Nicci Silva was five months pregnant when she began having heart palpitations on a late October night in 2022. She and her husband, Aynsley, didn’t think twice before visiting the nearest urgent care clinic.
Urgent care could not help, and the Silvas were encouraged to visit the nearest emergency department instead: PeaceHealth Southwest Medical Center in Vancouver. What they expected to be a short checkup to ensure Nicci Silva and the baby’s safety turned into an eight-hour visit — one that ended with almost $10,000 in medical bills, including an unexpected charge of $4,178 from PeaceHealth.
Nicci Silva gave birth to a baby boy, Everett, in March 2023. But more than a year later, the couple is still paying off that emergency department bill and hoping for more transparency from hospital systems on the cost of care.
A PeaceHealth spokeswoman declined to comment on the Silvas’ situation Tuesday, citing federal privacy law that protects patients’ medical records and other personal health information from being shared with others.
“I think it’s confusing on purpose. I’m not really sure what the rules are for this game,” said Aynsley Silva, 41. “It makes me wonder what the actual cost of things are. There’s this weird money-grab game that they’re playing, and it doesn’t seem forthright.”
Visit to the ER
When Nicci Silva, 32, visited the PeaceHealth emergency department Oct. 20, 2022, she had just started a new job and didn’t have health insurance. It took a while before the nurses checked her in and asked about her heart palpitations.
“By that time, they had stopped, and I wondered if it was even worth it with the cost,” Nicci Silva said. “But we wanted to be safe.”
Individual providers performed a series of tests, including a blood panel, pap smear and a computed tomography angiogram. The couple said the providers at PeaceHealth quoted them accurate prices for treatment, but staff did not tell them there would be a separate charge for the hospital.
The No Surprises Act is a federal law that went into effect Jan. 1, 2022. A section on PeaceHealth’s website about surprise billing states, “When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center in Washington, you are protected from surprise billing or balance billing.”
“We have a central PeaceHealth team that provides estimates to any patient requesting. That being said, ED visits are among the most difficult charges to estimate,” PeaceHealth spokeswoman Debra Carnes said in an email Tuesday.
At the end of the eight-hour visit, nurses told the couple Nicci Silva was OK to go home. They left knowing the bill would be expensive, but they still thought it would be manageable.
A couple weeks later, the couple received a series of separate bills: one larger bill from PeaceHealth and multiple small bills from individual providers contracted with the hospital.
The original bill from PeaceHealth totaled $9,590 and was adjusted to $6,233 after a personal pay discount was applied, a discount that is only available to uninsured patients. The bills from the separate providers totaled about $2,500. Aynsley Silva said he still didn’t understand why they were being charged by the hospital, and individual providers, for seemingly the same set of tests.
But one charge in particular included in the PeaceHealth bill surprised the couple: a “Level 5 ER visit” charge for $4,178. It was the most expensive charge and outweighed the entire cost of the blood panel and other tests Nicci Silva received that night.
“The contractors were charging us for the services they provided and so was the hospital. It was super frustrating because I’m a counselor, so when the No Surprise Act got rolled out, it was a big deal in our field because you have to give the cost of all the services possible to your clients,” Aynsley Silva said. “I was aware it didn’t apply to the emergency room, because it’s not technically a scheduled visit. But we wouldn’t have known to ask about a $4,000 ‘facility fee.’”
‘Just in case fee’
Around February 2023, Aynsley Silva said he reached out to PeaceHealth’s general billing department to inquire about the $4,178 charge and to see if the couple qualified for Charity Care.
According to the Washington State Hospital Association, Charity Care is a state law that requires hospitals to provide free or discounted inpatient and outpatient care. Each hospital is responsible for maintaining its own charity care program.
“Since 2018, our practice has been to counsel and share information about charity care — or financial assistance — with patients and their loved ones at every step of their journey,” Carnes said in an email. “When patients arrive for an appointment, onsite signage about billing begins with clear, plain language about financial assistance. At check-in, financial assistance is discussed at the earliest opportunity with patients, along with how to apply.”
The couple said they were not eligible for financial assistance because their income was just above the threshold.
Aynsley Silva said when he inquired about the $4,000 charge, one representative told him it was a general “facility fee” but could not explain exactly what that meant.
The couple had already paid the bills from the individual providers before they were sent to collections and hoped the PeaceHealth hospital bill could be reduced.
“I ended up escalating it up to a manager, where I finally got on the phone with this lady who said it was a ‘just-in-case fee,’ which didn’t make sense either,” Aynsley Silva said. “We already paid the money to the individual providers. So, I’m either paying twice, or there’s this mystery fee that you guys dropped on me that no one talked to us about.”
The bill states the charge is due to Nicci Silva’s visit being classified as a Level 5 ER visit. According to the American College of Emergency Physicians, symptoms that constitute a Level 5 visit could include blunt, penetrating trauma; severe burns; hypothermia; and severe infections requiring antibiotics.
PeaceHealth’s response
In an Aug. 23, 2023, letter PeaceHealth Clinical Risk Manager Jon Irving addressed the family’s billing concerns.
“You stated that you were not told about a $4,000 facility fee upon your arrival and inquired about prices not posted in the ED upon entering. Unfortunately, it is not possible to predict what an ED bill will be, as it varies based on a patient’s acuity and the treatments/tests performed,” Irving wrote. “Per federal law, we are required to treat all patients who present to the ED to be seen, regardless of their ability to pay. We do not delay a patient’s care to discuss pricing and financial options.”
Irving said Nicci Silva’s case would have constituted a Level 5 ER visit as defined by the American College of Emergency Physicians.
“In your case specifically, the $4,178 charge for the ‘ER Visit Level 5’ is based directly on the care you received,” Irving said. “This charge would include the IV you received, the triage assessment performed on you, preparation for your CT angiogram and monitoring of vital signs. You can find the definition of these levels at www.acep.org/administration/reimbursement/ed-facility-level-coding-guidelines.”
After nearly a year of trying to understand the charge, Nicci and Aynsley Silva said they were frustrated by the unclear explanations from management across PeaceHealth. Aynsley Silva also said no one was able to explain why they paid both individual providers and the hospital for the services Nicci Silva received.
However, they wanted the ordeal to be over, so they set up a payment plan with PeaceHealth and transferred the balance to a zero-interest credit card. They hope to have that credit card paid off by the end of summer.
“When you’re paying for services in medicine, there should be a very clear reason why you’re paying this charge,” Aynsley Silva said. “It’s a game, and there are a lot of ways to play it. ”
