Julie Appleby, KFF Health News
Physician Lauren Hughes was heading to see sufferers at a clinic about 20 miles from her Denver house in February when one other driver T-boned her Subaru, totaling it. She was taken by ambulance to the closest hospital, Platte Valley Hospital.
A shaken Hughes was examined within the emergency room, the place she was recognized with bruising, a deep reduce on her knee, and a damaged ankle. Physicians advisable rapid surgical restore, she mentioned.
“They said: ‘You have this fracture and a big gaping wound in your knee. We need to take you to the OR to wash it out and make sure there’s no infection,’” she mentioned. “As a clinician, I thought, ‘Yes.’”
She was taken to the working room within the early night, then admitted to the hospital in a single day.
A pal took her house the subsequent day.
Then the payments got here.
The Medical Procedure
Surgeons cleaned the reduce on her proper knee, which had hit her automotive’s dashboard, and realigned a damaged bone in her proper ankle, stabilizing it with metallic screws. Surgery is usually advisable when a damaged bone is deemed unlikely to heal correctly with solely a solid.
The Final Bill
$63,976.35, charged by the hospital — which was not in-network with the insurance coverage plan she acquired via her job — for the surgical procedure and in a single day keep.
The Problem: Should I Stay or Should I Go?
Hughes’ insurer, Anthem, totally coated the practically $2,400 ambulance trip and a few smaller radiology fees from the ER however denied the surgical procedure and in a single day keep fees from the out-of-network hospital.
“Sixty-three thousand dollars for a broken ankle and a cut to the knee, with no head injury or internal damage,” Hughes mentioned. “Just to stay there overnight. It’s crazy.”
Insurers have broad energy to find out whether care is medically necessary — that’s, what is required for remedy, analysis, or reduction. And that call impacts whether or not and the way a lot they may pay for it.
Four days after her surgical procedure, Anthem notified Hughes that after consulting medical tips for her kind of ankle restore, its reviewer decided it was not medically essential for her to be totally admitted for an inpatient hospital keep.
If she had wanted extra surgical procedure or had different issues, comparable to vomiting or a fever, an inpatient keep may need been warranted, in accordance with the letter. “The information we have does not show you have these or other severe problems,” it mentioned.
To Hughes, the notion that she ought to have left the hospital was “ludicrous.” Her automotive was in a junkyard, she had no household close by, and he or she was taking opioid painkillers for the primary time.
When she requested for additional particulars about medical necessity determinations, Hughes was directed deep inside her coverage’s profit booklet, which outlines that, for a hospital keep, documentation should present “safe and adequate care could not be obtained as an outpatient.”
It seems the surgical procedure fees have been denied due to an insurance coverage contract quirk. Under Anthem’s settlement with the hospital, all claims for companies earlier than and after a affected person is admitted are accredited or denied collectively, mentioned Anthem spokesperson Emily Snooks.
A hospital keep shouldn’t be usually required after ankle surgical procedure, and the insurer discovered Hughes didn’t want the form of “comprehensive, complex medical care” that will necessitate hospitalization, Snooks wrote in an e-mail to KFF Health News.
“Anthem has consistently agreed that Ms. Hughes’ ankle surgery was medically necessary,” Snooks wrote. “However, because the ankle surgery was bundled with the inpatient admission, the entire claim was denied.”
Facing payments from an out-of-network hospital the place she was taken by emergency responders, although, Hughes didn’t perceive why she wasn’t shielded by the No Surprises Act, which took impact in 2022. The federal regulation requires insurers to cowl out-of-network suppliers as if they’re in-network when sufferers obtain emergency care, amongst different protections.
“If they had determined it was medically necessary, then they would have to apply the No Surprises Act cost,” mentioned Matthew Fiedler, a senior fellow with the Center on Health Policy at Brookings. “But the No Surprises Act is not going to override the normal medical necessity determination.”
There was yet another oddity in her case. During one in every of many calls Hughes made attempting to kind out her invoice, an Anthem consultant informed her that issues may need been totally different had the hospital billed for her hospitalization as an in a single day “observation” keep.
Generally, that’s when sufferers are stored at a facility so employees can decide whether or not they should be admitted. Rather than being tied to the keep’s period, the designation primarily displays the depth of care. A affected person with fewer wants is extra more likely to be billed for an statement keep.
Insurers pay hospitals much less for an statement keep than admission, Fiedler mentioned.
That distinction is a giant concern for sufferers on Medicare. Most usually, the federal government well being program won’t pay for any care needed in a nursing home if the affected person was not first formally admitted to a hospital for at least three days.
“It’s a classic battle between providers and insurers as to what bucket a claim falls in,” Fiedler mentioned.
The Resolution
As a doctor and a director of a well being coverage heart on the University of Colorado, Hughes is a savvier-than-usual policyholder. Yet even she was annoyed in the course of the months spent going backwards and forwards together with her insurer and the hospital — and nervous when it appeared like her account could be despatched to a set company.
In addition to interesting the denied claims, she sought the assistance of her employer’s human sources division, which contacted Anthem. She additionally reached out to KFF Health News, which contacted Anthem and the Platte Valley Hospital.
In late September, Hughes acquired calls from a hospital official, who informed her that they had “downgraded the level of care” the hospital billed her insurance coverage for and resubmitted the declare to Anthem.
In a written assertion to KFF Health News, Platte Valley Hospital spokesperson Sara Quale mentioned that the power “deeply regrets any anxiety this situation has caused her.” The hospital had “prematurely” and erroneously despatched Hughes a invoice earlier than figuring out the stability with Anthem, she wrote.
“After a careful review of Ms. Hughes’ situation,” Quale continued, “we have now stopped all billing to her. Furthermore, we have informed Ms. Hughes that if her insurance company ultimately assigns the remaining balance to her, she will not be billed for it.”
Anthem spokesperson Stephanie DuBois mentioned in an e-mail that Platte Valley resubmitted Hughes’ invoice to the insurer on Oct. 3, this time for “outpatient care services.”
An rationalization of advantages that was despatched to Hughes reveals the hospital rebilled for round $61,000 — about $40,000 of which was knocked off the overall by an Anthem low cost. The insurer paid the hospital practically $21,000.
In the top, Hughes owed solely a $250 copayment.
The Takeaway
There are locations the place sufferers receiving emergency care at an out-of-network hospital might fall via the cracks of federal billing protections, specifically throughout a section which may be practically indistinguishable to the affected person, often known as “post-stabilization.”
Generally, that happens when the medical supplier determines the affected person is stable enough to travel to an in-network facility utilizing nonmedical transport, mentioned Jack Hoadley, a analysis professor emeritus on the McCourt School of Public Policy at Georgetown University.
If the affected person prefers to remain put for additional remedy, the out-of-network supplier should then ask the affected person to sign a consent form, agreeing to waive billing protections and proceed remedy at out-of-network charges, he mentioned.
“It’s very important that if they give you some kind of letter to sign that you read that letter very carefully, because that letter might give them your permission to get some big bills,” Hoadley mentioned.
If potential, sufferers ought to contact their insurer, along with asking the hospital’s billing division: Are you being totally admitted, or stored below statement standing, and why? Has your care been decided to be medically essential? Keep in thoughts that medical necessity determinations play a key position in whether or not protection is accredited or denied, even after companies are supplied.
That mentioned, Hughes didn’t recall being informed she was secure sufficient to depart with nonmedical transportation, nor being requested to signal a consent kind.
Her recommendation is to shortly and aggressively query insurance coverage denials as soon as they’re acquired, together with by asking to your case to be escalated to the insurer’s and hospital’s management. She mentioned anticipating sufferers to navigate difficult billing questions whereas within the hospital after a severe damage isn’t sensible.
“I was calling family,” Hughes mentioned, “alerting my work colleagues about what happened, processing the extent of my injuries and what needed to be done clinically, arranging care for my pet, getting labs and imaging done — coming to grips with what just happened.”
Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical payments. Since 2018, this sequence has helped many sufferers and readers get their medical payments lowered, and it has been cited in statehouses, on the U.S. Capitol, and on the White House. Do you might have a complicated or outrageous medical invoice you wish to share? Tell us about it!
