A freestanding emergency room (FSER) is a medical facility that provides emergency care but operates outside the physical structure of a main hospital campus. These centers are equipped to handle serious illnesses and injuries that require immediate attention. The increasing presence of FSERs has introduced a new option for acute care, but it has also created confusion regarding their function, capabilities, and associated costs. This article clarifies the operational standards, medical services, differences from urgent care centers, and unique financial implications of a visit.
The Operational Structure of a Freestanding ER
A facility must meet specific structural requirements to qualify as a freestanding emergency room. FSERs are required to operate 24 hours a day, seven days a week. They must maintain a dedicated staff that includes licensed physicians and registered nurses available on-site at all times. In many states, the physician staffing the FSER should be a board-certified or board-eligible emergency physician.
The regulatory status of an FSER depends largely on its affiliation. Some facilities operate as Hospital Outpatient Departments (HOPD), falling under the license of a parent hospital. Others are independent, non-affiliated facilities owned by private organizations, which may lead to differences in regulatory oversight. Regardless of ownership, FSERs must meet the same state licensing and quality assurance requirements as a traditional hospital emergency department. These regulations ensure standards regarding equipment, administration, and professional staff qualifications are met.
Scope of Medical Capabilities
Freestanding ERs are mandated to provide medical services comparable to a hospital-based emergency department. They are equipped with advanced diagnostic imaging technology, including on-site X-ray, ultrasound, and computed tomography (CT) scanning. These facilities also operate full-service laboratories capable of performing hematology, chemistry studies, and cardiac enzyme analysis for immediate results. This equipment allows for the rapid diagnosis and treatment initiation for acute conditions.
The staff is trained and equipped to stabilize life-threatening emergencies, such as stroke, major trauma, and cardiac events. They stock intravenous (IV) fluids, resuscitative medications, and controlled substances necessary for immediate stabilization. However, FSERs are not equipped for inpatient stays or complex surgical procedures that require an operating room. For patients requiring admission or specialized surgical intervention, the FSER must have established transfer protocols to transport the patient promptly and safely to a full-service hospital.
The Critical Difference from Urgent Care
The distinction between a freestanding ER and an urgent care center relates directly to the level of care provided. Urgent care centers typically focus on minor, non-life-threatening conditions, such as simple sprains, sore throats, or minor fevers. In contrast, FSERs are designed to address acute, severe conditions that a prudent layperson would believe could seriously jeopardize their health or impair bodily function without immediate care.
A primary difference lies in staffing: FSERs are staffed 24/7 by emergency-trained physicians and registered nurses. Urgent care centers, however, are often staffed by primary care physicians, physician assistants (PAs), or nurse practitioners (NPs), and they operate with limited or extended business hours. Furthermore, urgent care facilities usually lack the high-level diagnostic equipment, such as CT scanners, necessary to evaluate medical emergencies.
The regulatory framework further separates the two types of facilities. Hospital-affiliated FSERs are subject to the Emergency Medical Treatment and Active Labor Act (EMTALA), which requires them to provide a medical screening examination and stabilizing treatment regardless of a patient’s ability to pay. Urgent care centers are not governed by EMTALA and can legally refuse treatment or require payment upfront. Because urgent care cannot handle true emergencies, acutely ill patients may need to be referred and transported to a higher-level facility.
Understanding Freestanding ER Billing
A visit to a freestanding ER carries a cost structure comparable to a hospital-based emergency department, which is substantially higher than urgent care. A major component of this high cost is the “facility fee,” a charge applied for the overhead of maintaining a fully equipped, 24/7 emergency facility, regardless of the treatment complexity. This fee is billed in addition to the professional fee for the physician’s services and can range from hundreds to thousands of dollars.
Patients often face significant financial responsibility due to issues with insurance network participation. Independent FSERs may not contract with all major insurance providers, operating as out-of-network facilities. Even hospital-affiliated FSERs may have out-of-network physicians, leading to balance billing and higher out-of-pocket costs. State laws have attempted to mitigate this by requiring insurers to cover emergency care at an in-network rate based on the prudent layperson standard.