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It was a Sunday morning in late November when Bryan Keller hopped on a bike for a routine ride to pick up his 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 an 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 regular cyclist who’s lived in New York City for three decades. Even in post-accident “delirium,” he said, he asked several times whether the stitches would be covered by his health insurance because it struck him as unusual that a plastic surgeon would do them.

“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 transport in an air ambulance. But one gray area: visits to urgent care clinics, which have proliferated in recent years as patients seek speed and convenience over waiting hours at an emergency room or weeks to get a regular doctor’s appointment. There are roughly 10,500 urgent care centers in the U.S., according to the Urgent Care Association, which lobbies on their behalf.

Urgent care clinics were not explicitly addressed in the No Surprises Act, but Keller’s experience underscores patients’ predicament ― insurers often try to steer patients to urgent care and away from costly emergency rooms, but individuals could still get hit with large bills in the process. The Biden administration has expressed an interest in prohibiting surprise bills in those clinics, which may treat serious conditions but not life-threatening injuries and illnesses.

In July, several federal agencies issued interim that largely would not protect patients from surprise urgent care bills. Regulation varies significantly across states, and data is scarce on how common surprise bills are in those facilities. Before the surprise billing rules are finalized, the Department of Health and Human Services and three other federal agencies have asked for information on issues such as the frequency of such bills at urgent care facilities and how health insurers contract with the clinics.

The current regulatory gap, if left untouched before the new law takes effect in January, is one that health care experts say 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, research emeritus for Georgetown University’s McCourt School of Public Policy.

CityMD, which was founded by doctors in 2010 and with the large medical practice Summit Medical Group in 2019, operates a massive chain of urgent care clinics in New York and New Jersey. Most of its physicians are emergency doctors. The combined enterprise created Summit Health, which is backed by private equity with investments from well-known firms Warburg Pincus ― which 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. Though he was unable to comment on the specifics of Keller’s situation, he 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.”

“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 did not respond to a request for comment.

Last month the Biden administration proposed prohibiting surprise bills at urgent care centers licensed to perform emergency procedures, essentially treating them as free-standing emergency rooms. Some states, like 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, according to health care advocates that have tracked the issue and 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 show up at an urgent care facility for an acute illness or injury.

KHN also found that the urgent care clinic where Keller was treated describes several of its services as emergency care even though many are not 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 where the absence of immediate medical attention could seriously jeopardize a patient’s health.

Summit Health spokesperson Gove said the use of the term “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.” CityMD has never marketed itself as an emergency room designed to treat all emergency conditions, Gove said.

Lou Ellen Horwitz, CEO of the Urgent Care Association, said urgent care clinics are akin to private doctor practices rather than an emergency room or hospital facility that would be subject to broad bans on surprising billing. 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 these clinics as something akin to 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 nonemergencies will not be protected if treated by an out-of-network provider at an in-network urgent care facility, according to health care experts. “You don’t have protections if it turns out the doctor or the physician assistant was out of network,” Hoadley said.

A 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. Those licenses give state officials greater leeway to set standards for care, staffing levels, inspections or price transparency, but could also make care more expensive by increasing providers’ expenses.

Without being licensed as a health care facility ― something that exists for hospitals, ambulatory surgery centers and critical access hospitals ― urgent care clinics are generally treated as private physician practices subject to less regulation. “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 should not be lumped in with those providers because their operations are fundamentally different.

Unlike hospitals and other practices that include facility fees in their charges to patients, “we don’t charge or receive payments as a facility,” she said.

In the midst of an injury, however, making such distinctions can be difficult. Keller said his motivation in going to urgent care was to get his wounds 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 particular CityMD clinic for a covid test, so he knew it accepted his insurance.

Keller hadn’t been wearing a helmet the day of his accident, caused by 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 himself ― he was given a tetanus shot and had elevated blood pressure from the shock of the accident. Still, in that moment, he thought it was odd that a plastic surgeon was being called in to give him a handful of 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 is not subject to facility licensure requirements because it’s considered a private physician practice, said Jeffrey Hammond, a spokesperson for the New York State Department of Health. As a result, rather than more sweeping regulations that would govern the practices of urgent care clinics, state health officials oversee individual practitioners and investigate complaints related to misconduct.

On its website for the location Keller visited, CityMD advertised 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.

About six weeks after receiving his stitches, Keller said, he went to the same plastic surgeon to get them 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 still has a visible scar.

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