Henry Higgins, MD
Many new forms of healthcare facilities and office settings have developed over the past 20 years. No facility has caused more confusion than the Freestanding Emergency Center (FEC). Most-lay people are familiar with the concept of a hospital and a physician’s office. Many-lay people have become familiar with urgent cares. Fewer still are knowledgeable regarding ambulatory surgery centers (ASC). Patient are still often confused when their doctor can no longer treat them when they become hospitalized due to the fact that they no longer do “in patient.” Fewer lay-people have any knowledge or understanding of what Freestanding Emergency Centers are, what they can treat, how they are operated, who owns them, how they bill or if they are allowed to use them when they have an emergency. Much of the medical profession is also still ignorant of what Freestanding Emergency Centers are capable of or how they are staffed. Even EMS systems frequently have very little knowledge of the Licensing requirements and capabilities of Freestanding Emergency Centers.
To make matters worse the Freestanding Emergency Center goes by many many names. It is understandable that lay-people may be confused regarding the Freestanding Emergency Center. This article will summarize some of the more common names used for Freestanding Emergency Centers and attempt to use some of the reasons behind these alternative names used.
Patients who have “discovered” Freestanding Emergency Centers, especially physician owned ones prefer to use them for their emergency care at a dramatic rate. Freestanding Emergency Centers are likely to be a very permanent facility in our healthcare delivery system. It makes sense for everyone to begin using one term to denote these facilities. While the public slowly continues to discover what these new facilities are capable of it makes sense for everyone to begin using one term that denotes these facilities. Essentially the Freestanding Emergency Center is open 24/7 and is staffed with the same level or higher level of emergency physicians and nurses and has at least the same diagnostic and therapeutic modalities available in hospital based emergency department.
When the federal government imposed law that hospitals must offer a room that was open for 24/7 diagnosis and treatment for emergencies this room became known as the emergency room or ER. This room actually consisted of several rooms but the name stuck. Similarly the operating room became known as the OR, the labor hall and the general patient room area became known as “the floor.” So when EMS arrived at the hospital with a patient they often wanted to know if they were to deliver the incoming patient to the ER, OR, floor or labor hall. These names are still widely used today by most lay-people and hospital personnel.
As the various hospital departments grew each has attempted to acquire a more suitable name. The operating rooms have attempted to be called surgical suites or surgical floors. Labor halls have been somewhat successful in changing their name to “labor and delivery” or L&D for short. In the 1980’s emergency medicine was well on its way to changing their work places name from emergency room (ER) to emergency department (ED). The wildly popular television show “ER” all but forever destroyed emergency medicine’s ability to rename their work place. As a result the word ER is by far the most common term used when people are explaining where they are or where they are going or what they do. Even those of us who have been taught in medical school and residency to use the term “Emergency Department” still catch ourselves using the term ER.
So with one of the most revolutionary emergency medicine treatment model to date it is no surprise that this new freestanding facility has garnered so many different names. Many of us in emergency medicine have fallen victim to attempting to more properly name our work place. Some of the names designate who owns the freestanding emergency center. Other names attempt to emphasize that the facility is a satellite facility that is somehow connected to a bigger health network nearby. Some have names that simply emphasize the lack of attachment to a hospital (standalone). In the end we should likely just refer to these new centers as ERs because 99% of the public will always call them ERs.
Freestanding Emergency Center –Term adopted by TAFEC (Texas Association of Freestanding Emergency Centers) as the name designation causing least confusion
FSEC – acronym for Free Standing Emergency Center
FEC – shortened acronym for Freestanding Emergency Center
Freestanding Emergency Department – Term that attempts to use the modern and more academically acceptable emergency department designation within its name
FED – acronym for Freestanding Emergency Department Freestanding ER-a variant that allows the lay-public to gain understanding of the facility by including the familiar ER component within the name
FER – Acronym for Freestanding ER Standalone Emergency Center-name that emphasizes the facilities lack of attachment to a hospital
Satellite Emergency Center – name that emphasizes that the facility is somehow connected to a larger health system
SEC – Acronym for Standalone Emergency Center &/or Satellite Emergency Center
Standalone Emergency Room – once again the old “ER” is embedded in this name
Satellite Emergency Room – variant that reverts back to the widely recognized ER designation
SER – acronym for Standalone Emergency Room
HOPD – hospital outpatient department is another name for a hospital ER that may or may not be physically attached to a hospital but is owned and operated by a hospital and bills like an
Type B Emergency Department – an urgent care that is owned by a hospital can become designated as a type B Emergency Department and therefore bill at the same levels as an emergency department while not being required to fulfill the majority of Emergency Department duties such as having physicians present or meeting any of the ER building code requirements. These facilities do not even have to stay open 24 hours a day but still are allowed to bill the same as ERs. Many of these facilities present themselves to the public and market themselves as Urgent Cares yet patients are still billed at ER levels. This creates a great deal of additional confusion for the public
Urgent Care – a non-emergency care environment that fails to have any standard requirements and is found in many forms. The vast majority of these facilities are not open 24 hours a day and frequently staffed primarily with midlevel providers
It is not surprising that the public, policy makers and even healthcare professionals remain confused regarding the Freestanding Emergency Center. Even within this industry we have not been able to agree upon what to call these facilities.
Amidst this confusion the Type B Emergency Department and HOPD have created a great deal of anger and animosity by holding themselves out to the public as an urgent care yet charging ER prices for care. These facilities are all hospital owned and operated. These facilities are not stringently regulated and they do not comply with the expensive staffing requirements or building code requirements that ERs must, nor do they remain open for 24 hours a day.
Since most policy makers and the general public do not understand the nature and rules of the various facilities mentioned in this article the billing practices of the HOPD and Type B Emergency Departments have led to a tremendous number of complaints by the public to their policy makers regarding “they thought that they were going into an urgent care but they received an ER bill.” In reviewing these facilities online marketing materials they are calling themselves Urgent Cares and nowhere in their marketing material does it mention that they bill as an ER.
In the best interest of the public some policy makers such as State Senator Schwertner of Texas have been sponsoring bills that will force all ERs to be more forthcoming regarding their billing practices (Senate Bill # 425). Other Senators have attempted to remove the right for facilities and physicians to balance bill patients, giving the insurance industry the absolute authority to dictate how much they choose to pay for any and all medical services. Some have proposed automatic mediation rules which if passed will likely result in the vast majority of medical claims not being paid until after they have undergone very lengthy and costly mediation processes with 3rd party mediators and the insurance companies. None of these legislative proposals will likely even effect the HOPDs and Type B Emergency Departments that have caused these complaints.
In studying the billing practices of physician owned Freestanding Emergency Centers it is the norm for these facilities to be some of the most cost transparent and upfront facilities to date. These facilities typically have a very large sign on their store front that reads “EMERGENCY ROOM.” They provide patients with paperwork that describes the facility and they verbally inform the patient that this is an ER and you will be billed similar to a hospital based ER. These facilities even have patients sign a document acknowledging that they were informed of these billing practices.
In turn the physician owned facilities frequently greatly discount, if not provide pro bono care for those that have no insurance. These facilities voluntarily participate in EMTALA by providing medical screening and treatment to all medical emergencies that arrive at their facilities without regard to insurance status. The physician owned facilities are not recognized by CMS as a facility simply because they are not hospital owned. This lack of CMS recognition causes all federal insurance programs such as Medicare, Tricare and Medicaid to ignore and not pay any facility fees.
It is important for the field of Freestanding Emergency Medicine to adopt a unified name for this new ER model. It is likely that the suggestions of the Texas Association of Freestanding Emergency Centers (TAFEC) be adopted throughout the country and begin calling these “Freestanding Emergency Centers” (FEC) all the while recognizing that most people will simply refer to them as ERs. It may also be wise for policy makers and the public to become aware, that under all of the confusion regarding facility types, that some very powerful antitrust occurrences are happening. Under the radar hospital owned HOPDs and Type B Emergency Departments are creating great confusion and harm to patients. These hospital owned and operated facilities are also harming those in this field who are being very upfront and forthcoming regarding the “real” Freestanding Emergency Centers.