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Denver Health medical center, photographed on Thursday, April 4, 2019. (Jesse Paul, The Colorado Sun)

Take a deep breath and imagine an unpleasant scenario: It’s late at night, your kid is really sick and you need to go to the emergency room.

How much are you going to be charged just to walk through the door?

The answer, according to a new analysis by a Colorado nonprofit, varies widely depending on where you go and how serious the hospital thinks the situation is. It could be as little as $190 at the cheapest hospitals and for the least-serious conditions. Or it could be more than $4,500 at more expensive emergency rooms treating the most grave conditions.

And that just covers the portion of the bill for evaluation and management. The cost for the actual medical treatment gets added on to that.

The analysis was produced this month by the Center for Improving Value in Health Care, which manages the state’s all-payer claims database, a massive collection of information on insurance claims paid out across Colorado.

“I think the whole point is there is variation, just like with any service category in health care,” said Cari Frank, a spokeswoman for the center. “And it doesn’t always have a rhyme or reason to it.”

A chart showing the results of the Center for Improving Value in Health Care’s analysis of emergency room facility fees in Colorado. (Courtesy of CIVHC)

The new report isn’t a shopping guide; it doesn’t show how much emergency room visits cost at specific hospitals. But, by providing an overarching view of emergency pricing at Colorado hospitals, it sheds light on two of the most important — and least talked about — aspects of your emergency room bill: The facility fee that a hospital charges and the severity code it assigns to your case.

The facility fee relates to the costs just to keep the emergency room up and running. The severity code (it goes from one at the lowest to five at the highest) allows for more expensive charges for more complicated medical situations.

Hospitals currently must post their emergency facility fee charges per severity level on their websites, which has previously provided some hint of the variation. Take, for instance, three hospitals that sit just off Colfax Avenue in Denver and Aurora.

At Saint Joseph Hospital in Denver, the facility fee for a level one ER visit is about $143, while a level five visit costs $1,753. Across the street at Presbyterian/St. Luke’s Medical Center, the same levels of visits cost $670 and $6,405, respectively. And down the road at the University of Colorado Hospital in Aurora, those charges are $223 and $2,666, respectively.

Hospital advocates are quick to point out that not all emergency departments are created equal. Some are equipped to handle more serious situations — or higher volumes of patients — than others. And that has an influence on their facility fees.

These numbers also usually come with another big caveat: They are the charges that someone without insurance would be billed. The hospitals have likely negotiated separate rates with insurance companies, which will be passed onto people with coverage.

Those two caveats, combined with the distance you might have to travel to get to a hospital, mean that it’s practically impossible for a person who really needs an emergency room to choose one based solely on price.

“ER visits aren’t something you’re always shopping for,” Frank said.

But Frank said that’s why the new report is important. It sets a baseline so patients, regulators and lawmakers — who this year passed a bill requiring more price transparency from hospitals — know what is normal and what is exorbitant.

Denver Health medical center, photographed on Thursday, April 4, 2019. (Jesse Paul, The Colorado Sun)

The report, along with a few others, also provides insight into a concern that is slowly gaining national attention. Are hospitals “upcoding,” as in listing a patient’s medical condition at a higher severity level than necessary in order to charge a bigger fee?

A report this summer by the national Health Care Cost Institute found that, across the country, the percentage of ER visits coded at the highest severity level rose to 27% in 2017 from 17% in 2008, while the use of the three least-severe code levels dropped. Nearly two-thirds of all ER visits across the country are now put in the highest-severity codes.

When CIVHC looked at the issue in 2017, it found a similar trend for Colorado. Level one codes were almost never used, and level five codes increased to more than 33% of all ER visits in 2016 from 23% in 2009 for people with private insurance.

To hospital advocates, this is an example of the system working better — only the most serious medical situations should end up in the ER, everything else should go to urgent care or lower. Total ER visits across the state declined from 2016 to 2017, and while the number of visits increased in 2018 in raw numbers, they fell again relative to population growth, a spokeswoman for the Colorado Hospital Association said.

“We should start to see more ED visits coded at the highest level if the system is working correctly, because only the sickest patients are seeking care in the ED,” Steven Summer, the head of the hospital association, said in a statement, using the modern medical lingo acronym for emergency department instead of the more colloquial ER.

But Frank said the trend bears closer watching to be sure that’s what’s actually happening.

“We need more analysis to figure that out,” she said.

This article was updated at 12:05 p.m. on Aug. 21, 2019, to correct that Colorado Hospital Association numbers show emergency room visits falling from 2017 to 2018 relative to population growth, not relative to total patient volume.

John Ingold is a co-founder of The Colorado Sun and a reporter currently specializing in health care coverage. Born and raised in Colorado Springs, John spent 18 years working at The Denver Post. Prior to that, he held internships at...