I knew she had been treated for vertigo in a hospital ER in August. But why hadn’t her health insurance covered this?
My mother, Pauline Gulotta, an Austrian war bride, was old-school. When she received a demand for payment from a doctor, she paid it without question. So when the bill arrived for services provided by a physician who, we eventually surmised, was not a participant in her Medicare Advantage plan, she wrote out the check and put it in the mail. That simple act would send me on a nine-month journey involving countless hours on the phone, endless letters and emails, and a formal complaint to the New York State Attorney General’s Office in an effort to get my mother’s money returned.
The bill my mother paid, and subsequent bills she received for additional hospital visits, are termed “surprise medical bills.” They are often sent by ER physicians and medical test providers who don’t have negotiated agreements with the patient’s insurance, even though the hospitals where they practice are typically “in network.” In a normal world, patients check to make sure a doctor they want to see accepts their insurance. But taken by ambulance with the world spinning out of control, my mother didn’t question the ER doctor who treated her, especially since she knew the hospital was in network.
She is not alone. Several recent studies have concluded that millions of hospital patients are faced with surprise bills, often for similar reasons to my mother’s. And those numbers and the bill amounts grow larger each year.
A recently published study by Stanford University researchers of 13.6 million ER visits concluded that, in 2010, 32.3 percent resulted in a surprise medical bill averaging $220. By 2016, that percentage had grown to 42.8 percent, with the average bill at $628. Inpatient jumps were even more substantial, according to the study. Of 5.5 million inpatient visits, surprise bill percentages increased from 26.3 to 42 percent, with the average out-of-network bill rising from $804 to $2,040.
“It’s obvious from our study that if you go to the hospital, there is a pretty good chance you’re going to be hit with a surprise bill,” said study co-author Michelle Mello, a professor of law and of health research and policy at Stanford. These bills hit the low-income the hardest, she added, pointing to a recent Federal Reserve survey that concluded 4 in 10 people would not be able to readily cover an unexpected $400 bill.
Public opinion is clear on the topic: According to multiple surveys, a clear majority want surprise bills to end. But efforts to pass federal legislation so far have gone nowhere.
Twenty-eight states have taken matters into their own hands, passing laws that offer at least some restrictions on surprise billing, but federal regulations limit their reach. For example, those covered under self-insured group health plans, which apply to employees of most large corporations, are not protected by state laws. In the D.C. region, only Maryland is among the 28.
As a New York resident, my mother was covered by one of the country’s strongest surprise-bill laws, so I naively believed that her honest mistake would be quickly remedied. Within a few weeks, I realized she might have a better chance of winning the Powerball jackpot.
Her health insurance company pointed me to the provider, while the provider sent me back to the health insurance company. They both threw up privacy roadblocks, claiming they couldn’t talk with me as my mother’s health declined; copies of my power of attorney were lost and “appointment of representative” forms routinely disappeared.
The waters got even muddier when the insurance company tried to slough me off on an affiliated company that processed claims. Voice-mail menus became my diabolical purgatory. Meanwhile, more and more surprise bills arrived, emanating from three visits my mother made to the same emergency hospital, and phone calls threatening collection started.
My increasingly frail mother was becoming distraught and often told me she wanted to just pay them so she could rest. From hundreds of miles away, I urged her to dig in her heels and stay strong. And I continued to do battle on her behalf.
In my mother’s situation, the out-of-network ER doctor had already received a $179.88 reimbursement on the $783 bill. That should have been the end of the story. Instead, the doctor’s billing service sent a “balance bill” stating, “The remaining balance due is your responsibility.”
In February, I filed a complaint with the N.Y. State Attorney General’s Office. By early March, I received a letter stating that they had intervened on my behalf and that the billing service had agreed to send a full refund, which my mother would receive within 60 to 90 days.
On June 2, my mother died. She had never received that refund.
My grief turned into anger at a health system that, even after death, kept sending her surprise bills. Instead of letting it go, I became obsessed. I sent letters to each of the hospital’s board members and to the religious organization that runs the hospital, mailed dozens of official forms disputing the charges and emailed elected officials. Crickets.
The attorney general’s advocate kept turning up the heat on both the insurance company and the provider, but even he felt stymied, advising in an email, “It’s pretty clear that the provider does not want to issue this refund.” I just kept on hammering.
Finally, on Aug. 10, a thin letter arrived from a company that, I realized then, owned not only the hospital but also the company that had billed on the doctor’s behalf. In it was a check for $603.12. I’m not ashamed to say that I put my head in my hands and wept. The money had long since ceased being the point: I’d figured out months earlier that if I divided up the money by the hours spent, it was worth pennies on the dollar.
What had fueled my quest were thoughts of all the elderly, gravely ill, financially struggling patients who routinely just pay these unfair bills because they don’t know the law or don’t have the strength to fight, and all of those unlucky souls living in states where they have no recourse but to pay.
Corny as it sounds, it became all about the principle of the thing.
After I got the check, I sat down at my mother’s grave and told her all about our victory. But it didn’t feel as sweet as I thought it would. Mom wasn’t around to share it with me. And in the weeks that followed, more similarly bogus bills arrived, with no end in sight. Had my mother paid every one of these bills, which she would have done without me on her side, she would have spent $3,709.76. And there are millions like her. Do the math.