A toddler was tested for covid and flu at an ER. The bill was $445.

Ryan Wettstein Nauman was sobbing one evening last December. After being put down for bed, the 3-year-old from Peoria, Illinois, kept crying, and nothing would calm her down.

Her mother, Maggi Wettstein, feared it could be a yeast or urinary tract infection, something they had been dealing with during potty training. The urgent care centers near them were closed for the night, so around 10:30 p.m. she took Ryan to the emergency room at Carle Health.

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The medical procedure

The ER wasn’t busy when they arrived at 10:48 p.m., Wettstein recalled. Medical records indicate they checked in and she explained Ryan’s symptoms, including an intermittent fever. The toddler was triaged and given a nasal swab test to check for covid-19 and influenza A and B.

Wettstein said they sat down and waited to be called. And they waited.

As Wettstein watched Ryan in the waiting room’s play area, she noticed her daughter had stopped crying.

In fact, she seemed fine.

So Wettstein decided to drive them home. Ryan had preschool the next day, and she figured there was no point keeping her awake and getting stuck with a big ER bill.

There was no one at the check-in desk to inform that they were leaving, Wettstein said, so they just headed home to go to bed.

Ryan went to her preschool the next day, and Wettstein said they didn’t think about the ER trip for eight months.

Then the bill came.

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The final bill

$445 for the combined covid and flu test – from an ER visit in which the patient never made it beyond the waiting room.

The billing problem

Even though Ryan and her mother left without seeing a doctor, the family ended up owing $298.15 after an insurance discount.

At first, Wettstein said, she couldn’t recall Ryan being tested at all. It wasn’t until she received the bill and requested her daughter’s medical records that she learned the results. (Ryan tested negative for covid and both types of flu.)

The bill seemed high to her considering Walgreens sells an at-home covid and flu combination test for $30 and can do higher-quality PCR testing for $145.

Under the covid public health emergency declared in 2020, insurance companies were required to pay for coronavirus tests without co-payments or cost sharing for patients.

That ended when the emergency declaration expired in May 2023. Now, it is often patients who foot the bill – and ER bills are notoriously high.

“That’s a pretty healthy markup the hospital is making on it,” Loren Adler, associate director of the Brookings Institution’s Center on Health Policy, told KFF Health News when contacted about Ryan’s case.

The rates the insurance companies negotiate with hospitals for procedures are often based on multipliers of what Medicare pays, Adler said.

Medicare pays $142.63 for the joint test that Ryan received, but the family is on the hook for more than twice that amount, and the initial hospital charge was more than three times as much.

The hospital is “utilizing their market power to make as much money as possible, and the insurance companies are not all that good at pushing back,” Adler said.

Brittany Simon, a public relations manager for Carle Health, did not respond to specific questions but said in a statement, “We follow policies that support the safety and wellbeing of our patients, which includes the initial triage of symptomatic patients to the Emergency Department.”

The family’s insurer, Cigna, did not have to pay for the tests because the family had not yet met their $3,000 yearly deductible.

A Cigna representative did not respond to requests for comment.

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The resolution

Wettstein said she knew she could just pay the bill and be done with it, “but the fact that I never saw a provider, and the fact that it was just for a covid test, is mind-blowing to me.”

She contacted the hospital’s billing department to ask whether the bill was correct. She explained what happened and said the hospital representative was also surprised by the size of the bill and sent it for further review.

“‘Don’t pay this until you hear from me,’” Wettstein remembered being told.

Soon, though, she received a letter from the hospital explaining that the charge was correct and supported by documentation.

Wettstein thought she was avoiding any charges by taking Ryan home without being seen. Instead she got a bill “that they have verified that I have to pay.”

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The takeaway

ERs are among the most expensive options for care in the nation’s health system, and the charges can start piling up as soon as you check in – even if you check out before receiving care.

If your issue isn’t life-threatening, consider an urgent care facility, which is often cheaper (and look for posted notices to confirm whether it’s actually an urgent care clinic). The urgent care centers near Ryan’s home were closed that evening, but some facilities are open late or around-the-clock.

Making the decision about where to go is tough, especially in a stressful situation – such as when the patient is too young to communicate what’s wrong.

If you decide to leave an ER without treatment, don’t just walk out. Tell the triage nurse that you’re leaving. You might get lucky and avoid some charges.

Wettstein said she paid half of her emergency room bill while she held out hope she could convince the hospital to resolve the rest.

Now she’s resigned that is not going to happen.

“I guess I have to pay this,” she said.

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Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol and at the White House.