Joshua Bates knew something was seriously wrong. He had a high fever, could barely move and felt a sharp pain in his stomach every time he coughed.

The 28-year-old called his roommate, who rushed home that day in July 2018. The pair drove to the nearest emergency room, the Carolinas Medical Center in Charlotte, N.C.

After several tests, including a CT scan of his abdomen, the emergency team determined Bates had acute appendicitis.

"They said my appendix was minutes away from rupturing," Bates said.

Not mentioned, he said, was that the hospital was out of network with the insurance plan provided through his job. Even so, he couldn't have jumped up and gone elsewhere. His appendix was about to burst.

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He had surgery that night, which went smoothly, and went home the next day.

"Everything seemed according to plan," said Bates.

Then the bill came.

Patient: Joshua Bates, a technical recruiter for a staffing firm, who lives in Charlotte, N.C. The Continental Benefits insurance plan comes with a deductible of $2,000 and an annual out-of-pocket maximum of $6,350.

Total bill: $41,212 covering the surgery, one night at the hospital and the emergency room charges. After payments by both Bates and his insurer, the hospital sent Bates a bill for the balance, just over $28,000.

Service provider: Carolinas Medical Center, owned by Atrium Health, a for-profit health system based in Charlotte.

What gives: Bates was "balance billed" because he went to an out-of-network hospital — and, even though it was an emergency, he fell through the limited protections in existing law.

"Terrifying," is how Bates describes the feeling when he first saw the bill for $28,000. Don't worry, his insurer told him, it would negotiate with the hospital.

"If you pay your complete deductible, this will all go away," Bates recalled the insurer saying. "I pay. It doesn't get resolved."

More than a year later, negotiations between the hospital and his insurer were at a standstill. With his credit score falling because the $28,000 debt had gone to collections, a frustrated Bates contacted the Bill of the Month team.

"From what my insurance is telling me, the hospital is just non-responsive to them trying to negotiate this price," he said.

His situation is not unusual. A recent study found that about 18% of emergency room visits have at least one such charge for out-of-network care.
A balance bill is the difference between what insurers pay toward a bill and a provider's "list charges," which facilities set themselves and often bear little or no relationship to actual costs.

In Bates' case, the insurer paid $8,944 toward the $41,212 charges, according to his explanation of benefits from his insurer. On top of that, Bates paid the hospital about $4,000, a combination of his annual deductible and his coinsurance for emergency care. That left $28,295 of the hospital's charges unpaid.

The online site Healthcare Bluebook, which calculates costs based on health insurers' claims data, estimates a laparoscopic appendectomy (the type that Bates had) ranges from $9,678 to more than $30,000 in Bates' ZIP code. The "fair price" it suggests for the surgery is $12,090 — completely in the ballpark of the $12,944 that Bates and his insurer already paid the hospital. Fair Health, another site that collects claims data, estimates total costs for an out-of-network appendectomy at $19,292 — about $11,000 less than the hospital says Bates still owes.

"It's ridiculous. He's a young kid who goes to the emergency room and he has insurance," said Duane Sunby, the insurance broker for Bates' employer.

Sunby added that Continental's payment to the hospital was nearly 2½ times more than Medicare would have paid for similar services, but the facility is going after Bates for more than seven times what the federal government would pay. A growing outcry about such balance bills has attracted attention from statehouses and Congress, but current protections for patients often fall short.

Congress last year debated several bills that would have provided federal protection nationwide, especially for emergency room patients. But bipartisan efforts stalled late in the year following intense lobbying by providers, including private equity-backed physician groups, over how to calculate what insurers should pay providers.

Bates is the kind of person who would be helped by a federal law, because his employer "self-funds" his insurance plan — all such plans are regulated by the federal government.

In the absence of federal rules, about 21 states have taken action, although a study from policy experts at Georgetown University Health Policy Institute cites only nine as having comprehensive protections.

North Carolina, where Bates lives, has partial protections for people in state-regulated plans, according to the study. It limits, for example, the amount patients owe in out-of-network emergency cases. But the state law doesn't cover Bates' type of job-based insurance.

"We really need a federal solution," said Maanasa Kona, an assistant research professor at Center on Health Insurance Reforms at Georgetown.

Bates' insurer brought in a third-party firm called Advanced Medical Pricing Solutions, which examined his bill and called the nearly $28,000 "excessive charges." The company sought in September an adjustment or an explanation of the charges.

That move came not long after Bates received a "final" payment notice from a collections group connected with the hospital. A credit reporting agency "told me it would continue to impact my credit score," said Bates. He said his score had dropped by almost 200 points and that change meant he'd had to put his plans to buy a house on hold.

Resolution: After Kaiser Health News inquired about his bill with the hospital, insurer and AMPS, Bates received a call from a top executive at the Carolinas Medical Center.

"He seemed really eager to help me out," said Bates, "which is crazy after two years of reaching out and trying to communicate with them. They call shortly after they catch wind of the story."

However, in an email to KHN, a spokesperson for Atrium Health, the hospital's parent company, essentially pointed to the insurer for a solution.

"We believe it is imperative that insurance companies cover the costs for patients who are unable to choose where they are treated due to a medical emergency," wrote Dan Fogleman. "We continue to be willing to work with this patient to pursue any additional payments that may be due to them from the insurer."

Continental Benefits CEO Betsy Knorr declined to comment: "It is a legal issue at this point, and we do not want to prejudice the process."

Bates is deflated.

"The hospital is trying to put all the burden on the insurance, and the insurance is trying to put the burden on them. I'm back to square one, essentially," he said.

The takeaway:

Insurance plans' yearly out-of-pocket maximums only apply if you stay in network.

So, if possible, check ahead of time to see if your hospital is in your plan's-network — and the network status of anyone who might be involved with your care.

Sometimes that isn't possible, as in Bates' case. What then?

If you get a balance bill after your insurer has paid the provider, check state laws and with your state's insurance regulators to see what protections you may have, said Kona, particularly if your bill resulted from an emergency room visit.

Ask your insurer or employer to pay the bill or to negotiate a discount with the provider, said Mark Hall, a law professor at Wake Forest University who studies contract law and medical billing issues.

Check online claims data websites, such as Healthcare Bluebook and Fair Health, to research what insurers pay for similar care in your area. Use that price range in negotiations about what you may owe.

Even if your employer plan is exempt from state laws limiting patient responsibility for out-of-network emergency care, ask the provider to honor that benefit. They don't have to agree, but it can be worth a shot.

Hall also said patients may be able to hire a lawyer and go to court challenging whether the amount being charged is reasonable, although that could be costly and success is not guaranteed.

NPR produced and edited the audio report by NPR's Selena Simmons-Duffin.


LINK: https://www.npr.org/sections/h...ts-appendicitis-pain

One of my biggest complaints with healthcare.

There should be a price. Period. There shouldn't be 1,000 different prices for the exact same item/procedure. We will take $1,000 from this guy, and $1,800 from this guy, but not you. No, you pay $30,000.

Same damn thing happened to me. Total was $32k, I didn’t stay the night either. Insurance picked up around $17k, I got the remaining $15k. Hospital didn’t give a shit and my out of network insurance felt they had done enough to pay the $17k.

I don't get it. For scheduled services, it makes sense. But for emergency services, you should be able to go to whatever service provider is closest, in or out of network. Or maybe there should be some allowance for people who die while trying to get to in network emergency - the hospitals and insurance companies need to pay up a la life insurance in these cases.

What happens with the uninsured homeless guy that needs care? Recall seeing a sign in the ER that talked about care but don’t recall the details.

In this situation, most hospitals have a cash price to settle if the insurance co. has failed to come to an equitable settlement.

What happens with the uninsured homeless guy that needs care? Recall seeing a sign in the ER that talked about care but don’t recall the details.
^^^^^^^^^^
If you're not experiencing an emergency, and you don't have medical insurance or the ability to pay, the hospital emergency room is not legally required to treat you. ... Once your condition has stabilized, the hospital has the option of moving you to another facility.

quote:

In this situation, most hospitals have a cash price to settle if the insurance co. has failed to come to an equitable settlement.

How many prices should they have? Shouldn't goods or services be essentially priced the same regardless of who the buyer is?

When I had mine out the denial letter from the insurance BEAT me home!!!
The Hospital went to bat for me and insurance covered a portion. I paid $13,000 out of pocket. The appendectomy was performed at the Hospital that provided our family’s insurance at the time.

If the same situation were to occur now I would pay $0 out of pocket.

quote:

Originally posted by a1abdj:

quote:

In this situation, most hospitals have a cash price to settle if the insurance co. has failed to come to an equitable settlement.

How many prices should they have? Shouldn't goods or services be essentially priced the same regardless of who the buyer is?

That works if every patient is the same and needs the same care. But that doesn't occur.

A surgery you have, may require extended time staying in the hospital due to emphysema because of your smoking for 20 years. The next guy having the same surgery could be out days before you because his overall health was better. You needed more post surgical care, thus a different cost for those additional services.

quote:

That works if every patient is the same and needs the same care. But that doesn't occur.

A surgery you have, may require extended time staying in the hospital due to emphysema because of your smoking for 20 years. The next guy having the same surgery could be out days before you because his overall health was better. You needed more post surgical care, thus a different cost for those additional services.

I'm not suggesting the same price for every ailment. I'm suggesting the same price for every service. Why should a hospital room be billed out at 50 different prices with a range of hundreds of dollars just because there are 50 different possible payers involved?

I understand that healthcare is like many other services provided to the public. Sometimes you don't know what you're dealing with until you're in the process of digging through things, but there should be some sort of baseline. Hourly charges, or flat fees for items or services. Because that's exactly how they do it now, except the prices vary depending upon who you are or who insures you.

A better way may be similar to auto insurance. Get rid of all of the preventative maintenance and focus on the unexpected catastrophes. And perhaps your insurance caps what they will pay. Need a colonoscopy? They will cover $2,000, and you can then choose any doctor you wish. No networks, no BS. And if that doctor charges more than $2,000 you know up front and you pay the difference.

Why is it that medical care is the only service for which they can't tell you the fees until after you have received the care?

Send a bill to the hospital for $1 billion. They sent mail to your house. You opened the mail they sent. You deserve to be compensated for you time and effort. $1 billion is what you charge them for opening their mail.

Our entire system is broken beyond repair.

This is the new phenomenon of going to an in network hospital and receiving out of network care. This stuff is hidden until you get slammed with the out of network bill. Most times it is impossible to veryify that all your services will be in network.

There is a ton of lobbying money pouring in to ensure that things stay the way they are because of the profitibility of sticking the patient with non network services.

This worries me. My employer only offers a high deductible plan and when I called to see how the 'free yearly physical' worked, they said it depends. If I'm over 40, the doctor discusses anything medical, or orders any blood tests the cost would probably be between $160 to $1900. Any tests would be extra. The same goes for any doctor visit.

If talking to a doctor can cost that much, it's sounding like a last resort.

My policies changed to eliminate the co-pay for a doctor visit while also increasing in price. But that silver lining of not having to pay a co-pay!

So now instead of the $40 co-pay, it's only a $42 office visit that will be applied towards my deductible.

Health insurance has got to be the biggest joke we've got going on. Unfortunately we are the punch line.

quote:

Originally posted by AZSigs:
In this situation, most hospitals have a cash price to settle if the insurance co. has failed to come to an equitable settlement.

So far my experience has been that the cash price is significantly more than the insurance companies pay.

quote:

So far my experience has been that the cash price is significantly more than the insurance companies pay.

My experience reflects this as well. Clearly the hospital is loosing money on every insurance paid procedure, but making it up in volume.

quote:

Originally posted by a1abdj:

quote:

So far my experience has been that the cash price is significantly more than the insurance companies pay.

My experience reflects this as well. Clearly the hospital is loosing money on every insurance paid procedure, but making it up in volume.

I was dealing with a hospital bill a few years ago and they told me they COULD NOT accept anything less than the billed difference because if they did, they would be in violation of their contract with my insurance company.

quote:

I was dealing with a hospital bill a few years ago and they told me they COULD NOT accept anything less than the billed difference because if they did, they would be in violation of their contract with my insurance company.

^^^^^^^^^
That is incorrect. The hospital CANNOT routinely DISCOUNT bills, but they can certainly write off the remainder of the bill if the patient is unable to pay. They can work out payment plans over time as well. For example, doctors cannot routinely waive copayments for patients, but they can certainly forgive the debt if a financial hardship exists.