It was a Sunday morning in late November when Bryan Keller hopped on a bike to pick up groceries, cruising with ease in a relatively empty New York City.
The surprises came fast and hard: a fall that sent his head into the pavement and left him bleeding profusely and in shock, a trip to a nearby urgent care clinic for five stitches and then a $1,039.50 bill.
Keller's health insurance covered much of the cost of his visit to the CityMD clinic on Manhattan's Lower East Side. But it didn't cover the physician who arrived to stitch his forehead — an out-of-network plastic surgeon with a Park Avenue office.
"The people at CityMD just said [this] sort of thing is covered as part of an emergency procedure," said Keller, a cyclist who has lived in New York City for three decades. Even in post-accident "delirium," he said, he asked several times whether his health insurance would cover the stitches, because it struck him as unusual that a plastic surgeon would do them.
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"It really irked me that — it's this classic thing you hear in this country all the time," Keller said. "When you do all the right things, ask all the right questions and you're still hit with a large bill because of some weird technicality that there's absolutely no way for you to understand when you're in the moment."
Under a law Congress passed last year, many surprise medical bills will be banned starting in January. Patients with private insurance will be protected against unexpected charges for emergency out-of-network care, for treatment by out-of-network providers at in-network facilities and for transportation in air ambulances. But there is a gray area: visits to urgent care clinics, which have proliferated in recent years as patients seek speed and convenience over waiting hours at emergency rooms or weeks to get regular doctor's appointments. There are about 10,500 urgent care centers in the U.S., according to the Urgent Care Association, which lobbies on their behalf.
Urgent care clinics weren't explicitly addressed in the No Surprises Act. Keller's experience underscores patients' predicament — insurers often try to steer patients to urgent care and away from costly emergency rooms, but they could still get hit with large bills. The Biden administration has expressed an interest in prohibiting surprise bills in clinics, which may treat serious conditions but not life-threatening injuries and illnesses.
Several federal agencies this month issued interim regulations that largely wouldn't protect patients from surprise urgent care bills. Regulation varies significantly across states. Before the surprise billing rules are finalized, the Department of Health and Human Services and three other agencies have asked, for instance, about the frequency of such bills at urgent care facilities and how health insurers contract with the clinics.
Experts say that if it's left untouched before the new law takes effect, the regulatory gap could leave patients at risk.
"There's a real interesting question about whether it should apply to the extent that people perceive these as places to go for an emergency," said Jack Hoadley, a research professor emeritus at Georgetown University's McCourt School of Public Policy.
CityMD, which was founded by doctors in 2010 and merged with the large medical practice Summit Medical Group in 2019, operates a massive chain of urgent care clinics in New York and New Jersey. The combined enterprise created Summit Health, which is backed by private equity investments from Warburg Pincus — which acquired CityMD in 2017 — and Consonance Capital Partners.
Matt Gove, chief marketing officer of Summit Health, confirmed that the plastic surgeon who treated Keller — Dr. Michael Wolfeld — has an agreement with the company that allows him to see patients at certain CityMD clinics. Gove said CityMD's "normal procedure" is to "make the patient aware that this is available to them and that they can then make the choice as to whether or not it's important to them to be seen by a plastic surgeon." Most of CityMD's physicians are emergency doctors, he said.
"This is a patient choice," Gove said. "We certainly don't require that a patient be seen by Dr. Wolfeld or any other provider."
But Keller said it was never put to him as an option. "It was framed to me as this is how we do things," he said. "In order to have a preference, I would have to know that there is an alternative." Wolfeld didn't respond to a request for comment.
The Biden administration this month proposed prohibiting surprise bills at urgent care centers licensed to perform emergency procedures, essentially treating them as free-standing emergency rooms. Some states, such as Arizona, allow urgent care centers to provide emergency services, but they then are considered free-standing ERs, a spokesperson for the state Department of Health Services said. But urgent care centers aren't licensed as health care facilities in most states, let alone encouraged to provide emergency services, said advocates who have pushed for greater government oversight of the industry.
New York, where Keller lives, doesn't consistently regulate urgent care providers, requiring licenses for some companies but not for CityMD clinics.
Regardless of what's prescribed in state regulations, what's considered an "emergency" versus "urgent" can vary by patient. That potentially creates confusion about whether patients would be protected from certain kinds of out-of-network bills if they visit urgent care facilities for acute illnesses or injuries.
Kaiser Health News also found that the urgent care clinic where Keller was treated describes several of its services as emergency care even though many aren't meant to treat emergency conditions as envisioned in federal law. For example, the clinic characterizes physical exams, flu shots and vaccinations as emergency medical services. Under federal law, an emergency medical condition is defined as one in which the absence of immediate medical attention could place a person's health in serious jeopardy.
You don't have protections if it turns out the doctor or the physician assistant was out of network.
Gove, the Summit Health spokesperson, said the use of the word "emergency" is meant to be "patient-facing and patient-centric, and not having to do with miscategorizing or misrepresenting the nature of the services we provide."
The provider is "just making it clear to people that when you have something you need done quickly, which you might call personally an emergency, we're here to do that," Gove said, adding that CityMD has never marketed its facilities as emergency rooms.
Lou Ellen Horwitz, CEO of the Urgent Care Association, said urgent care clinics are akin to private doctor practices rather than emergency rooms or hospital facilities. She said that even as urgent care clinics grow more common, there's "no data" to suggest consumer confusion about what they treat.
The association would oppose any federal push to classify the clinics as something like independent emergency departments, Horwitz said. Indeed, she said, such a move "contradicts" their very purpose: to treat non-life-threatening injuries and illnesses.
"The standard practice of the industry, as well, is that we don't hold ourselves out to be emergency departments," she said. "The likelihood of this being misunderstood is very low."
Nationwide, under the Biden administration's interim regulations, patients needing care for non-emergencies won't be protected if they are treated by out-of-network providers at in-network urgent care facilities, experts said. "You don't have protections if it turns out the doctor or the physician assistant was out of network," Hoadley said.
A report in March from Community Catalyst, a Boston-based health care advocacy organization focused on consumer issues, and the National Health Law Program, a civil rights advocacy group, found that fewer than 10 states issue facility licenses for urgent care clinics.
"They're really flying under the radar now in many cases," said Lois Uttley, director of the Women's Health Program at Community Catalyst.
Horwitz, however, said the clinics shouldn't be lumped in with providers categorized as health care facilities, which include hospitals, critical access hospitals and ambulatory surgical centers.
When someone is bleeding and in pain, however, making such distinctions can be difficult. Keller said his motivation in going to urgent care was to get treated quickly instead of waiting hours in an ER amid a spike in Covid-19 cases that would presage the country's deadly winter. He had also been to that CityMD site for a Covid test, so he knew it accepted his insurance.
Keller hadn't been wearing a helmet the day of his accident, which was caused by his trying to prevent a bag of groceries from falling off his bike. With a bleeding forehead and banged-up knees and wrists — Keller brushed a parked car and went off the bike — he was given a tetanus shot and had elevated blood pressure from shock. He thought it was odd that a plastic surgeon was being called in for a few stitches, he said.
"It sounds expensive, and it sounds like something optional," he said. "I said, 'OK, is this going to be covered?' And they said: 'Oh, yeah, they should be covered. He does this, he comes here all the time.'"
In New York, CityMD isn't subject to facility licensing requirements because it's considered a private physician practice, said Jeffrey Hammond, a spokesperson for the State Health Department.
On its website for the location Keller visited, CityMD advertises many of the services it provides as "emergency medical services." They include physical exams, vaccinations, pediatric care, lab tests, X-rays and treatment for sore throats and ear infections.
"Just stop by the CityMD walk-in clinic located on 138 Delancey St. between Norfolk and Suffolk St, where quick, reliable, emergency care service is available 365 days a year," the website reads.
Keller said he went to the same plastic surgeon six weeks later to have the stitches removed. His health insurer, Aetna, has denied an appeal to fully cover the cost.
"It's so clear that getting stitches for a wound, for an open bleeding wound, is an emergency procedure to the normal world," Keller said.
As for his forehead, eight months later Keller's scar is visible.