A Hospital Charged $722.50 to Push Medicine Through an IV. Twice.

Claire Lang-Ree was in a lab coat taking a college chemistry class remotely in the kitchen of her Colorado Springs, Colorado, home when a profound pain twisted into her lower abdomen. She called her mom, Jen Lang-Ree, a nurse practitioner who worried it was appendicitis found a nearby hospital in the family’s health insurance network.

After a long wait in the emergency room of Penrose Hospital, Claire received morphine an anti-nausea medication delivered through an IV. She also underwent a CT scan of the abdomen a series of tests.

Hospital staffers ruled out appendicitis surmised Claire was suffering from a ruptured ovarian cyst, which can be a harmless part of the menstrual cycle but can also be problematic painful. After a few days — a chemistry exam taken through gritted teeth — the pain went away.

Then the bill came.

Patient: Claire Lang-Ree, a 21-year-old Stanford University student who was living in Colorado for a few months while taking classes remotely. She’s insured by Anthem Blue Cross through her mom’s work as a pediatric nurse practitioner in Northern California.

Total Bill: $18,735.93, including two $722.50 fees for a nurse to “push” drugs into her IV, a process that takes seconds. Anthem’s negotiated charges were $6,999 for the total treatment. Anthem paid $5,578.30, the Lang-Rees owed $1,270 to the hospital, plus additional bills for radiologists other care. (Claire also anted up a $150 copay at the ER.)

Service Provider: Penrose Hospital in Colorado Springs, part of the regional health care network Centura Health.

What Gives: As hospitals disaggregate charges for services once included in an ER visit, a hospitalization or a surgical procedure, there has been a proliferation of newfangled fees to increase billing. In the field, this is called “unbundling.” It’s analogous to the airlines now charging extra for each checked bag or for an exit row seat. Over time, in the health industry, this has led to separate fees for ever-smaller components of care. A charge to put medicine into a patient’s IV line — a “push fee” — is one of them.

Though the biggest charge on Claire’s bill, $9,885.73, was for a CT scan, in many ways Claire her mom found the push fees most galling. (Note to readers: Scans often are significantly more expensive when ordered in an ER than in other settings.)

“That was so ridiculous,” said Claire, who added she had previously taken the anti-nausea drug they gave her; it’s available in tablet form for the price of a soda, no IV necessary. “It works really well. Why wasn’t that an option?”

In Colorado, the average charge for the code corresponding to Claire’s first IV push has nearly tripled since 2014, the dollars hospitals actually get for it has doubled. In Colorado Springs specifically, the cost for IV pushes rose even more sharply than it did statewide.

A typical nurse in Colorado Springs makes about $35 an hour. At that rate, it would take nearly 21 hours to earn the amount of money Penrose charged for a push of plunger that likely took seconds or at most minutes.

The hospital’s charge for just one “IV push” was more than Claire’s portion of the monthly rent in the home she shared with roommates. In the end, Anthem did not pay the push fees in its negotiated payment. But claims data shows that in 2020 Penrose typically received upward of $1,000 for the first IV push. And patients who didn’t have an insurer to dismiss such charges would be stuck with them. Colorado hospitals on average received $723 for the same code, according to the claims database.

“It’s insane the variation that we see in prices, there’s no rhyme or reason,” said Cari Frank with the Center for Improving Value in Health Care, a Colorado nonprofit that runs a statewide health care claims database. “It’s just that they’ve been able to negotiate those prices with the insurance company the insurance company has decided to pay it.”

Penrose initially charged more money for Claire’s visit than the typical Colorado hospital would have charged for live birth, according to data published by the Colorado Division of Insurance.

Even with the negotiated rate, “it was only $1,000 less than an average payment for having a baby,” Frank said.

In an emailed statement, Centura said it had “conducted a thorough review determined all charges were accurate” went on to explain that “an Emergency Room (ER) must be prepared for anything everything that comes through the doors,” requiring highly trained staff, plus equipment supplies. “All of this adds up to large operating costs can translate into patient responsibility.”

As researchers have found, little stands in the way of hospitals charging through the roof, especially in a place like an emergency room, where a patient has no choice. A report from National Nurses United found that hospital markups have more than doubled since 1999, according to data from the United States Bureau of Labor Statistics. In an email, Anthem called the trend of increasing hospital prices “alarming” “unsustainable.”

But Ge Bai, an associate professor of accounting health policy at Johns Hopkins University, said that when patients see big bills it isn’t only the hospital’s doing — a lot depends on the insurer, too. For one, the negotiated price depends on the negotiating power of the payer, in this case, Anthem.

“Most insurance companies don’t have comparable negotiating or bargaining power with the hospital,” said Bai. Prices in a state like Michigan, where Bai said the autoworkers union covers a big portion of patients, will look very different from those in Colorado.

 Also, insurers are not the wallet defenders patients might assume them to be.

“In many cases, insurance companies don’t negotiate as aggressively as they can, because they earn profit from the percentage of the claims,” she said. The more expensive the actual payment is, the more money they get to extract.

Though Anthem negotiated away the push fees, it paid the hospital 30% more than the average Level IV emergency department visit in Colorado that year, it paid quadruple what Medicare would allow for her CT scan.

Resolution: Claire her mom decided to fight the bill, writing letters to the hospital searching for information on what the procedures should have cost. The prices of the IV pushes the CT scan infuriated them — the hospital wanted more than double what top-rated hospitals typically charged in 2019.

But the threat of collections wore them out ultimately they paid their assigned share of the bill, $1,420.45, which was mostly coinsurance.

“Eventually it got to the point where I was like, ‘I don’t really want to go to collections, because this might ruin my credit score,’” said Claire, who didn’t want to graduate from college with dinged credit.

Bai Frank said Marylcan be a useful benchmark for medical bills, since the state sets the prices that hospitals can charge for each procedure. Data provided by the MarylHealth Care Commission shows that Anthem Claire paid seven times what she likely would have paid for the CT scan there, nearly 10 times what they likely would have paid for the Level IV ER visit. In Maryland, IV pushes typically cost about $200 apiece in 2019. A typical Marylhospital would have received only about $1,350 from a visit like Claire’s, the Lang-Rees would have been on the hook for about $270.

Claire’s pain has come back a few times but never as bad as that night in Colorado. After visiting multiple specialists back home in California, she learned it might have been a condition called ovarian torsion. Claire has avoided reentering an emergency room.

The Takeaway: Even at an in-network facility with good insurance, patients can get hurt financially by visiting the ER. A few helpful documents can help guide the way to fighting such charges. The first is an itemized bill.

“I just think it’s wrong in the U.S. to charge so much,” said Jen Lang-Ree. “It’s just a little side passion of mine to look at those make sure I’m not being scammed.”

Bai, of Johns Hopkins, suggests asking for an itemized explanation of benefits from the insurance company, too. That will show what the hospital actually received for each procedure.

Find out if the hospital massively overcharged. The Medicare price lookup tool can be useful for getting a benchmark. And publicly available data on health claims in Colorado at least 17 other states can help, too.

Vincent Plymell with the Colorado Division of Insurance encourages patients to reach out if something looks sketchy. “Even if it’s not a plan we regulate,” he wrote in an email, such departments “can always arm the consumer with info.”

Finally, make it fun. Claire Jen made bill-fighting their mother-daughter hobby for the winter. They recommend pretzel chips cocktails to boost the mood.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


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