By Amanda Holpuch, Dec. 29, 2022, The New York Times.

In the next few weeks, tens of thousands of people in Cook County, Ill., will open their mailboxes to find a letter from the county government explaining that their medical debt has been paid off.
Officials in New Orleans and Toledo, Ohio, are finalizing contracts so that tens of thousands of residents can receive a similar letter in the coming year. In Pittsburgh on Dec. 19, the City Council approved a budget that would include $1 million for medical debt relief.

More local governments are likely to follow as county executives and city councils embrace a new strategy to address the high cost of health care. They are partnering with RIP Medical Debt, a nonprofit that aims to abolish medical debt by buying it from hospitals, health systems and collections agencies at a steep discount.

“What we need in this country is universal health care, clearly,” Toni Preckwinkle, the president of the Board of Commissioners in Cook County, said. “But we’re not there as a nation yet, and so those of us who are responsible for local units of government have to do everything we can to make health care available, accessible to people.”

About 18 percent of Americans have medical debt that has been turned over to a third party for collection, according to a report published in July 2021 in the medical journal JAMA. That figure does not account for medical debt that is carried on credit cards or all medical bills owed to providers. Research shows that people with medical debt are less likely to seek needed care and that medical debt can damage people’s credit and make it more difficult for them to secure employment.

Cook County plans to spend $12 million on medical debt relief and expects to erase debt for the first batch of beneficiaries by early January. In Lucas County, Ohio, and its largest city, Toledo, up to $240 million in medical debt could be paid off at a cost of $1.6 million. New Orleans is looking to spend $1.3 million to clear $130 million in medical debt. The $1 million in Pittsburgh’s budget could wipe out $115 million in debt, officials said.

ProMedica Toledo Hospital is one of the largest hospitals in Toledo, where the city, Lucas County and RIP Medical Debt are working out a $1.6 million plan to relieve eligible residents of medical debt.

These initiatives are all being funded by President Biden’s trillion-dollar American Rescue Plan, which infused local governments with cash to spend on infrastructure, public services and economic relief programs. Health policy experts say that while medical debt relief provides an immediate benefit to people, it does not address the root causes of medical debt, which is almost nonexistent outside the United States.

To be eligible for debt relief through RIP Medical Debt, people must have a household income up to 400 percent of the federal poverty level, or about $111,000 for a family of four, or have medical debts that exceed 5 percent of their annual income. People cannot apply to be considered for debt relief, and they do not pay taxes on the purchase of their debt. RIP Medical Debt analyzes debt portfolios to determine who qualifies.

Wendy Pestrue, the chief executive of the United Way of Greater Toledo, said debt relief could remove a source of economic stress for the 43 percent of families who either were living in poverty or were unable to afford housing, child care, food, transportation or health care in Toledo, which has a population of nearly 269,000.

“It puts some of this economic strength back in the hands of those who are having debt exonerated and really helps them plan for their stability,” she said.

Michele Grim, who joined Toledo’s City Council in January 2022, pushed for some of the city’s $180 million in American Rescue Plan funds to be used for medical debt relief after she read about the Cook County initiative.

Michele Grim is one of the leading voices behind Toledo’s use of the American Rescue Plan for medical debt relief.

“Here’s something so simple that local governments can do, maybe even state governments can do, to really help ease that burden on people, because we really need an overhaul in our system, and that’s going to take years,” said Ms. Grim, who is leaving the council at the end of the year because she was elected in November to be a Democratic state representative.

Toledo’s City Council voted 7-5 on Nov. 9 to provide $800,000 to pay off the debts. Its contribution was matched by Lucas County, resulting in $1.6 million for medical debt relief. The city, the county and RIP Medical Debt are now working out a contract.

One council member who opposed the plan was George Sarantou, who said that he voted against it because his top funding priority was public safety, including upgrading city fire stations and police vehicles. While Mr. Sarantou said he was not opposed to medical debt relief, he was concerned about state funding for cities and villages, which is expected to be 1.66 percent of Ohio’s 2022-23 budget. “Ohio has the money,” he said. “Toledo does not.”

Medical debt relief appears to be popular. A poll by Tulchin Research found that 71 percent of respondents supported it. Fifty percent supported relieving student loan debt, 65 percent supported “Medicare for all” and 68 percent supported expanding Medicaid. The national poll of 1,500 people was conducted online from Nov. 14 to 20, after the Toledo vote, and had a margin of sampling error of plus or minus three percentage points. (Ms. Grim’s husband works for the polling company.) This debt relief comes as states change how medical debt is treated.

In November, Gov. Kathy Hochul of New York signed legislation that blocked health care providers from using property liens or garnishing wages to collect medical debt. The day before the Toledo City Council vote, 72 percent of Arizona voters chose to lower interest rates for medical debt and to increase protections for people who owe debt, though a judge has since halted part of the measure.

Officials in Toledo and other cities are partnering with a nonprofit organization that aims to abolish medical debt by buying it from hospitals, health systems and collections agencies at a steep discount.

Wesley Yin, an associate professor of economics at the University of California, Los Angeles, said medical debt relief could be a “game changer” for some people, but governments should also be addressing the causes of medical debt, including high costs and limited access to good health insurance.

In partnership with RIP Medical Debt, Professor Yin is studying how the group’s work affects people’s livelihoods. “I believe there are some positive effects economically, but it might be more muted compared to the face value of the debt that is being forgiven,” he said.

Daniel Skinner, a health policy professor at Ohio University in Athens, said that debt relief was “low-hanging fruit,” considering that the mean amount of medical debt people carry is in the hundreds, not tens of thousands, of dollars.

“We need to get the cost of medicine under control, ultimately,” Professor Skinner said. “I’m all for what Toledo is doing, I’m all for what Cook County and now New Orleans are doing, but, ultimately, we can’t come back every couple of years and do this. It’s not good policy, it’s not efficient.”

Supporters of debt relief measures agree that there is more to be done.

RIP Medical Debt’s chief executive, Allison Sesso, said that a key part of the group’s work was to further discussions about changing the health care system.

In the past two years, RIP Medical Debt has placed more of an emphasis on buying debt directly from hospitals and health systems, before it reaches collectors. Ms. Sesso said that this gave the group a direct channel to talk with hospitals about how their own health repayment plans for low-income patients work. Some of the people whose debt RIP Medical Debt buys should have qualified for these programs in the first place, but they were not enrolled, she said.

“I do this job every day, and I appreciate that what we’re doing is really important and helpful for the individuals that we are helping and it’s resolving this problem for them,” Ms. Sesso said. “At the same time, I can’t help but wonder and question why my existence as an institution is needed in the first place.”

Link to article.

By Rae Ellen Bichell, NPR, Jun 28, 2021.

Claire Lang-Ree was in a lab coat taking a college chemistry class remotely in the kitchen of her Colorado Springs, Colo., home when a profound pain twisted into her lower abdomen. She called her mom, Jen Lang-Ree, a nurse practitioner who worried it was appendicitis and found a nearby hospital in the family’s health insurance network.

After a long wait in the emergency room of Penrose Hospital, Claire received morphine and an anti-nausea medication delivered through an IV. She also underwent a CT scan of her abdomen and a series of tests.

Hospital staffers ruled out appendicitis and surmised Claire was suffering from a ruptured ovarian cyst, which can be a harmless part of the menstrual cycle but can also be problematic and painful. After a few days — and a chemistry exam taken through gritted teeth — the pain went away.

Then the bill came.

Patient: Claire Lang-Ree, a 21-year-old Stanford University student who was living in Colorado for a few months while taking classes remotely. She’s insured by Anthem Blue Cross through her mom’s work as a pediatric nurse practitioner in Northern California.

Total Bill: $18,735.93, including two $722.50 fees for a nurse to “push” drugs into her IV, a process that takes seconds. Anthem’s negotiated charges were $6,999 for the total treatment. Anthem paid $5,578.30, and the Lang-Rees owed $1,270.45 to the hospital, plus additional bills for radiologists and other care. (Claire also anted up a $150 copay at the ER.)

Service Provider: Penrose Hospital in Colorado Springs, part of the regional health care network Centura Health.

What Gives: As hospitals disaggregate charges for services once included in an ER visit, a hospitalization or a surgical procedure, there has been a proliferation of newfangled fees to increase billing. In the health field, this is called “unbundling.” It’s analogous to the airlines now charging extra for each checked bag or for an exit row seat. Over time, in the medical industry, this has led to separate fees for ever-smaller components of care. A charge to put medicine into a patient’s IV line — a “push fee” — is one of them.

Though the biggest charge on Claire’s bill, $9,885.73, was for a CT scan, in many ways Claire and her mom found the push fees most galling. (Note to readers: Scans are frequently many times more expensive when ordered in an ER than in other settings.)

“That was so ridiculous,” says Claire, who adds she had previously taken the anti-nausea drug they gave her; it’s available in tablet form for the price of a cup of coffee, no IV necessary. “It works really well. Why wasn’t that an option?”

In Colorado, the average charge for the code corresponding to Claire’s first IV push has nearly tripled since 2014, and the dollars hospitals actually get for the procedure has doubled. In Colorado Springs specifically, the cost for IV pushes rose even more sharply than it did statewide.

A typical nurse in Colorado Springs makes about $35 an hour. At that rate, it would take nearly 21 hours to earn the amount of money Penrose charged for a push of plunger that likely took seconds or at most minutes.

The hospital’s charge for just one “IV push” was more than Claire’s portion of the monthly rent in the home she shared with roommates. In the end, Anthem did not pay the push fees in its negotiated payment. But claims data shows that in 2020 Penrose typically received upward of $1,000 for the first IV push. And patients who didn’t have an insurer to dismiss such charges would be stuck with them. Colorado hospitals on average received $723 for the same code, according to the claims database.

“It’s insane the variation that we see in prices, and there’s no rhyme or reason,” says Cari Frank with the Center for Improving Value in Health Care, a Colorado nonprofit that runs a statewide health care claims database. “It’s just that they’ve been able to negotiate those prices with the insurance company and the insurance company has decided to pay it.”

To put the total cost in context, Penrose initially charged more money for Claire’s visit than the typical Colorado hospital would have charged for helping someone give birth, according to data published by the Colorado Division of Insurance.

Even with the negotiated rate, “it was only $1,000 less than an average payment for having a baby,” Frank says.

In an email statement, Centura said it “conducted a thorough review and determined all charges were accurate” and went on to explain that “an Emergency Room (ER) must be prepared for anything and everything that comes through the doors,” requiring highly trained staff, plus equipment and supplies. “All of this adds up to large operating costs and can translate into patient responsibility.”

As researchers have found, little stands in the way of hospitals charging through the roof, especially in a place like an emergency room, where a patient has few choices. A report from National Nurses United found that hospital markups have more than doubled since 1999, according to data from the U.S. Bureau of Labor Statistics. In an email, Anthem called the trend of increasing hospital prices “alarming” and “unsustainable.”

But Ge Bai, an associate professor of accounting and health policy at Johns Hopkins University, says when patients see big bills it isn’t only the hospital’s doing — a lot depends on the insurer, too. For one, the negotiated price depends on the negotiating power of the payer, in this case, Anthem.

“Most insurance companies don’t have comparable negotiating or bargaining power with the hospital,” said Bai. Prices in a state like Michigan, where Bai said the UAW union covers a big proportion of Michigan patients, will look very different than those in Colorado.

Also, insurers are not the wallet defenders patients might assume them to be.

“In many cases, insurance companies don’t negotiate as aggressively as they can, because they earn profit from the percentage of the claims,” she says. The more expensive the actual payment is, the more money they get to extract.

Though Anthem negotiated away the push fees, it paid the hospital 30% more than the average Level IV emergency department visit in Colorado that year, and it paid quadruple what Medicare would allow for her CT scan.

Resolution: Claire and her mom decided to fight the bill, writing letters to the hospital and searching for information on what the procedures should have cost. The cost of the IV pushes and CT scan infuriated them — the hospital wanted more than double for a CT than what top-rated hospitals typically charged in 2019.

But the threat of collections wore them out and ultimately, they paid their assigned share of the bill — $1,420.45, which was mostly coinsurance.

“Eventually it got to the point where I was like, ‘I don’t really want to go to collections, because this might ruin my credit score,'” says Claire, who didn’t want to graduate from college with dinged credit.

Bai and Frank say the state of Maryland can provide a useful benchmark for medical bills, since it sets the prices that hospitals can charge for each procedure. Data provided by the Maryland Health Care Commission shows that Anthem and Claire paid seven times what she likely would have paid for the CT scan there, and nearly 10 times what they likely would have paid for the emergency department Level IV visit. In Maryland, intravenous pushes typically cost about $200 apiece in 2019. A typical Maryland hospital would have received only about $1,350 from a visit like Claire’s, and the Lang-Rees would have been on the hook for about $270.

Claire’s pain has come back a few times, but never as bad as that night in Colorado. She has avoided reentering an emergency room since then. After visiting multiple specialists back home in California, she learned she might have had a condition called ovarian torsion.

The Takeaway: Even at an in-network facility and with good insurance, patients can get hurt financially by visiting the ER. A few helpful documents can help guide the way to fighting such charges. The first is an itemized bill.

“I just think it’s wrong in the U.S. to charge so much,” says Jen Lang-Ree. “It’s just a little side passion of mine to look at those and make sure I’m not being scammed.”

Bai, of Johns Hopkins, suggests asking for an itemized explanation of benefits from the insurance company, too. That will show what the hospital actually received for each procedure.

Find out if the hospital massively overcharged. The Medicare price lookup tool can be useful for getting a benchmark. And publicly available data on health claims in Colorado and at least 17 other states can help.

Vincent Plymell with the Colorado Division of Insurance encourages patients to reach out if something on a bill looks sketchy. “Even if it’s not a plan we regulate,” he wrote in an email, departments such as his “can always arm the consumer with info.”

Finally, make scrutinizing such charges fun. Claire and Jen made bill fighting their mother-daughter hobby for the winter. They recommend pretzel chips and cocktails to boost the mood.

Article link

By Julie Appleby, KHN, Apr 22, 2021.

Mark Gottlieb’s life changed in an instant when another driver crashed into his car, damaging four vertebrae in his upper spine and smashing six teeth.

In the months following that January 2019 crash, Gottlieb got the teeth crowned and, for debilitating neck pain, tried injections, chiropractic care and physical therapy. The treatments were all covered by his car insurance.

New Jersey law, as in 12 other states, requires drivers to buy personal injury protection, or PIP, coverage to pay medical expenses. Gottlieb had the maximum: $250,000.

Unfortunately, Gottlieb’s pain persisted. “Nothing was working. The only other thing was surgery,” he said.

Though he wanted his operation performed near his home, Gottlieb said, staff members at the Bergen Pain Management clinic, where he was receiving care, insisted he go to Hudson Regional Hospital in Secaucus. On April 3, 2020, Gottlieb underwent a complex type of fusion surgery on the herniated discs in his cervical spine. He went home the same day.

His pain improved a bit. Then the bills came.

The Patient: Mark Gottlieb, 59, a marketing consultant in Little Ferry, New Jersey, covered for $250,000 in medical costs by his Geico car insurance. He also has an Aetna health insurance policy, which is secondary.

Medical Service: Anterior cervical discectomy and fusion, a type of neck surgery to replace damaged discs with bone grafts or implants to stabilize the spine.

Service Provider: Hudson Regional Hospital, a stand-alone, for-profit facility in Secaucus, New Jersey, and Bergen Pain Management in Paramus, New Jersey.

Total Bill: Taken together, the hospital and surgeon billed Gottlieb more than $700,000. The hospital billed $445,995 for the surgery, an amount reduced to $133,778 by Geico, which ultimately paid $103,354. Bergen Pain Management billed an additional $264,444 for the main surgeon. Based on a review, Geico reduced that to $141,548. It paid $52,365 toward that before Gottlieb’s medical coverage in his auto policy was exhausted. Then it was up to his health insurer or Gottlieb to deal with the rest.

What Gives: When injuries are the result of auto accidents, car insurance is primarily responsible to negotiate and pay the insurance portion of medical bills. That creates a host of financial landmines for patients.

Gottlieb hit all of them.

With the high charges common in the U.S. for treatment, accident victims can easily exhaust the policy limits of even generous personal injury coverage, leaving some vulnerable to huge bills.

Although it’s rare to hear car insurers complain that they paid a hospital or doctor too much, auto insurers “typically pay more for some of the same services” than health insurers, said Robert Passmore, a vice president at the American Property Casualty Insurance Association, a trade group.

That’s in part because auto insurers generally don’t have broad networks of medical providers who have agreed to negotiated discounts off their billed charges, as do health insurers. So patients end up “out of network,” subject to whatever list price the provider charges.

Gottlieb said he checked with Geico before his surgery but was told it had no information for him about networks. With about $190,000 remaining in his PIP fund at the time, he was not too worried. He said efforts to get cost estimates were unsuccessful.

Instead of network rates, car insurers generally use other payment calculations. Some states set specific payments on fee schedules. But not every medical billing code is listed and, in those cases, they sometimes pay whatever the provider bills.

In this case, that was a lot: Gottlieb’s hospital and surgeon’s charges, even after being reduced by Geico, were about eight times as high as what Medicare would have paid.

While Geico generally pays rates set by the state (which are dramatically lower than what was charged), Gottlieb’s bill included a bunch of billing codes not on the state schedule. For most, the insurer paid exactly what was charged. For example, Geico allowed the full price of $65,125 charged by the surgeon for the removal of a damaged disc and paid the hospital $39,195 for nine surgical screws.

By September — with bills from his various providers still rolling in — Gottlieb’s PIP fund ran out after the remaining $52,365 was paid to Bergen Pain Management, short of the $141,548 Geico had recommended as reimbursement for the surgeon.

Insurance pays bills as they are submitted, which is often not in the order in which the treatment was rendered.

“It appears that Bergen Pain Management is still entitled to the $89,183 balance of the billing from your procedure,” Geico wrote in a September letter to Gottlieb, which added that he could submit that balance to his health insurer or pay it himself.

When he submitted the surgeon’s bill to Aetna, he discovered neither the doctor nor hospital was in his insurance network. He had not checked before the operation since he never dreamed that outpatient surgery would exhaust the auto policy.

That means Aetna did not have a negotiated rate with his providers, which might have knocked the charges down dramatically.

Instead, Aetna said it would allow an out-of-network payment of $4,051 for the surgeon, according to a Jan. 28 email to Gottlieb. In a written statement to KHN, Aetna spokesperson Ethan Slavin said that amount was based on Gottlieb’s policy terms, which set physician payments about 10% above Medicare rates for out-of-network care.

Because he had not yet met his annual out-of-network deductible, Gottlieb himself would have to pay the $4,051. He withdrew his request for Aetna to pay. Because out-of-network surgeons frequently go after patients to pay the balance of such bills, Gottlieb is waiting to see if Bergen Pain Management — which has already been paid $52,365 for the surgery — will come after him for more.

Neither the Bergen clinic nor the surgeon has sent him to collections or sued for the amount. Neither responded to multiple emails and phone calls placed by KHN seeking comment.

In a written statement, Hudson Regional spokesperson Ron Simoncini said the hospital “charged the state-mandated fee” where applicable, and where there was no such mandate, “the charges were reasonable.” It is not seeking additional payment.

Citing policyholder privacy, Geico declined to answer KHN’s questions, including how it determines what it will pay.

Did the auto insurer pay too much?

Geico had set an allowable reimbursement of $141,548 as the surgeon’s fee.

“That is an outrageously high surgeon’s fee for this type of surgery,” said Dr. Eeric Truumees, a professor at Dell Medical School at the University of Texas-Austin.

“I do a tremendous amount of complex cervical spine surgery and never had a fee that high even for complex surgery that takes 10 hours,” said Truumees, president of the North American Spine Society. He had no direct knowledge of Gottlieb’s case.

Altogether, Geico recommended and partly paid nearly $245,000 to the hospital and surgeon for the procedure.

In contrast, Medicare would have paid about $29,500 for the entire procedure, with about $1,800 of that going to the surgeon and the rest to the hospital, according to researchers at Rand Corp. who analyzed Gottlieb’s bills at KHN and NPR’s request.

The surgeon’s bill was also high compared with what private insurance usually pays, according to Barry Silver of Healthcare Horizons Consulting Group in Knoxville, Tennessee. Silver compared Gottlieb’s bills with hundreds of similar claims from two carriers that administer employer-based health insurance nationwide. The total Geico paid the hospital was in line with what employers paid and was actually less than the two highest fees seen in his data. But the highest allowed charge in Silver’s database for the surgeon’s fee was $87,549, far less than the $141,458 Geico recommended.

Resolution: Gottlieb remains in the dark about whether Bergen Pain Management will seek the remaining $89,000 toward his bill.

Previously, Gottlieb sued the driver who caused the accident — and won a substantial “pain and suffering” court settlement. He wants to preserve it for future medical needs.

He has filed numerous complaints about his bills with state regulators, lawmakers and his insurers. Aetna sent his surgeon’s bill to its internal Special Investigations Unit following his complaint.

But, “based on our investigation, we determined there was no further need for action,” spokesperson Slavin said.

The Takeaway: Most people are unaware that auto insurance kicks in first after an accident and that it works very differently from health insurance — so you have to pay attention to how the policies coordinate.

That’s especially true if the accident requires major treatment.

If you have a low amount of personal injury coverage in your car policy, your medical bills may well kick over to your health policy. So, when you sign up for nonemergency treatment — especially if it’s extensive, like surgery — it’s important to make sure the providers are in your health insurer’s network.

Some auto insurers have networks. Ask whether yours does.

Try to get cost estimates in writing for nonemergency care and compare that with what you have left in your auto policy coverage.

“If it’s more than you have left, it may be possible to negotiate with the hospital or doctor to reduce their charges,” said Silver at Healthcare Horizons.

Article link: https://khn.org/news/article/after-accident-patient-crashes-into-700000-bill-for-spine-surgery/

When Darius Settles died from COVID-19 on the Fourth of July, his family and the city of Nashville, Tenn., were shocked. Even the mayor noted the passing of a 30-year-old without any underlying conditions — one of the city’s youngest fatalities at that point.

Settles was also uninsured and had just been sent home from an emergency room for the second time, and he was worried about medical bills. An investigation into his death found that, like many uninsured COVID-19 patients, he had never been told that cost shouldn’t be a concern.

Back at the end of June, Settles and his wife, Angela, were both feeling ill with fevers and body aches. Then Darius took a turn — bad enough that he asked his wife to call an ambulance.

“My husband is having issues breathing and he’s weak, so we’re probably going to need a paramedic over here to rush him to the hospital,” she told the operator, according to the 911 recordings obtained by WPLN News.

Darius Settles was stabilized and tested for the coronavirus at the hospital, according to his medical records. The doctor sent him home with antibiotics and instructions to come back if things got worse.

Three days later, they did. And now he also knew he had COVID-19; his test results were in.

But Settles was also between full-time jobs, playing the organ at a church as he launched a career as a suit designer. So he had no health insurance.

His wife, who works for Tennessee State University, says he was worried about costs as he went back to the hospital a second time; she tried to reassure him

“He said, ‘I bet this hospital bill is going to be high.’ And I said, ‘Babe, it’s going to be OK.’ And we left it alone, just like that,” she says.

When he returned to TriStar Southern Hills Medical Center, owned by the for-profit hospital chain HCA, physicians tested his blood oxygen levels, which are usually a first sign that a COVID-19 patient is in trouble. They had dropped to 88%. An X-ray of his lungs “appears worse,” the physician wrote in the record.

But the doctor also noted that his oxygen saturations improved, and he was breathing on room air after a few hours in the emergency room. The records show they discussed why he might not want to be admitted to the hospital since he was otherwise young and healthy and didn’t note any risk factors for complications.

And when Angela Settles called to check in, he seemed to be OK with leaving despite his persistent struggle to breathe.

He was a COVID-19 patient so, “I could not go up there to see him,” she says. “He was saying that I might as well go home.”

Angela Settles was surprised since her husband was the one who wanted to go to the hospital in the first place.

At first, she thought the hospital just didn’t want to admit a man without insurance who would have trouble paying a big bill. But TriStar Southern Hills admits hundreds of patients a year without insurance — more than 500 in 2019, according to a spokesperson.

And in this case, the federal government would have paid the bill. But no one said that when it might have made a difference to Darius Settles.

Message never makes it to patients
TriStar, like most major health systems, participates in a program through the Centers for Medicare and Medicaid Services in which uninsured patients with COVID-19 have their bills covered. It was set up through the pandemic relief legislation known as the CARES Act.

But TriStar doesn’t tell its patients that upfront. Neither do other hospitals or national health systems contacted by WPLN News. There’s no requirement to, which is one of the program’s shortcomings, says Jennifer Tolbert of the Kaiser Family Foundation who studies uninsured patients. (KHN is an editorially independent program of the foundation.)

“This is obviously a great concern to most uninsured patients,” Tolbert says. Her research finds that people without insurance often avoid care because of the bill or the threat of the bill, even though they might qualify for any number of programs if they asked enough questions.

Tolbert says the problem with the COVID-19 uninsured program is that even doctors don’t always know how it works or that the program exists.

“At the point when the patient shows up at the hospital or at another provider site, it’s at that point when those questions need to be answered,” she says. “And it’s not always clear that that is happening.”
Among clinicians, there’s a reluctance to raise the issue of cost in any way and run afoul of federal laws. Emergency rooms must at least stabilize everyone, regardless of their ability to pay, under a federal law known as the Emergency Medical Treatment and Labor Act, or EMTALA. Asking questions about insurance coverage is often referred to as a “wallet biopsy,” and can result in fines for hospitals or even being temporarily banned from receiving Medicare payments.

Physicians also don’t want to make a guarantee, knowing a patient still could end up having to fight a bill.

“I don’t want to absolutely promise anything,” says Ryan Stanton, an ER physician in Lexington, Ky., and a board member of the American College of Emergency Physicians.

“There should not be a false sense that it will be an absolute smooth path when we’re dealing with government services and complexities of the health care system,” he says.

“Could I have done more?”
Darius Settles knew he was in bad shape. But he didn’t attempt to make a third trip to the hospital. Instead of 911, he called his father, pastor David Settles, and asked his father to come pray for him.

When the elder Settles replied that he was always praying for his son, Darius said, “No, I really need you to pray for me. I need you to get the oil, lay hands on me and pray,” David Settles recalls, and so he went, despite concern for getting COVID-19 himself.

He sat by his son’s side. Darius’ wife made some peppermint tea, and when they put it to his lips, Darius didn’t sip. They thought he had fallen asleep. But he was unconscious.

At that point, they called 911 again and the operator instructed them to get Darius to the floor and perform chest compressions until paramedics arrived.
For 11 minutes, Angela Settles pumped her husband’s chest, occasionally asking the dispatcher “what’s taking so long,” the 911 recordings show. Even after help showed up, Darius never revived.

Pastor Settles was back in the pulpit just a few weeks later, preaching on suffering and grief after the death of his son, “whom I watched as the breath left his body,” he told his congregation. “The Lord gives, and the Lord takes away.”

Darius Settles left behind his own son, who was 6. And his widow’s head is still spinning. She says she can’t shake a sense of personal guilt.

“Could I have done more?” Angela Settles asks. “That’s hard, and I know that he would not want me to feel like that.”

She wonders, too, if the hospital could have done more for him. And even after failing to disclose its policy for uninsured COVID-19 patients, it did send her a bill for part of her husband’s care. Asked why, a TriStar spokesperson says it was sent in error and does not have to be paid.

Article link: https://www.npr.org/sections/health-shots/2020/10/22/925942412/hospital-bills-for-uninsured-covid-19-patients-are-covered-but-no-one-tells-them

By Markian Hawryluk, KHN, Jul 22, 2020

Izzy Benasso was playing a casual game of tennis with her father on a summer
Saturday when she felt her knee pop. She had torn a meniscus, one of the friction-
reducing pads in the knee, locking it in place at a 45-degree angle.

Although she suspected she had torn something, the 21-year-old senior at the
University of Colorado in Boulder had to endure an anxious weekend in July 2019
until she could get an MRI that Monday.

“It was kind of emotional for her,” said her father, Steve Benasso. “Just sitting there
thinking about all the things she wasn’t going to be able to do.”

At the UCHealth Steadman Hawkins Clinic Denver, the MRI confirmed the tear, and
she was scheduled for surgery on Thursday. Her father, who works in human
resources, told her exactly what to ask the clinic regarding her insurance coverage.

Steve had double-checked that the hospital; the surgeon, Dr. James Genuario; and
Genuario’s clinic were in her Cigna health plan’s network.

“We were pretty conscious going into it,” he said.

Isabel met with Genuario’s physician assistant on Wednesday, and the following day
underwent a successful meniscus repair operation.

“I had already gotten a ski pass at that point,” she said. “So that was depressing.” But
she was heartened to hear that with time and rehab she would get back to her active
lifestyle.

Then the letter arrived, portending of bills to come.

The Patient: Izzy Benasso, a 21-year-old college student covered by her mother’s
Cigna health plan.

The Total Bill: $96,377 for the surgery was billed by the hospital, Sky Ridge
Medical Center in Lone Tree, Colorado, part of HealthONE, a division of the for-
profit hospital chain HCA. It accepted a $3,216.60 payment from the insurance
company, as well as $357.40 from the Benassos, as payment in full. The surgical
assistant billed separately for $1,167.

Service Provider: Eric Griffith, a surgical assistant who works as an independent
contractor.

Medical Service: Outpatient arthroscopic meniscus repair surgery.

What Gives: The Benassos had stumbled into a growing trend in health care: third-
party surgical assistants who aren’t part of a hospital staff or a surgeon’s practice.
They tend to stay out-of-network with health plans, either accepting what a health
plan will pay them or billing the patient directly. That, in turn, is leading to many
surprise bills.

Even before any other medical bills showed up, Izzy received a notice from someone
whose name she didn’t recognize.

“I’m writing this letter as a courtesy to remind you of my presence during your
surgery,” the letter read.

It came from Eric Griffith, a Denver-based surgical assistant. He went on to write
that he had submitted a claim to her health plan requesting payment for his services,
but that it was too early to know whether the plan would cover his fee. It didn’t talk
dollars and cents.

Steve Benasso said he was perplexed by the letter’s meaning, adding: “We had never
read or heard of anything like that before.”

Surgical assistants serve as an extra set of hands for surgeons, allowing them to
concentrate on the technical aspects of the surgery. Oftentimes other surgeons or
physician assistants — or, in teaching hospitals, medical residents or surgical fellows
— fill that role at no extra charge. But some doctors rely on certified surgical
assistants, who generally have an undergraduate science degree, complete a 12- to
24-month training program, and then pass a certification exam.

Surgeons generally decide when they need surgical assistants, although the Centers
for Medicare & Medicaid Services maintains lists of procedures for which a surgical
assistant can and cannot bill. Meniscus repair is on the list of allowed procedures.

A Sky Ridge spokesperson said that it is the responsibility of the surgeon to
preauthorize the use and payment of a surgical assistant during outpatient surgery,
and that HealthOne hospitals do not hire surgical assistants. Neither the assistant
nor the surgeon works directly for the hospital. UC School of Medicine, the surgeon’s
employer, declined requests for comment from Genuario.

Karen Ludwig, executive director of the Association of Surgical Assistants, estimates
that 75% of certified surgical assistants are employed by hospitals, while the rest are
independent contractors or work for surgical assistant groups.

“We’re seeing more of the third parties,” said Dr. Karan Chhabra, a surgeon and
health policy researcher at the University of Michigan Medical School. “This is an
emerging area of business.”

And it can be lucrative: Some of the larger surgical assistant companies are backed
by private equity investment. Private equity firms often target segments of the health
care system where patients have little choice in who provides their care. Indeed,
under anesthesia for surgery, patients are often unaware the assistants are in the
operating room. The private equity business models include keeping such helpers
out-of-network so they can bill patients for larger amounts than they could negotiate
from insurance companies.

Surgical assistants counter that many insurance plans are unwilling to contract with
them.

“They’re not interested,” said Luis Aragon, a Chicago-area surgical assistant and
managing director of American Surgical Professionals, a private equity-backed group
in Houston.

Chhabra and his colleagues at the University of Michigan recently found that 1 in 5
privately insured patients undergoing surgery by in-network doctors at in-network
facilities still receive a surprise out-of-network bill. Of those, 37% are from surgical
assistants, tied with anesthesiologists as the most frequent offenders. The
researchers found 13% of arthroscopic meniscal repairs resulted in surprise bills, at
an average of $1,591 per bill.

Colorado has surprise billing protections for consumers like the Benassos who have
state-regulated health plans. But state protections don’t apply to the 61% of
American workers who have self-funded employer plans. Colorado Consumer Health
Initiative, which helps consumers dispute surprise bills, has seen a lot of cases
involving surgical assistants, said Adam Fox, director of strategic engagement.

Resolution: Initially, the Benassos ignored the missive. Izzy didn’t recall meeting
Griffith or being told a surgical assistant would be involved in her case.

But a month and a half later, when Steve logged on to check his daughter’s
explanation of benefits, he saw that Griffith had billed the plan for $1,167. Cigna had
not paid any of it.

Realizing then that the assistant was likely out-of-network, Steve sent him a letter
saying, “we had no intention of paying.”

Griffith declined to comment on the specifics of the Benasso case but said he sends
letters to every patient, so no one is surprised when he submits a claim.

“With all the different people talking to you in pre-op, and the stress of surgery, even
if we do meet, they may forget who I was or that I was even there,” he said. “So the
intention of the letter is just to say, ‘Hey, I was part of your surgery.’”

After KHN inquired, Cigna officials reviewed the case and Genuario’s operative
report, determined that the services of an assistant surgeon were appropriate for the
procedure and approved Griffith’s claim. Because Griffith was an out-of-network
provider, Cigna applied his fee to Benasso’s $2,000 outpatient deductible. The
Benassos have not received a bill for that fee.

Griffith says insurers often require more information before determining whether to
pay for a surgical assistant’s services. If the plan pays anything, he accepts that as
payment in full. If the plan pays nothing, Griffith usually bills the patient.

The Takeaway: As hospitals across the country restart elective surgeries, patients
should be aware of this common pitfall.

Chhabra said he’s hearing more anecdotal reports about insurance plans simply not
paying for surgical assistants, which leaves the patient stuck with the bill.

Chhabra said patients should ask their surgeons before surgery whether an assistant
will be involved and whether that assistant is in-network.

“There are definitely situations where you need another set of hands to make sure
the patient gets the best care possible,” he said. But “having a third party that is
intentionally out-of-network or having a colleague who’s a surgeon who’s out-of-
network, those are the situations that don’t really make a lot of financial or ethical
sense.”

Article link: https://khn.org/news/ever-heard-of-a-surgical-assistant-meet-a-

It took years for Leslie Miller to find the prescription drug that worked for her. But in December, she got a letter from her insurer that the medicine would no longer be covered by her insurance plan starting January 1.

“My heart started racing immediately,” says Miller, a graduate teaching assistant in the University of Oklahoma’s sociology department. “I’ve had this happen before and it’s scary.”

Miller, 42, of Lawton, Okla., was diagnosed with cancer when she was a teenager in the 1990s. She underwent nine surgeries in four years. Although she’s cancer-free today, her treatment left her with nerve damage that hindered her ability to go to the bathroom. A drug called Linzess helped. With a manufacturer’s coupon, she was able to get the medicine for as little as $30 a month.

That was before her insurer dropped Linzess from the list of drugs it covers, called a formulary. Miller needed her doctor to get permission from the insurance company to prescribe the drug, a process called prior authorization. But even that was denied.

“So here I am in January, needing this medication because I’m five days almost out, and I had to pay $330 after the manufacturer coupon,” Miller says, adding that she is asking her doctor to appeal the decision.

She’s not alone. Insurance plans are covering fewer drugs, according to new research by GoodRx, a website that helps patients get discounts on drugs. And even the ones they do cover are getting harder to access.

GoodRx analyzed thousands of Medicare Part D plans from 2010 through 2019 and discovered that the proportion of available drugs covered by the average plan dropped from 73% to 56%. But because Medicare has coverage rules that private plans like Miller’s don’t, such as a requirement to cover all cancer drugs, its possible private plans are even worse, according to GoodRx.

CVS Caremark and Express Scripts, companies that handle drug coverage for many commercial insurance plans in the U.S., announced that they would stop covering dozens of additional drugs in 2020, pushing their lists of formulary exclusions to around 300 each. Express Scripts says many of its newly excluded drugs have alternatives with lower cost generic, brand or biosimilar alternatives.

“The odds of a drug being covered are much worse year over year than they had been,” says Thomas Goetz, chief of research for GoodRx. “That can be a real shock to the system for people. And then the question is, ‘Well, OK, what do I do?’ “

Sometimes, when a brand-name drug is kicked off a formulary, the patient is forced to switch to the generic. Other times, there may not be a generic. Patients may have to jump through hoops to get back on their drug, or they may have to switch drugs — or insurance plans — altogether.

So why is drug coverage shrinking?

Pharmacy benefits managers, the middlemen who negotiate with drug makers on behalf of employers and insurers, are looking to drive better deals.

“It’s important to recognize that not all exclusions are bad,” says Ameet Sarpatwari, assistant director of Harvard Medical School’s Program on Regulation, Therapeutics and Law. “In the case where there are many drugs on the market for a particular condition, a PBM will attempt to negotiate with manufacturers, saying that… ‘If you do not provide a good price, we will not cover your drug and instead cover somebody else’s drug.’ “

The problem, he says, arises if a drug is chosen or excluded from a plan based only on cost. Sarpatwari says PBMs should also consider how effective a drug is relative to the other drugs. But there isn’t enough transparency in how formulary decisions are made to know whether that’s happening.

PBMs convene committees to weigh all these factors, says JC Scott, who leads the PBM trade group, Pharmaceutical Care Management Association. But if PBMs were fully transparent, he says, the negotiated rates could get out and actually drive prices up.

He acknowledges that PBMs and doctors don’t always see eye to eye about which drug to prescribe. “I think we’re all collectively trying to grapple with higher drug costs from drug manufacturers,” Scott says. “And we all have a part to play in trying to address those costs.”

Miller’s insurer seemed to be trying to push patients to a rival drug, Trulance, which struck her as odd because it was only $10 cheaper than Linzess. She called her doctor to find out about her options

Many patients don’t think to call their doctor when they find out a drug is no longer covered, says oncologist Barbara McAneny, a past president of the American Medical Association.

“Often, we end up calling the patient to say, ‘Did you get that medication?’ ” she says. “Or we’ll see a patient back for a follow-up visit and say, ‘How are you doing on that medicine?’ And they’ll say, ‘I never got it.’ “

Physicians and members of their staff spend hours every week on the phone seeking help with prescriptions from insurance companies. Sometimes, the drug isn’t covered. Or sometimes, there are just hoops the insurer wants the patient to jump through.

GoodRx also found that 42% of drugs covered in 2019 still had various restrictions on reimbursement. These could include a requirement that a patient try and fail other, cheaper drugs before getting access to the expensive one a doctor recommends. Or it could mean prior authorization, which means health care providers need to obtain advance approval from insurers before prescribing a drug.

McAneny says at her cancer care practice, she has “five employees who do nothing but prior authorization.”

Even if her office can find a workaround to get patients restricted or off-formulary drugs, it takes time. “Emotionally, it’s agony for the patient because they get increasingly scared, as anyone would,” she says. “But medically, it’s very bad to have an interruption in treatment.”

As for Miller, she decided to stay on Linzess and appeal to her insurer.

“That’s what I do,” she says. “I’ve done it my whole life with insurance companies.”

In March, after more than two months of fighting, her insurer agreed to cover the drug.

Studies have shown 1 in every 6 emergency room visits and inpatient hospital stays for patients with health insurance through their employer led to at least one out-of-network medical bill in 2017. Researchers from the University of Michigan in Ann Arbor, Brigham and Women’s Hospital in Boston and Harvard Medical School in Boston found surprise medical bills are likely just as common in elective services as in the ER. While often framed as an emergency room issue, patients undergoing elective surgery aren’t immune from surprise out-of-network bills, according to a study published in JAMA.

For elective services like knee surgery and hysterectomy, patients with employer-based coverage may ensure their surgeons and hospital are in network. However, patients can receive out-of-network bills from clinicians who aren’t their choice, like anesthesiologists and surgical assistants.

For their study, the researchers completed a retrospective analysis of nearly 350,000 surgical episodes based on claims from a large national payer. The episodes were among commercially insured patients who underwent an elective surgery with an in-network surgeon and facility between 2012-17.

The researchers found of the episodes studied, 20.5 percent, or 1 in 5, involved out-of-network charges. Anesthesiologists and surgical assistants were each associated with 37% of surprise bills.

The mean potential balance bill per episode was $2,011.

“In this retrospective analysis of commercially insured patients who had undergone elective surgery at in-network facilities with in-network primary surgeons, a substantial proportion of operations were associated with out-of-network bills,” the authors concluded.