The doctor was stuck with a $64,000 bill for his ankle surgery and hospital stay

Doctor Lauren Hughes was headed to see patients at a clinic about 20 miles from her home in Denver in February when another driver struck her Subaru, totaling it. She was taken by ambulance to the nearest hospital, Platte Valley Hospital.

A shaken Hughes was examined in the emergency room, where she was diagnosed with bruising, a deep cut on her knee and a broken ankle. She said doctors recommended immediate surgical repair.

“You have this fracture and a big gash in your knee,” they said. “We need to take you to the operating room to wash it and make sure there is no infection.” “As a doctor, I thought: ‘Yes.’”

She was taken to the operating room in the early evening and then admitted to the hospital overnight.

A friend took her home the next day.

Then came the bills.

Medical procedure

Surgeons cleaned the wound in her right knee, which had hit the dashboard of her car, and realigned the broken bone in her right ankle, securing it with metal screws. Surgery is usually recommended when a broken bone is unlikely to heal properly with just a splint.

Final draft law

The hospital — which was not in-network for the insurance plan she obtained through her job — charged $63,976.35 for the surgery and overnight stay.

Problem: Should I stay or should I go?

Hughes’s insurance company, Anthem, covered the costs of the roughly $2,400 ambulance ride and some smaller radiology fees from the emergency room, but denied surgery and overnight stays from the out-of-network hospital.

“Sixty-three thousand dollars for a broken ankle and a cut knee, no head injury or internal damage,” Hughes said. “Just stay there all night. It’s crazy.”

Insurers have broad discretion Whether the care is medically necessary – That is, what is needed for treatment, diagnosis or relief. This decision affects whether and how much they will pay for it.

Four days after surgery, Anthem informed Hughes that after consulting clinical guidelines for the type of ankle repair, her reviewer determined it was not medically necessary for her to be fully admitted for a hospital stay.

If she needs additional surgery or has other problems, such as vomiting or fever, a hospital stay may be necessary, according to the letter. She added: “The information available to us does not show that you suffer from these or other serious problems.”

For Hughes, the idea of ​​leaving the hospital was “ridiculous.” Her car was in a junkyard, she had no family nearby, and she was taking opioid painkillers for the first time.

When I asked for more details about the medical necessity determinations, Hughes was directed deeply into her policy’s benefits booklet, which explains that for a hospital stay, documentation must show “cannot obtain safe and adequate care as an outpatient.”

It turned out that the surgery fee had been denied due to a flaw in the insurance contract. Under Anthem’s agreement with the hospital, all claims for services before and after a patient’s admission are approved or denied together, said Emily Snooks, an Anthem spokeswoman.

A hospital stay is not generally required after ankle surgery, and the insurance company found that Hughes did not need the kind of “extensive and complex medical care” that would require hospitalization, Snooks wrote in an email to KFF Health News.

“Anthem has consistently agreed that Ms. Hughes’ ankle surgery was medically necessary,” Snooks wrote. “However, because the ankle surgery was included with the hospital admission, the entire claim was denied.”

Facing bills for an out-of-network hospital where she was transported by emergency responders, Hughes didn’t understand why she hadn’t been protected before Law no surpriseswhich takes effect in 2022. Federal law requires insurers to cover out-of-network providers as if they were in-network when patients receive emergency care, among other protections.

“If they decide it’s medically necessary, they’ll have to apply the cost of no-surprises law,” said Matthew Fiedler, a senior fellow at the Center for Health Policy at the Brookings Institution. “But the no-surprises law would not go beyond a determination of ordinary medical necessity.”

There was another oddity in her condition. During one of several calls Hughes made to try to settle her bill, an Anthem representative told her that things might have been different if the hospital had billed her admission as an overnight “observation” stay.

Generally, this is when patients are kept in the facility until staff can determine whether they need to be admitted or not. Rather than being related to length of stay, designation primarily reflects intensity of care. A patient with fewer needs is more likely to be billed for an observation stay.

Insurers pay hospitals less for probation stays than for admission, Fidler said.

This discrimination is a big problem for patients on Medicare. In most cases, the government health program will not pay for it Any care required in a nursing home If the patient is not formally admitted for the first time to A Hospital for at least three days.

“It’s a classic battle between providers and insurers over which group the claim falls into,” Fidler said.

decision

As a physician and director of the Center for Health Policy at the University of Colorado, Hughes is a savvier policyholder than usual. However, she herself was frustrated during the months she spent shuttling between the insurance company and the hospital — and worried when it looked like her account would be sent to a collections agency.

In addition to appealing the dismissed claims, she sought assistance from her employer’s human resources department, which contacted Anthem. She too I reached out to KFF Health NewsThat contacted Anthem and Platte Valley Hospital.

In late September, Hughes received phone calls from a hospital administrator, who told her they had “downgraded the standard of care” for which the hospital billed her insurance and resubmitted the claim to Anthem.

In a written statement to KFF Health News, Platte Valley Hospital spokeswoman Sarah Kowal said the facility “deeply regrets any distress this situation has caused it.” She wrote that the hospital billed Hughes “prematurely” and by mistake before calculating the balance with Anthem.

After a careful review of Ms. Hughes’ situation, Coyle continued, “We have now stopped all billing for her. “Furthermore, we informed Ms. Hughes that if her insurance company ultimately allocated the remaining balance to her, she would not be billed for it.”

Platte Valley resubmitted Hughes’ bill to the insurance company on Oct. 3, this time for “outpatient care services,” Anthem spokeswoman Stephanie DuBois said in an email.

An explanation of benefits sent to Hughes shows the hospital repaid about $61,000 in bills — about $40,000 of which was removed from the total through Anthem’s deductible. The insurance company paid the hospital approximately $21,000.

In the end, Hughes only owed a co-payment of $250.

Ready meals

There are places where patients receiving emergency care at an out-of-network hospital may fall through the cracks of federal billing protections, particularly during a phase that may be almost indistinguishable to the patient, known as “post-stabilization.”

Generally, this occurs when a medical provider determines a patient’s condition Stable enough for travel to an in-network facility that uses non-medical transportation, said Jack Hoadley, research professor emeritus at Georgetown University’s McCourt School of Public Policy.

If the patient prefers to stay put for further treatment, the out-of-network provider should ask the patient To sign the consent formHe said he agreed to waive billing protection and continue treatment at out-of-network rates.

“It’s very important, if they give you a letter to sign, that you read that letter very carefully, because that letter may give them permission to get some big bills,” Hoadley said.

If possible, patients should contact their insurance company, in addition to asking the hospital’s billing department: Are you fully admitted, or kept on observation, and why? Has your care been determined to be medically necessary? Keep in mind that medical necessity determinations play a major role in approval or denial of coverage, even after services are provided.

However, Hughes did not recall being told she was stable enough to leave by non-medical transportation, nor was she asked to sign a consent form.

Her advice is to quickly and aggressively question an insurance denial as soon as you receive it, including by asking to escalate your case to insurance company and hospital leadership. Expecting patients to deal with complex billing questions while in the hospital after a serious injury is unrealistic, she said.

“I was calling my family, alerting my coworkers of what had happened, processing the extent of my injury and what needed to be done clinically, arranging care for my pet, performing laboratory and imaging tests — and coming to terms with what had just happened,” Hughes said.

Bill of the Month is a group investigation by KFF Health News and The Washington Post Well-Being + Being Who dissects and explains medical bills. Since 2018, this series has helped many patients and readers reduce their medical bills, and has been cited in state institutions, at the U.S. Capitol, and at the White House. Do you have a confusing or expensive medical bill that you want to share? Tell us about it!