EP464: ER Visits Now 6% of Total Plan Spend. Is It Upcoding or What? With Al Lewis

Emergency room costs now make up 6% of total healthcare plan spending — why? In this episode, host Stacey Richter welcomes Al Lewis to break down the data behind rising ER expenses, separating fact from fiction. They discuss whether increased patient acuity or widespread upcoding is driving costs, the impact of the No Surprises Act, and why plan sponsors struggle to negotiate fair ER rates. Plus, Al shares actionable strategies for employers to push back against inflated charges. If you want to understand the hidden forces behind escalating ER bills, this is a must-listen.

WHAT YOU'LL LEARN

✅ What's really going on in ER visits, and how big of a deal the total spend actually is at 6% of total plan spending

✅ Why ER visit prices are going up when the underlying acuity of care, in many cases, isn't — and what that gap tells you about upcoding

✅ What the major source of unexpected medical debt actually is, and why code creep is a bigger driver than most plan sponsors realize

✅ Why plan sponsors are structurally unable to negotiate emergency room services the way they can negotiate other parts of the network

✅ Why it matters not to agree to consent when you go in to visit the ER — and what concrete steps plan sponsors can take to proactively limit ER spending for their employees

WHY THIS MATTERS

ER spend at 6% of total plan spending isn't simply a reflection of how sick people are — it's shaped by code creep, consent practices, and a negotiating dynamic that structurally favors the hospital. Al Lewis's message is that plan sponsors aren't powerless here; they just need to understand the mechanics well enough to push back before the bill is finalized, not after.

MENTIONED IN THIS EPISODE

EP415 with Rob Andrews: Apple Podcasts | Spotify | Other Apps

EP386 with Al Lewis: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

🫙 Support the podcast with a small donation to the Tip Jar

📺 Subscribe to our YouTube channel

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Bluesky ✭ Threads ✭ X

00:00 Introduction.

08:32 What is going on in ER visits, and how big of a deal is the total spend?

10:16 Why is the price of ER visits going up when it should be going down?

11:59 What is the major source of unexpected medical debt?

13:27 What is code creep, and why is it happening?

16:26 Why are plan sponsors unable to negotiate emergency room services?

25:53 Why is it important not to agree to consent when you go in to visit the ER?

31:28 What steps can plan sponsors take to be proactive about limiting ER spending for their employees?