Obstetrical emergency departments are a new aspect of some hospitals that can inflate medical bills for even the easiest, healthiest births. Just ask baby Gus' parents about their $2,755 ER charge.


SCOTT DETROW, BYLINE: Is the on-time birth of a healthy baby an emergency? Seems pretty straightforward. But that question gets us to the heart of our medical bill of the month. Dr. Elisabeth Rosenthal is the editor-in-chief of our partner, Kaiser Health News. And she is here to discuss this one with us. Welcome back, Elisabeth.

ELISABETH ROSENTHAL: Hi, Scott. Nice to be here again.

DETROW: So who are we hearing from today?

ROSENTHAL: Today we're meeting a young family from Fort Collins, Colo. There's Caitlin Wells Salerno, her husband, Jon, and their two very cute little boys, Hank and Gus.

DETROW: Those are two good names for two little kids, look forward to hearing from them. All right. So your reporter, Rae Ellen Bichell, met the family. Let's listen to her story. And then you and I are going to talk about it afterwards.

RAE ELLEN BICHELL, BYLINE: Caitlin Wells Salerno is a conservation biologist who studies how much animals invest in their babies. An elephant pregnancy lasts almost two years.

CAITLIN WELLS SALERNO: I mean, I don't envy elephants because that is a long time to be pregnant.

BICHELL: She does not envy the golden-mantled ground squirrel that she studies, either. They nurse their babies until the babies collectively weigh twice what the mom does, the equivalent of a human mom breastfeeding a 300-pound child.

C SALERNO: But then they're done. Then they just send them on their way. And they forage for themselves and disperse.

BICHELL: But humans are stuck with their offspring for decades. And they are the only animal that can spend parental energy playing phone tag with a hospital billing office. The subject of those calls? - Gus, a roly-poly toddler fond of biting things, walking like a drunken sailor and picking not ripe tomatoes.

JON SALERNO: What did you just put in your mouth?

C SALERNO: Is that tomato?

GUS: (Shrieking).

J SALERNO: Come here.

BICHELL: Gus was born in April 2020 in the early weeks of COVID lockdowns. Caitlin and her husband, Jon Salerno, said the experience was a little weird, like how they had to enter through the emergency room because it was the only door open.

J SALERNO: It was totally quiet, empty.

BICHELL: But the birth was quick and smooth.

C SALERNO: Yeah. His birth was great.

BICHELL: Gus arrived right on his due date.

C SALERNO: And he was enormous and healthy. And that's all we wanted.

BICHELL: When the bill came, it showed the hospital wanted more than $16,000. And the family was responsible for 3,600 of it.

C SALERNO: I first saw. And I was just like, whoa (laughter). That's interesting.

BICHELL: Caitlin and Jon's first child, Hank, had a tricky birth. But it was cheap. It cost the family a mere $30, basically the same as what they would have paid at the grocery store for a brick of cheddar cheese the size of Hank. The family knew not to expect that again. They were in a different state with different insurance. Still, what really made their eyeballs pop was a line for a Level 5 emergency department charge for nearly $3,000.

C SALERNO: It seemed like that could have been a mistake and that we went through the ER but it was not an emergency.

BICHELL: So they asked around. An ER doctor relative said that level of emergency is usually for really serious stuff.

C SALERNO: It's gunshots and car accidents is how it was described to us. And I didn't even have a high-risk pregnancy. I was fine.

BICHELL: So they made a bunch of calls to UCHealth, the company that runs the hospital where Caitlin delivered, trying to figure out what this charge was for. No one seemed to know. Finally...

C SALERNO: I got a voicemail that said...


UNIDENTIFIED PERSON: And the emergency room charge is actually the OB triage little area that you go into before they take you to the labor and delivery room. So at this point, we are showing that that charge is correct.

C SALERNO: And at that point, I didn't know what else to do. And I was too tired to do anything else. So we just paid it.

BICHELL: But they wondered, were other families getting these charges, too?

J SALERNO: We complain a lot. But we can pay the hospital bills, you know? So many people can't.

BICHELL: And at the end of the day, they have two awesome kids, even if one did cost 100 times more than the other. I'm Rae Ellen Bichell in Fort Collins, Colo.

DETROW: And Dr. Elisabeth Rosenthal, the editor-in-chief of Kaiser Health News, is is still here. Elisabeth, we have been reporting a lot on inflation on this program. But $30 to more than 3,000 is a wild, wild increase. What is going on here?

ROSENTHAL: Oh, in part, it's the typical yet irrational variation we see throughout our private health care system. But there's also something relatively new going on. It's a new-fangled billing construct called OB-ED - that's obstetrics emergency department. But the thing is, it's more of a concept than a physical place for any emergency medical intervention. I mean, in Caitlin's case, that's just the room where a nurse placed an IV and where Caitlin's doctor examined her and confirmed she was in active labor. So that line item on the bill was just for the routine care that every woman gets before you're moved into the delivery room.

DETROW: So let me just get this straight. You're talking about a new concept here. Is this a new room? Is this a new type of service provided in the hospital?

ROSENTHAL: No. It didn't even happen in the emergency room. It's just the OB triage area that's always been there on the labor and delivery floor. This is really just rebranding routine care and charging more for it - a lot more. In fact, we found documents from medical staffing companies that are very transparent. They said hospitals are, quote-unquote, "leaving money on the table" if they don't charge these ER OB fees and called this an entrepreneurial way of bringing in more money.

DETROW: And what about this way of scaling emergencies? This is a Level 5 emergency and, again, for a pretty straightforward birth.

ROSENTHAL: Yeah. I mean, there was no emergency going on here. It's a huge stretch. As Caitlin said, Level 5 emergencies are the very highest level of charge. They're for things like heart attacks, car accidents, not a baby arriving on his due date with zero complications. But this is something we call upcoding. And hospitals have been doing it more and more for decades.

DETROW: So what do you do if you find yourself being upcoded?

ROSENTHAL: Well, first of all, for births, be prepared to ask your hospital, doctor and insurer to estimate what you're going to owe. And see if they have this new-fangled OB-ED charge because that's going to increase your costs. And even in a genuine ER, always look at the level of billing. If you see a Level 4 or 5 charge on the bill but you know nothing very intensive was performed or needed, you should protest. Your insurer doesn't know what happened in that room, but you do, so question it.

DETROW: Well, now I've learned a new word today, upcoding. Elisabeth Rosenthal, thank you so much for joining us.

ROSENTHAL: Sure. It's a scary word. And I wish it hadn't entered our vocabulary. But it's considered fraud. And it will get the billing department's attention.

DETROW: So if you have a confusing or outrageous medical bill or a combination of both, please, go to NPR's Shots blog and tell us about it. Dr. Elisabeth Rosenthal is the editor-in-chief of our partner, Kaiser Health News.

(SOUNDBITE OF DARKSIDE'S "GOLDEN ARROW") Transcript provided by NPR, Copyright NPR.