© Jun Michael Park for Vox Park Seong-jin, 39, wakes up his son Jeong-whan, 2, from a daytime nap in their home, in South Korea.

An ER patient can be charged thousands of dollars in “trauma fees” — even if they weren’t treated for trauma.

On the first morning of Jang Yeo-im’s vacation to San Francisco in 2016, her eight-month-old son Park Jeong-whan fell off the bed in the family’s hotel room and hit his head.

There was no blood, but the baby was inconsolable. Jang and her husband worried he might have an injury they couldn’t see, so they called 911, and an ambulance took the family — tourists from South Korea — to Zuckerberg San Francisco General Hospital.

<iframe width="300" height="350" id="_mN_dy_256630909" frameborder="0" marginwidth="0" marginheight="0" scrolling="no" style="box-sizing: border-box margin-bottom: 0px margin-left: 0px margin-right: 0px margin-top: 0px padding-bottom: 0px padding-left: 0px padding-right: 0px padding-top: 0px">The doctors at the hospital quickly determined that baby Jeong-whan was fine — just a little bruising on his nose and forehead. He took a short nap in his mother’s arms, drank some infant formula, and was discharged a few hours later with a clean bill of health. The family continued their vacation, and the incident was quickly forgotten.

© Jun Michael Park for Vox

A photo of Park Jeong-whan at Zuckerberg San Francisco General Hospital after his admission shows bruise marks on the forehead and nose from his fall.

Two years later, the bill finally arrived at their home: They owed the hospital $18,836 for the 3 hour and 22 minute visit, the bulk of which was for a mysterious fee for $15,666 labelled “trauma activation,” which sometimes is known as “a trauma response fee.”

“It’s a huge amount of money for my family,” said Jang, whose family had travel insurance that would cover only $5,000. “If my baby got special treatment, okay. That would be okay. But he didn’t. So why should I have to pay the bill? They did nothing for my son.”

American hospital bills today are littered with multiplying fees, many of which don’t even exist in other countries: fees for blood draws, fees for checking the blood oxygen level with a skin probe, fees for putting on a cast, minute-by-minute fees for lying in the recovery room.

© Jun Michael Park for Vox

Original medical certificate, final notice, and medical bill for $18,836 from Zuckerberg San Francisco General Hospital.

But perhaps the kingpins are the “trauma fees,” in part because they often run more than $10,000 and in part because they seem to be applied so arbitrarily.

A trauma fee is the price a trauma center charges when it activates and assembles a team of medical professionals that can meet a patient with potentially serious injuries in the ER. It is billed on top of the hospital’s emergency room physician charge and procedures, equipment, and facility fees.

Emergency room bills collected by Vox and Kaiser Health News show that trauma fees are expensive — typically thousands of dollars — and vary widely from one hospital to another.

Charges ranged from $1,112.00 at a hospital in Missouri to $50,659.00 at a hospital in California, according to Medliminal, a company that helps insurers and employers around the country identify medical billing errors.

“It’s like the Wild West. Any trauma center can decide what their activation fee is,” says Renee Hsia, director of health policy studies in the emergency medicine department at the University of California, San Francisco.

Hsia is also an emergency medicine doctor at Zuckerberg San Francisco General Hospital, but was not involved in the care of the patients discussed in the story — and spoke about the fees generally.

Comprehensive data from the Health Care Cost Institute shows that the average price that health insurers paid hospitals for trauma response (which is often lower than what the hospital charges) was $3,968 in 2016. But hospitals in the lowest 10 percent of prices received an average of $725 — while hospitals in the most expensive 10 percent were paid $13,525. Data from Amino Health, a health cost transparency company, shows the same trend. On average, Medicare pays just $957.50 for the fee.

According to Medicare guidelines, the fee can only be charged when the patient receives at least 30 minutes of critical care provided by a trauma team — but hospitals do not appear to be following that rule when billing non-Medicare patients.

At the turn of the century, such fees didn’t even exist.

But today many insurers willingly pay them, albeit at negotiated rates, for hospitals in their networks. Six insurers and industry groups each declined to discuss the fees, and a spokesperson for America’s Health Insurance Plans, the industry trade group, said, “We have not seen any concerning trends surrounding trauma center fees.”

© Jun Michael Park for Vox

The Jang family near their apartment complex in Suwon, an hour south of Seoul, South Korea.

Trauma centers argue that these fees are necessary to train and maintain a full roster of trauma doctors, from surgeons to anesthesiologists, keeping them on-call and able to respond to medical emergencies at all times.

Zuckerberg San Francisco General Hospital spokesperson Brent Andrew defended the hospital’s fee of over $15,000, even though Jeong-whan didn’t require those services.

“We are the trauma center for a very large, very densely populated area. We deal with so many traumas in this city — car accidents, mass shootings, multiple vehicle collisions,” Andrew said. “It’s expensive to prepare for that.”

Patients face steep bills — and questionable charges — when trauma teams “activate”

Experts who’ve studied trauma fees say that there’s little rationale behind how some hospitals calculate the charge and when the fee is billed. But, of course, those decisions have tremendous financial implications.

After Alexa Sulvetta, a 30-year-old nurse, broke her ankle rock climbing at a San Francisco gym this past January, she faced an out-of-pocket cost of $31,250.

An ambulance brought Sulvetta to San Francisco General Hospital, where, she recalled, “my foot was twisted sideways. I had been given morphine in the ambulance.”

Sulvetta was evaluated by an emergency medicine doctor and sent for emergency surgery. She was discharged the next day.

© Heidi de Marco/KHN

Alexa Sulvetta and her husband, Ben Verley, at their home in Oakland, California.

The hospital charged Sulvetta a $15,666 trauma response fee, a hefty chunk of her $113,336 bill. Her insurance decided that the hospital fees for the one-day stay were too high, and — after negotiations — agreed to pay only a charge it deemed reasonable. The hospital then went after Sulvetta for $31,250.

“My husband and I were starting to think about buying a house, but we keep putting that off because we might need to use our life savings to pay this bill,” she said.

Andrew, the hospital spokesperson, said that the hospital is justified in pursuing the bill. “It’s fairly typical for us to pursue patients when there are unpaid balances,” he said. “This is not an uncommon thing.”