Rohnert Park Urgent Care -- Or Emergency Room?

I have come to have a love-hate relationship with St. Joseph Urgent Care ,aka Rohnert Park Urgent Care, located at 1450 Medical Center Drive in Rohnert Park. The medical care facility that is owned by St. Joseph Health System, the operators of Santa Rosa Memorial Hospital and Petaluma Valley Hospital, both in Sonoma County and about 10 miles from my home.

On the one hand, it's nice to have a medical facility just down the street that is open long hours seven days a week.  On the other hand, they never get the billing right, instead charging higher copay amounts than what is contracted with insurance companies. In spite of being an Urgent Care facility, which is supposed to help keep people out of the far more expensive Emergency Rooms, my insurance has without fail been billed as "Emergency Department" and I have also been sent a bill for a higher copay.

The most recent occasion was February 16, when I went to St. Joseph's Rohnert Park urgent care facility on a Saturday evening to get help for what had become a very painful and infected toenail.  As I was being admitted, I showed the $35 copay listed on the front of my Cigna Insurance card and paid the $35 before leaving the facility.

What I received in the mail a couple of weeks later was a statement of benefits from the insurance carrier indicating that my time there had been billed as an "Emergency Department" visit with separate charges totaling $962.97.  This was followed by a bill on Santa Rosa Memorial Hospital letterhead referencing the date of service, and asking for an additional $65 copay. My copay for Emergency Room visit is $100, which was one of the reasons I went to Rohnert Park Urgent Care. On the website for St. Jospehs Urgent Care, it even says that using urgent care is an affordable alternative to the emergency room.

On Friday of last week, I called the billing department phone number listed on the bill and told the clerk on the other end of the phone about the situation. She was sorry, she said, but there was nothing that she could do about it. Instead, she assigned blame to the insurance company, saying that they must have entered an incorrect code.

I called Cigna and spoke to a rep about the claim. The rep looked it up and said that St. Joseph/Santa Rosa Memorial Hospital had billed the February 16 visit as being Emergency Room.  She explained to me how the coding worked and how she could tell that it was the billing department's issue, and not the insurance company.  She went one step further and looked up the contract that the hospital group has with Cigna, and according to the Cigna rep, there is no Urgent Care designation on the contract -- only Emergency Room.

So, consequently, any claims that come from St. Joseph Urgent Care are going to be billed at the higher Emergency Department rate, and patients will routinely receive higher bills for their copay. She said that to get this resolved, that the hospital group would have to resubmit the bill with some designation of this being an Urgent Care visit.

I called back to the St. Joseph/Santa Rosa Memorial Hospital billing department and spoke to the same clerk.  She said that there was no way that they were going to resubmit the billing. She suggested that I speak to her supervisor, who due to the hour on Friday afternoon could not speak to me until Monday. I agreed to do so.

Monday rolled around and no call back from the supervisor.  Late Tuesday afternoon, a pleasant-sounding woman named Rosa did call, and we played phone tag until Thursday.  The bottom line, she said when we talked, was that this had been billed correctly.  She parroted her clerk and put the fault of the mistakes squarely on the insurance company.  She said that the billing may have "scanned wrong" in Cigna's system.

I told her that I found this difficult to believe, based on my experience of being over-billed in this same fashion at least a half-dozen times over the years, and with different insurance companies.  And that just last August, my wife, who had been treated cut lip injury from the gym, had received an "Emergency Room" bill with higher copay -- and had just paid it instead of making the time to dispute it.  I added that it seemed like something illegal may be taking place with billing of the Urgent Care.  How many people get over-billed, and then simply pay the bill, as my wife had done?

I told Rosa that I intend to contact hospital administration about this, and quite possibly the California Department of Insurance. It seemed to me that there was a pattern of wrongful billing going on at the facility. (Stay tuned for details).

Rosa said that she would take care of the $65 bill that had been sent, making it go away. But she added that the problem itself was not likely to disappear anytime soon.  It was quite possible if I were to return to St. Joseph Urgent Care in Rohnert Park, that I should "expect this to happen again," she said.