Woman taken to 'wrong' hospital faces bankruptcy

[UglyGreed]

Woman taken to ‘wrong’ hospital faces bankruptcy

MADISON, Wis. -
Megan Rothbauer would rather be discussing an impending engagement, her future marriage and eventually, children. However, the 30-year-old Madison resident is instead scouring the Internet looking for solutions to stave off bankruptcy.

A project manager for a manufacturing company, she is one year removed from a cardiac arrest and the subsequent physical recovery is being dwarfed by a near-impossible fiscal recovery. She was sent last Sept. 9 to the emergency room at St. Mary's Hospital, which was out of her insurance network, instead of to Meriter Hospital, three blocks away, which was covered by her insurance. It's the difference between a $1,500 maximum out-of-pocket expense and the now-$50,000-plus she's facing in bills.

"I was unconscious when I was taken to the hospital," she said. "Unfortunately, I was taken to the wrong hospital for my insurance.

"I was in a coma. I couldn't very well wake up and say, 'Hey, take me to the next hospital.' It was the closet hospital to where I had my event, so naturally the ambulance took me there. No fault to them. It's unfortunate that Meriter is in network and was only three blocks away from St. Mary's," Rothbauer said.


http://www.channel3000.com/news/woman-taken-to-wrong-hospital-faces-bankruptcy/29648000

[Dale Neiburg]

1. Being conscious might not have helped.

In many jurisdictions, ambulances are required to take patients to the nearest hospital. A co-worker of my wife's had medical treatment delayed for several hours for that reason -- the ambulance couldn't take him to the hospital where his doctor was on staff and was actually waiting for him.

[ColesCountyDem]

9. Exactly.

About 30 years-ago, I was a volunteer paramedic for our county's ambulance service, and our 'resource hospital' established a protocol that required us to transport critically-ill patients to the nearest E.R., no exceptions. Patients who were seriously (but not critically) ill fell under a 'stability' decision tree, the prime question being whether or not the patient was medically stable enough to be transported to their hospital of choice, as opposed to the nearest E.R. .

I feel so sorry for this lady! What's happening to her is just plain wrong. Thankfully, she realizes that the paramedics AND receiving E.R./hospital are not at fault-- her insurance company is.

[Ruby the Liberal]

2. She needs to call her insurance company

There is a concept out there these days called "invisible providers" - providers who are not in network, but you didn't purposely select. Often seen in hospital situations where people/services like anesthesiology or pathology are not in network but the patient has no control over their selection.

Drive-by care is a close corollary to this.

The NYT did a GREAT article about this a few weeks ago. In most cases, the provider will work with the insurance company on payment even if it isn't as much as they billed.

[TBF]

14. You really think that

in the throes of bankruptcy she has not already called her insurance company? Talk about blame the victim. My guess is that she's getting some lower level worker at the end of the phone who does not have discretion to change the codes in the computer. This happens to people everyday. This is why we need single-payer rather than an ACA that involves insurance middle-men(women).

[Ruby the Liberal]

18. Agree completely on ACA and single-payer

But you would be surprised at how many don't know how to work with this situation and to escalate if they don't get help. I faced it 3x in the last year and wouldn't have known a year ago that it was even a thing.

No victim-blaming here. Just posting information for those who may also find themselves in the same position as myself and the woman in the article. Hope you didn't injure yourself jumping to that conclusion.

[TBF]

29. I see it so much on here

that it is not even a surprise anymore - but I'm glad to hear your clarification. I know ACA is an improvement over what we had in the past but really look forward to an eventual single payer system. We already have Medicare and Tricare - I can't see why one of those couldn't be expanded to just cover everyone (not to mention the healthcare provided to Congress).

[Ruby the Liberal]

31. Medicare part "E"

as in Everyone. I do not disagree with anything you posted. Thanks for the response.

[Ms. Toad]

17. If you read the article, she's well past that.

The insurer treated it as an in-network provider for purposes of the amount it paid for her time in the hospital. Unfortunately, it is the provider that is insisting on being paid the balance of what it would have charged someone without insurance - since it did not have a contract with the insurance company requiring it to accept the UCR the insurer had set for her care as full payment.

[Ruby the Liberal]

20. Thank you for that assumption

I get that. As posted above, I went through it 3x in the last year. Thats why I posted what I did. For those who may find themselves in the same situation as me - there are ways around the crooks. You just need to know what to do/say to get it done.

Edit: Response #5 is a prime example of this. NYT did an expose a few weeks ago on the same concept: http://www.nytimes.com/2014/09/21/us/drive-by-doctoring-surprise-medical-bills.html

[Ms. Toad]

28. Since my comment was based on the fact that you suggested

a solution that she has already clearly implemented since her insurance company treated the provider as in-network, and is quoted in the article as being unable to provide any assistance with a provider who refuses to accept the standard in-network payment as payment in full, it certainly appeared that you didn't read the article (as is pretty common around here).

On top of that, the balance billing is not something the insurance company can fix. It has already done its part by treating the hospital as in-network by paying 100% of what it would have paid. It is the provider who now needs to step up to the plate and write off the balance - or at a minimum write off anything above what it would accept as payment in full from an insurance company for which it was in network. Either should wipe out most of the remainder of the bill.

[dembotoz]

33. fucked by the hospital--picket them

[Ms. Toad]

46. If negotiations fail,

publicity certainly wouldn't hurt.

The provider's beef is that they have already written off too much - they can't afford to write off more. That is a load of horsesh*t.

Every hospital has contracts with insurance companies which require them to accept payments for insured patients which are far lower than what they expect to be paid by uninsured patients. For Labwork the write-off is around 90%, for doctors the write-off is around 10-20%. Those are the two I remember off the top of my head without going back to my spreadsheets where I've tracked it ad nauseum.

Find out what these providers (it is likely lots of separate providers - anesthesiologists, radiology, etc.) accept from any of the insurance companies they have contracts with. Because they have already agreed to that equivalent payments are financially reasonable when the patient has a different insurance company, they cannot - without looking like fools - complain that they woudl take a bath if they accepted that amount from this one additional patient.

[Ruby the Liberal]

36. I can see that you have never been in this situation like I have

No, insurance has and will pay out above and beyond their negotiated rates. Likely to stem the outcry. Who knows. All I can tell you is that I have been billed for thousands of dollars over 3 incidents and all were cleared in full by my insurance.

My hope is that you are never in the position to have to navigate this, but if you are, you remember this conversation.

[Ms. Toad]

45. I am quite sure I have had far more wrangling with insurance companies

than you ever had.

Our billed expenses are between $40,000 and $60,000 a year, every year, and have been for 6 years. For more than 3 decades we have had to negotiate non-covered treatments and out of network providers for several different uncommon conditions. I have done pretty much every insurance negotiation imaginable with nearly all of the major insurance companies, and have never lost. (There were two small battles I chose not to fight, because the cost of each - under $200 - was not worth the time it would have taken to go through the appeals process.)

Your situation, described as you did in this thread, only works when the facility is in-network but sends work to an out of network provider (the invisible provider). We had a primary care provider who did that on a regular basis, because he had traveling radiologist who was out of network, and kept forgetting that he had a handful of patients for whom that provider was out of network. (It also happens on a semi-regular basis with labwork, anesthesiologists, and third party pre-op social work in my personal experience). In that situation, the in-network generally has violated their contract to have sent the work out of network in the first place. Part of their contract allowing them to be in network generally requires that they have arrangements with in-network providers. So when they send it out of network (invisibly), the insurance company has leverage to resolve the matter - and whether you are aware of it or not, the vast majority of the time the additional cost is eaten by the in-network provider who messed up.

The circumstances here are different. The person was taken to an out of network provider as the primary contact for this set of medical transactions. This provider (responsible for making the connections for all other care that followed) has no contract with the insurance company. The insurance company has no leverage in this case because the out of network provider has no contractual relationship with the provider. In this instance, the insurance company has paid the full amount that they pay anyone for this treatment. It is just that the provider (whose only relationship is with the patient) refuses to treat the payment by the insurance company as payment in full (even though they almost certainly accept an equivalent amount from the insurance companies they contract with.

Here, the person must negotiate directly with the provider for a reduced price which, for the record, is one of the many medical care negotiations I have had to undertake - and, like the others, I have been successful at.

I would approach it by requesting that they look to what they would have accepted as payment in full from any insurance company with which they have a contract - and only bill them for the difference (which should be minimal - and may be nothing at all).

[SalviaBlue]

32. Ruby, thanks for the link

and the advice...good information!

[Ruby the Liberal]

35. I was struggling to explain invisible/drive-by providers

that were not selected by choice (and their VERY aggressive billing practices) to family until that article. The author got the concept through to people I wasn't able to reach.

[Tripper11]

3. This happened to me years ago.

I'm Canadian and had been living in Seattle for about 4 years when I got leukemia.
At the time, I was being taken off my wife's work insurance because we couldn't afford it for all and we felt having the kids covered was the best approach. I was going to a clinic at the time, thinking I was not covered and that doctor sent me to University of Washington Medical Centre.

As a Canadian all I thought was it was the best place for me to be according to my doctor.
Once I got there, they started doing what they needed to. Get me into a room, start massive blood and other tests to best determine the course of treatment.

Meanwhile, my wife called her benefits person at work to see if she could "sneak" me back onto her insurance as we thought I was off by then. Luckily, as it turned out, that person wasn't as diligent as she could have been and I was actually still fully covered!
So as I started my treatment I would have social workers, doctors, financial/insurance people from the hospital coming in to talk to me and my wife as we proceeded.

One thing, we found out, was that UWMC was not in my network. As a Canadian, that didn't mean anything to me. I was laying there with chemo dripping into my chest(central line).
Then the insurance flak and my wife explained it to me.
Our insurance doesn't cover this hospital.
I was confused.
"What do you mean it's not covered. We have insurance right?"
"Yes."
"So I'm covered."
Yes, but not here."
"What?"
"You're out of network."
"But I have insurance."
"Yes."
"And I'm not covered at this hospital?"
"Right."
"I don't understand, we have insurance."

We ended up having to pay, I believe at that time, a $2,000 out of network fee which did get approved by out insurance company.
Me - still confused by the whole mess!

In Canada, a hospital is a hospital is a hospital. If you need to move hospitals, it's because you might need different care or care that your current hospital can't provide. Our system isn't perfect, but then again I'll take ours over all that confusion I had.

Oh and don't get me started on these "co-pays" of yours.

[LittleGirl]

6. I had that discussion with my spouse

who grew up in the UK. Same exact thing. I had to explain, deductibles, co-pays, in network, out of network...he was furious when I finished. Thankfully, it was only a one time offensive that I had to pay about 350 bucks for lab work that was 'out-of-network' until I gave up on western medicine/insurance and went to a Naturopathic doctor that didn't take insurance. And a biological dentist that didn't take insurance either. And we had excellent coverage from his job but 'regular' in network doctors and dentists failed me for years. I'm in remission with my illness now but i had to pay out of pocket for nearly everything to get here. It's a scam and daylight robbery.

[Diclotican]

10. Tripper11

Tripper11

Universal health care do have its benefits haven't it ? Or single payer as Americans tend to call it...

Diclotican

[Ms. Toad]

19. It's not just because you're from Canada...

I repeatedly have to explain the whole insurance company regime to my spouse and child. Both were born and raised in the U.S. The one my spouse could never get was her gynecologist who was in-network in one office, and out of network in the other - closer - one.

It's free, since an annual gyn appointment is covered without charge.
Yes - but only if you go to an in network provider.
My doctor is in network.
Your doctor is in network only in office A. You made the appointment in office B. Again.
I've always gone to office B.
I know. We have this discussion every year. Change the appointment.

[Nuclear Unicorn]

4. Provider networks are a horrible construct. Real healthcare reform will address costs control

through choice and competition, not restriction and scarcity.

[Sancho]

5. It's crazier than you can imagine!!

My wife had vertigo last year. When the EMS came, I called the insurance company to confirm which hospital was in network. I insisted they take her to that hospital.

Once there, I talked to the intake person to confirm they were in network. It turns out that some of the ER doctors who consulted and evaluated tests were out of network even though no one told us that or gave us a choice!!!

We got extra bills totaling several thousand!

Until we get single-payer, this entire mess won't get better.

[Ruby the Liberal]

24. Been there. My local hospital outsourced their ER.

You pay your $100 copay and it covers bloodwork, EKGs, etc - but the doctors are outsourced to a third party and the bill for "provider(s)" for thousands off dollars comes in 6 weeks after your visit. They call them invisible providers.

[drynberg]

7. Megan Rothbauer should consult with the best attorney she can find, as

This ain't right.

[B Calm]

8. Makes me afraid to take a family vacation out of network.

[csziggy]

34. Travel insurance for every trip

A PITA but it could save your finances!

I was just looking at what I can get through HealthCare.gov so my husband can retire. While all my doctors in town are in network - for the first time ever - it says "No" under the line "Out of state." Before I sign up, I have to check on that. If that means no coverage outside of Florida, we will have to look at travel insurance for every trip.

Hmmm - AAA provides up to $300,000 coverage for all Plus members automatically if the trip is arranged through them. I'll have to check to see if that means that if we get our maps and route through them we're covered even in our own cars. It seems to say that we would be. http://autoclubsouth.aaa.com/Assets/PDFs/TravelAccidentInsBrochure_Plus.pdf (May only be accessible for AAA members.)

[eridani]

11. Single payer! At the state level, obviously. n/t

[Triana]

12. This happened to my sister and BIL. They almost went bankrupt over it.

The is SO effed UP. Single-payer, universal healthcare would fix this.

[salib]

13. You know that Republicans are sitting around blaming Obamacare for this

The article even feeds that idea:
"However, balance billing is expressly permitted [by the Affordable Care Act] and Gaines said its results, like what's happened to Rothbauer, are far too common."

Others, like myself quite often, will simply say that we should have passed single-payer.

So, how are we to act in this case?

Just get angry and back to work? Maybe.

[riqster]

15. This: "Just get angry and back to work? Maybe."

Definitely.

[Ms. Toad]

21. Balance billing has always been standard practice.

It has nothing to do with the ACA - other than it did not abolish the practice.

[UglyGreed]

16. What will she

do if it happens again and she has already used her one chance to declare bankruptcy?

[Thav]

30. What republicans want her to do...

die quickly.

[UglyGreed]

38. Sad but true N/T

[alarimer]

22. I think the law needs to be changed to ban networks.

All doctors and hospitals are in network and they all have to take every insurance.

[Ruby the Liberal]

26. My dentist quit taking insurance all together

and says "if you have insurance, file for reimbursement - but today - you pay".

That is apparently becoming more common from what I hear.

[KingCharlemagne]

23. Yay, Capitalism! USA! USA! USA! :sarcasm: - nt

[bigwillq]

25. But, Obamacare.

What is Obamacare doing for this poor woman?

[Ruby the Liberal]

27. Nothing.

This is the providers and insurance company's response to the ACA. The new normal.

[TBF]

37. I was pre-registered, approved etc

when I had my second baby. All was well until I was wheeled into the unexpected emergency c-section (stuck baby to put it in layman's terms). Regular OB and the special surgeon. Thankfully my spouse was in the delivery room watching every sordid detail and saw that the special surgeon who was frantically called in did the work. He of course charged his fee (thousands) and insurance rejected it. "Only one doctor needed for baby" they said. Spouse (who happens to be a lawyer) called and said "I was there and he did all the work - if he hadn't been there they would've both died. If you don't cover this I'm filing in court". They paid. And it is absolutely crazy that you have to get in their face and threaten like that to get any relief.

[Xithras]

39. Happened to my daughter her first year in college.

She did a typical dumb teenager thing, and drank too much at her first college party. When she passed out, her friends took her to the nearest ER...which was not in our network. She ended up with a $4000 bill and all they did was "observe" her, give her some IV fluids, and do some bloodwork to screen for abnormalities and date rape drugs. If they'd taken her to our in-network hospital, her max out of pocket would have been $900 ($500 deductible + 10% coinsurance).

She learned an expensive lesson that night...date rapists aren't the only predatory assholes that young women in college have to worry about.

[AZ Progressive]

40. I can't believe that Americans would be fearful of socialism yet don't care about this barbarism

America, being such a wealthy nation, and yet only half civilized, while still half barbaric, should be the real outrage.

[Liberal Veteran]

41. And it isn't just hospitals. Doctor sent my blood work to out of network lab once.

Should have been covered completely. Ended up with a 700 dollar bill.

By the time I figured out what had happened, the shit was past due and sent them all but 50 dollars for the blood work. Called the lab and told them I would send them that amount this week and the remainder on my next pay check in two weeks and they said, "No problem". The next week, they sent the 50 dollars to collections. I got hung up on 10 times because I was so livid at the lab trying to explain that my payment was certainly evidence of good-faith attempt to pay. The supervisor said, "I don't understand why this was sent to collections, it says right here on the screen that we were okay with that payment option."

Either way, it was some bullshit. I was recovering from pneumonia and an diagnosis of full-blown AIDS and starting treatment. The last thing I needed to deal with was something like that. I am a pretty easy going guy, but get my dander up and all bets are off.

[Brigid]

42. Single.Payer.NOW.

That is all.

[KamaAina]

43. !Single payer ahora mismo!

[UglyGreed]

44. Yes Single Payer!!!!!

Life and good health is not just for the wealthy!