Frederick Cerise is a member of KFF’s board of trustees. KFF Health News is an editorially independent program of KFF.) The hospital is “very transparent” about the center’s status as an emergency room, Malaise KFF Health News said in a statement.
Malaise provided pictures of posted notices saying, “This facility is an independent urgent care facility,” and warning that patients will be charged emergency room rates and may also be charged a facility fee. He said notices were posted in the exam rooms, lobby and halls at the time of Zhang’s visits.
Zhang’s health plan required a $500 emergency room copay for each of two visits for his kidney stone.
When Zhang visited the center in 2021 for another health issue, he was charged just $30, his urgent care plan’s copay, he said. (A review of his insurance documents showed Parkland also used emergency department billing codes then. BCBS of Texas did not respond to questions about that visit.)
One of the reasons “I went to urgent care instead of the emergency room, even though they’re right next door, is the co-pay,” he said.
The list of services Parkland’s freestanding emergency room offers resembles that of urgent care centers — including, for some centers, diagnosing a kidney stone, said Ateev Mehrotra, a professor of health care policy at the School Harvard Medical School.
The choice lets patients themselves decipher not only the severity of their illness, but also the type of facility they are all visiting while dealing with a health concern. Self-treatment is “a very difficult thing,” Mehrotra said.
Zhang said he did not recall seeing posted notices identifying the center as a freestanding emergency department during his visits, nor did front desk staff mention a $500 copay. Plus, he knew Parkland also had an emergency room, and that wasn’t the building he visited, he said.
The name is “misleading,” Zhang said. “It’s like being cheated.”
Parkland opened the center in 2015 to reduce the number of patients in its main emergency room, which is the busiest in the country, Malaise said. He added that the Emergency Urgent Care Center, which is staffed with emergency room providers, is “an extension of our main emergency room and is clearly marked in many places as such.”
Malaise initially told KFF Health News that the facility is not a freestanding ER, noting that it is located in a hospital building on campus. Days later, he said the center is “held to the public as an independent emergency medical care facility within the definition provided by Texas law.”
The Urgent Care Center’s name is meant to prevent first responders and others facing life-threatening emergencies from visiting the center rather than the main emergency room, Malaise said.
“If you have an idea for a better name, you can certainly send it in for us to consider,” he said.
Putting the term “urgent” in a clinic’s name when charging emergency room prices is “dishonest,” said Benjamin Ukert, an assistant professor of health economics and policy at Texas A&M University.
When Ukert reviewed Zhang’s receipts at the request of KFF Health News, he said his first reaction was, “Wow, I’m glad he only got $500; it could have been a lot worse” – for example, if the facility had been off the grid.
Resolution: Zhang said he paid $400 of the $1,000 total owed to him to avoid collections, while he continues to dispute the amount.
Zhang said he first contacted his insurer, thinking his bills were incorrect, before contacting Parkland several times by phone and email. He said customer service representatives told him that, for billing purposes, Parkland does not distinguish its Urgent Care Clinic from its emergency department.
BlueCross and BlueShield of Texas did not respond to KFF Health News when asked for comment.
Zhang said he also contacted a Dallas county commissioner’s office, which never responded, and the Texas Department of Health, which said it had no jurisdiction over the billing issues. He said staff for his state representative, Morgan Meyer, contacted the hospital on his behalf but later told him the hospital would not change his bill.
By mid-May, his balance was $600, or $300 for each visit.
Takeaway: Lawmakers in Texas and around the country have tried to increase price transparency at freestanding emergency rooms, including by requiring them to release information about billing practices.
But experts said the burden still falls disproportionately on patients to navigate the growing menu of care options.
It’s up to the patient to get into the right building, said Mehrotra, the Harvard professor. It doesn’t help that most providers are vague about their billing practices, he said.
Mehrotra said some freestanding emergency departments in Texas use confusing names like “comprehensive care,” which mask the facility’s capabilities and billing structure.
Ukert said states could do more to resolve the confusion patients face at such centers, such as banning the use of the term “urgent care” to describe facilities that bill as emergency departments.
Bill of the Month is an investigation put together by KFF Health News and NPR that analyzes and explains medical bills. Do you have any interesting medical bills you’d like to share with us? Tell us about it!
Emily Sinner reported the audio narration.
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