Health & Medicine

The Lines Are Blurred Between Freestanding ERs and Urgent Care Centers

The vague distinction between the two may be misleading—and costing—unsuspecting patients in North Texas.

Last November in Frisco, Candie and Dustin Sandlin entered a Legacy ER & Urgent Care center—a walk-in clinic that also operates as a freestanding emergency center—because the couple’s primary-care physician was unavailable. Candie, experiencing symptoms of a migraine headache, was told by the on-site doctor that a CAT scan was needed to rule out any serious diagnoses.

Candie was reluctant, but agreed to the procedure. Afterward, Dustin says the doctor diagnosed his wife with a headache. The Sandlins returned to Legacy ER & Urgent Care five days later, with Candie still in pain. This time, Dustin says, another doctor suggested she may have vertigo, and ran a blood test to confirm the hunch. Once the diagnosis was confirmed, he says, the doctor could only provide “over-the-counter motion-sickness medicine, because the facility did not have medicine to specifically treat vertigo.” The total bill for the two visits? “$7,000,” Dustin says.

When asked by Dustin in a formal complaint why the bill was so high, he says the facility replied it was because Candie had received a CAT scan and a blood test and that these services were categorized as “emergent,” allowing Legacy to charge freestanding ER prices, without verbally notifying the patient. (Emergent care typically is required in case of a threat of grave disability, or an immediate threat to a patient’s life.)

Later, the Sandlins did recall seeing, in fine print, a reference in Candie’s paperwork to the possibility of some services being “emergent,” which for them meant out-of-network insurance care, carrying a higher price tag. For Dustin, though, a bigger question arose: “Why weren’t patients being notified which medical procedures are classified as urgent care—or emergency services—so they knew the difference?” Legacy didn’t return our calls seeking comment.

“There should be a list of services that is distinctly offered, so people are aware. But that list doesn’t exist.”

Dustin Sandlin, husband of patient

The Sandlins aren’t alone in their experience, or in their question. In Frisco alone, freestanding emergency centers owned by Legacy, Code 3 ER & Urgent Care, and other independent operators have attracted more than 10 pages of website reviews. There, patients have complained variously about exorbitant, hidden costs for the treatment of problems ranging from minor injuries to colds.

This is mostly because independently owned urgent care or freestanding emergency centers in general are able to “bait and switch consumers,” Dustin Sandlin alleges. “People are coming in for urgent care—it’s not our goal to go to the ER,” he says. “The transparency of what is and what isn’t considered an ‘emergent’ service determines the price point. There should be a list of services that is distinctly offered, so people are aware. But that list doesn’t exist.”

In Dallas-Fort Worth, according to a national urgent care database, there are at least 45 urgent care centers—26 of which operate as both urgent cares and freestanding ERs. There are more than 490 urgent care centers total in Texas. In addition, there are at least 40 freestanding ERs in North Texas, mostly in middle-to-high income areas, according to the Texas Association of Freestanding Emergency Centers (or TAFEC), and 325 such facilities statewide. Two-thirds of these ERs are independent, while the rest are hospital-operated.

Of course, not everyone believes like the Sandlins that independently operated, freestanding medical facilities are misleading patients. One who doesn’t is Dr. Carrie de Moor, president and CEO of Frisco-based Code 3 Emergency Physicians, and chairman of the American College of Emergency Physicians’ Freestanding Emergency Centers Section. She believes a lack of cooperation between insurance providers and the facilities is what leads to higher-than-expected, out-of-network bills.

In an April commentary for D CEO Healthcare titled “Willing healthcare providers seek fair in-network contracts,” de Moor wrote about the resistance by insurance companies to accepting these facilities as healthcare providers. She describes the facilities as providing expeditious, cost-effective emergency services in a transparent manner.

In an interview, de Moor adds, “I believe having a dual model—both an urgent care and a freestanding emergency center—actually helps us be transparent. We can distinguish if a patient has an emergency or not, and diagnose them on how to treat it.” According to TAFEC, urgent care facilities serve as alternative care options for patients with non-life-threatening injuries or illnesses. Meanwhile, freestanding emergency centers serve as facilities—staffed with 24/7, ER-trained physicians—that treat cases requiring immediate attention.

But Stephen Mansfield, CEO of Dallas-based Methodist Health System, contends that, in reality, there is little difference between the two. Mansfield says he knows of a few facility owners who “basically turned an urgent care into a freestanding ER, by changing [their] operating hours to be open 24/7, 365 days. They didn’t really change the staffing model, clinics, or equipment. They may add a CAT scan and a small lab. But the main difference is that the facility needed only four more visits a day [to stay in business], since the reimbursement is so much higher” for emergency centers.

With a highly profitable business model, and free rein to plant seeds in higher income areas following the passage of a 2010 Texas licensing law, it’s no wonder that freestanding ERs are proliferating here. “For a private entity investing in private money … there’s not any stipulation that you can’t set up a freestanding ER,” Mansfield says. “We don’t have [certificates-of-need] in Texas. … If you want to put one at an intersection or by a hospital, and you can get the land, you can do it. There is no regulatory body to tell you otherwise.”

While it may be relatively easy to set up shop, de Moor says independent freestanding centers face other obstacles. Her struggle working with insurance providers, for example, prevents her patients from being billed in-network, she says. “We’re trying to get patients to understand their healthcare plans better, and educate them so they know we’re trying our best to be in-network with them,” de Moor says. “ … We’re doing what we can.”

Kevin O’Donnell, managing partner at Dallas-based Healthcare Resources of America, believes patient safety is an additional concern with some of these facilities. “Urgent care centers and freestanding ERs have a lot of limitations on what medical services they can provide,” O’Donnell says. “In a serious emergency like a stroke or heart attack, [patients] won’t get the care they need there. They may be able to stabilize them for the next move—which is a hospital emergency room—but you’re putting their safety at risk, losing time.”

Says Mansfield: “Hospital systems pay millions of dollars every year for specialists to be on-call. If you go to an emergency room there, you’ll have a doctor that can cater to your problem well. At a freestanding ER, you’ll see a doctor with a limited skill set. What ends up happening is an ambulance will take you to a hospital ER. Then you have to pay for two visits, while putting your health at risk.”

Mansfield’s Methodist Health is one of the largest DFW healthcare systems that has yet to contract with any independently operated, freestanding ERs. Other systems have opted to open freestanding emergency centers, sometimes partnering with independent operations.

In a D CEO Healthcare article last year, Barclay Berdan, CEO of Texas Health Resources, said THR decided to partner with the First Choice Emergency Room chain, adding a number of freestanding emergency rooms in order to increase access to care.

As of now, Mansfield says, Methodist has no similar plans. “We believe everything we do either needs to improve quality of care for the patient or lower the cost,” he says. “So far, we’ve had a hard time convincing ourselves that freestanding ERs do that.” 

After this article went to press in D CEO’s July/August issue, Dustin Sandlin reported that his issues with Legacy ER & Urgent Care had finally been resolved.

Olivia Nguyen is the editor of D CEO Healthcare and a D CEO associate editor.


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  • Happy Bennett

    Consumers would do well to avoid any facility charging hospital rates of “out of network” insurance rates. In my experience, these operations which may include other facility “minor emergency” stalls in supermarkets, “doc in the box” operations, multigroup ACO or surgery (especially Orthopedists) with Imaging Center “profit generating centers”, do not offer the best or most cost efficient care. CT is now highly regulated by the TRCR TDH regulators for dose to patient compliance, but their is little evidence that Free Standing ERs are even dong an appropriate CT exam for the patient’s symptoms. Then, as the article above delineates, treatment options at “Free Standing” ERs at limited. What if a CVA is diagnosed, time is lost on the profit generating CT for the patient who needs time sensitive anticoagulation treatment not offered at the bandage station free standing ER? THR, is not, IMO, an honest broker here either, by perpetuating this flawed healthcare model through fire sale acquisition. In my experience, THR has a nasty history of bad mouthing competing imaging facilities which are fully compliant with state and national standards apparently to the patient’s financial and other detriment and to THR’s financial benefit.

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  • Marcie Batten

    I had an interesting interaction with a large multi-city Ortho group in Mansfield which had an in house MRI operated by a county hospital management firm.. BCBS directed me to an independent accredited outside imaging center for the MRI the Ortho doc told me I needed because the Ortho-hospital owned in office MRI would have cost me $2800 vs $425 at the other imaging center. The Orthopedist front desk girl tried to discourage me from the BCBS advised imaging center choice by making untrue remarks about the other facility. Needless to say, I followed my insurers advice, saved money and got a good exam.

  • Jarred

    There’s a lot of misinformation in this article. When patients are transferred from FECs to hospitals, in most cases they avoid the ER and are admitted to see a specialist. Also, there are significant differences between FECs and urgent cares. The state legislature created stringent regulations and requirements for licensing FECs, many of which exceed hospital requirements. FEC physicians are highly qualified board-certified physicians. FECs are required to be open 24/7/365 and maintain state of the art equipment that you won’t find at an urgent care. Some of the quoted comments are intentionally misrepresenting the services FECs provide.

    • Marcie Batten

      Transfers take time which as the commentor above stated may delay urgently needed specialty services. Also the extreme patient gouging prices at these places is a matter of record, so much so that the legislature has intervened on behalf of the patient. I think, that by stating that hospital “requirements” are surpassed by such facilities and yet a transfer to a hospital may be required due to limited services, for adequate or state of the art treatment, you are inadvertently defeating your own argument.

      • Jarred

        I think you are confusing the hospital ER with the inpatient services offered at a hospital, which is common. When it comes to the ER portion – apples to apples comparisons – they provide the same level of service. The Texas Legislature created them to be equivalent. However, transfers are warranted when patients need to utilize in-patient services. While FECs transfer via ambulance, hospitals transfer in a stretcher, typically to a different floor or section of the hospital.

        • Marcie Batten

          That’s just BS. State of the art stroke treatment, a good point brought up by the previous blogger for example, requires immediate diagnosis by CT or MRI and immediate in hospital transfer to a radiologic or other specialist for anti coagulation therapy possibly in a high tech cath lab. There is a window of possibly 30-60 minutes to avoid permanent brain death. Why waste time at a corner ER THEN get transferred by ambulance or other vehicle elsewhere? Are you a PR person for or investor in these facilities? The reason I ask Jarred is that a review of your commentary profile shows that ALL of your comments are in defense of free standing ER facilities in rebuttal to consumer advocates in D Business and other sites. Just sayin’…

          • Jarred

            Correct – I work in PR for this industry. And yes, I spend a lot of time correcting misinformation about freestanding ERs. The general idea is that patients can be seen and diagnosed faster at a freestanding ER and then transferred if a specialist if needed (most ER patients do not need to be admitted). This process can be a faster than if patients initially present at the hospital ER, which is often crowded with long wait times. Some patients who don’t express outward symptoms have to wait and then have a stroke or heart attack in the waiting room. Using your example, I think everybody would agree that if a patient has already had a stroke, going to a specialist / cath lab is the best bet.

          • MattL1

            “Correct – I work in PR for this industry.”

            So you didn’t think it prudent to (or unethical not to) reveal that you have a professional and financial interest in the businesses mentioned in this article until called out on it? Are you being paid to post these same talking points on articles critical of this industry?

          • Happy Bennett

            Yes. He appears to be an Accounts Manager for “Influence Opinions” the marketing and communications agency employed by the Texas Association of Freestanding Emergency Centers (TAFEC). Good Grief!

          • Jon Steadman

            I work in both Free Standing ERs and Trauma Centers. The anti-coagulation therapy you refer to is available at our Free Standing ERs as well as at the Trauma Centers that I work in. The key to determining whether cath intervention is needed is a CTA (CT Angiogram) study, which is available at most, if not all Free Standing ERs. The window you speak of is actually 3.5 to 4.5 hours depending on which articles you read, and the window for cath intervention is about 12 hours. There are only a few hospitals in the DFW area who offer this neuro-interventionalist service, which basically means that it doesn’t matter whether you go to a Free Standing ER or an established hospital ER, unless you choose the correct hospital, if you are a candidate for catheter intervention, you are going to get transferred to a center who offers that service. Even many Level 2 and 3 trauma centers don’t offer neuro-intervention; it is that specialized. MRIs are not typically used in Emergency Departments to diagnose a stroke, but rather is ordered and performed once a patient is admitted to the hospital, or after the initial diagnosis obtained through CT and CTA. An MRI is not a quick study. At our Free Standing ERs we can perform CT, CTA, give TPA (the same thing that is done in the hospital ERs), and directly admit patients to several local hospitals, helping you avoid additional ER charges at the receiving hospital. Not really a waste of time at the “corner ER”, but rather a different route to appropriate and efficient care.

        • Erik Sjolseth

          I don’t see that Jarred ever worked in the hospital/ER industry, but his comments are remarkably well-informed.

    • Constance Donovan

      Few hospitals have inpatient beds available consequently transfers from FECs to hospitals end up being a transfer to the hospital’s ER which must comply with all regulatory compliance standards, e.g. EMTALA. Regarding hand-off to specialist at the receiving hospital, typically the receiving hospital’s emergency physician provides hospital medical screening exam and hand-off to the receiving specialist. Emergency nurses provides care for the transferred patient until the patient is transferred to inpatient clinical services – often in overcrowded emergency departments with long queues and limited level of resources, e.g. available nurses and treatment rooms.

      FEC programs and hospital ERs, transfers from facility to facility (regulatory compliance), health plan coverage and billing policies, reimbursement for each site of service and costs of the transfer if by EMS, as well as legal liability of transfers by private vehicle are complicated and require clear protocols and policies to ensure optimal patient care, outcome and patient experience (sum of care, outcomes, efficiency and more).

  • David Apple

    An extremely poorly written article – this headline is getting old and misleading. Texas could be a case study for access to retail care and option but these customer gripe stories are getting redundant. If you go to Legacy ER & Urgent Care facebook page you will see full rebuttal that not only shows the patient jumped the gun and is wrong, but almost jeopardized his relationship with his insurance carrier. Legacy is a hybrid, not a free-standing ER, that allows in-network urgent care billing and in-network ER billing. Actually over 80% of the patients are billed at urgent care rates. The patient even went public with a note stating “Legacy will continue to be my Urgent Care and ER option of choice”. A poor source, and no attempted comment from Legacy. Access to care is important, FSER and urgent cares are not an attempt to “replace” care, they give patients convenient options. Free standing ERs out of network have caused issues with inflated billing, but they are going out of business or only seeing medicare patients. If we continue to scare patients instead of educating them on their benefits and how to use them, we are going to loose a extremely beneficial access to care option that is actually saving patients millions every year over . Boo to Dmagazine for the if it Bleeds it Leads story.

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  • Happy Bennett

    Commenters Erik Sjolseth, Jarred and most likely “one comment in his entire blogging history: David Apple” appear to be industry plants. 2 months ago “Jarred” was identified by a D Magazine Healthcare blogger-Lori Debetaz as an Account Manager for Influence Opinions the marketing and communications agency employed by the Texas Association of Freestanding Emergency Center (TAFEC) and “is PAID to promote these facilities” She goes on to say “(which) contribute to the high cost of health care for all of us…If FECs in Texas had to meet determination of need regulations, we wouldn’t have a ridiculous proliferation of these facilities.” I couldn’t agree more. Patients are being atrociously ripped off to meet the “we only need four patients (victims) a day to meet overhead.” Now according to ER physician manager Carrie de Moor, who has a vested interest in seeing this flawed model survive, the model must morph into something even less transparent AND be subsidized by the “uncooperative(according to her) health insurers”. Boy, someone must be really bleeding to lie this much about a dying industry model. (BTW–“Eric” upvotes ALL of “Jarred’s” comments)

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  • Britt Berrett

    When will the “Medical Industrial Complex” realize that the rest of the world does not truly understand the intricacies of healthcare and are left dazed and confused with all the dynamics of our industry? Kudos to the commentators in this section who make some very valid and important points (and revealing some dubious players).

    Simply stated, an FEC with its attached “facility-fee” makes sense in a rural setting where the financial viability of a full-service hospital is non-viable.

    An FEC in an affluent and well-served community is simply a price-gouging strategy to prey on the unsuspecting and uninformed patients. Perhaps the FEC model will collapse and eventually fold into integrated hospital systems.

    But unfortunately we are causing greater damage with those outside our profession that just interpret these activities as more money-seeking manipulations that require greater and greater regulations.

    So when we complain about the excessive regulation and governmental intervention in healthcare, well, we should look at ourselves and recognize that we did it to ourselves!

    Oh and to Jarred, et al, feel free to give me a call at UTD and perhaps we can engage in some research at UTD that will confirm or dismiss some of your suggestions.

  • Derek Bennetsen (AZ AZCOM 02)

    This article is an unfortunate misrepresentation of Legacy ER and Urgent Care’s business model. Disclosure: I have no affiliation with Legacy, but have worked in the FSED market since 2008, but never for Legacy. Their model is built on placing their patients interests (financial and otherwise) ahead of their own profits. This is evidenced by the fact that 70-80% of what walks in their door is seen on the Urgent Care side of their facility. Urgent care billing and collections is a fraction of a pure ER model. Their model now flourishes due to overwhelming support from the community noted by the high volume of patients visiting their facilities and the number of satisfied customer one can read about on the various social media outlets. In the beginning, the company struggled to gain traction, but the founding physicians (ER doctors) never compromised their core belief that non-emergent patients should not be charged ER rates.

    As for the remainder of the article, it belongs under the “fake news” section of D-Magazine/Healthcare.

  • From reading this article and comments, I wonder how patients are expected to have the knowledge and decision making capabilities, particularly during times of urgent/emergent care, to receive cost effective care covered by their insurance. If this gap is not closed in navigating the system, patients will be at the receiving end of high provider bills.

    Raj Dhameja, MD, MHA

  • Bait&Switch

    How timely of this article. I went into Emergis ER & Urgent Care in Dallas last month with a minor issue. I specifically googled “Urgent care near me” and this was the closest. I was there for a little over an hour and they couldn’t even fix what was ailing me. I had an IV of saline and one dose of a low cost medicine (that even on their outrageous bill was only $19). They weren’t equipped to deal with my issue and I had to go somewhere else. My bill for the facility was $2300. My bill for the doctor (who never touched me, only chatted casually and said they just had one thing to try) was $2125. $4500 for what I thought was going to be a $150 or so urgent care visit. This is bait and switch.