After a bike accident last April left Nina Dang semi-lucid with a broken arm, an ambulance transported her to the ED at Zuckerberg San Francisco General Hospital (ZSFG), the area's only top-tier trauma center.
'Surprise' medical bills, explained in 5 charts
Months later, Dang received a $24,074.50 bill. Her insurer agreed to cover only about $3,800—leaving her with an unpaid balance of more than $20,000.
The reason, as Sarah Kliff reports for Vox, is that ZSFG wasn't in Dang's insurance plan's network. In fact, it isn't in the network of any private insurance plan at all.
How an ED visit for a bike accident created $20k in medical debt
After Dang's bicycle accident, a bystander called an ambulance to the scene. An X-ray at the ED confirmed that Dang's arm was broken, and physicians also conducted a CT scan to look for brain or spinal injuries.
When the tests were complete, the doctors put Dang's arm in a splint, gave her pain medication, and told her to follow up with an orthopedist. A few months later, she received a bill for $24,074.50.
Zang's insurer, Premera Blue Cross, determined that it would cover $3,830.79, which it considered an appropriate value for the ED services. After Dang failed to pay the remaining balance, ZSFG in December 2018 said it would send her debt to collections.
"Eight months after my bike accident, I'm still thinking about [the bill], which is crazy to me," Dang said.
Are ZSFG's billing practices 'pretty common' or 'unusual'?
Vox, which has spent a year reporting on ED bills submitted by patients nationwide, reports that Dang's experience with ZSFG wasn't unique. In reviewing five bills submitted to its Emergency Room Billing Database by patients of ZSFG's ED, Vox found that privately insured patients sometimes paid significant amounts out-of-pocket after their insurers refused to cover their full bill.
Brent Andrew, a spokesperson for ZSFG, confirmed that the hospital is out-of-network for all private health insurance plans—a practice he described as "pretty common."
According to Andrew, the hospital focuses on serving patients with public insurance, which requires charging privately insured patients more to offset the costs. "We're the trauma center for the whole city," he said. "Our mission is to serve people who are underserved because of their financial needs. We have to be attuned to that population."
But Christopher Garmon, an economist at the University of Missouri Kansas City, said it's "unusual" for a large-hospital ED not to participate in any private insurance network. He added that he's "heard anecdotes of some hospitals trying a strategy like this, but my impression is that it doesn't last very long."
According to Garmon's research, only about 1% of patients receive a "surprise" bill because they were treated at an out-of-network ED. (It's much more common for patients to receive a surprise bill from an individual out-of-network doctor who works in an in-network ED—an issue that affects about one in five patients.)
In fact, many other public EDs accept a "long list" of private health insurance plans. That's partly because hospitals are almost always able to negotiate satisfactory rates with health insurance providers, as insurers know their patients will want to use ED facilities, Garmon said.
What's next for patients like Dang
Although some California senators have proposed state legislation to address out-of-network ED bills, for now there are few state or federal laws to protect patients like Dang, Kliff reports.
Patients can try to appeal the surprise bills to their insurance plans, the hospital, or the court system. But when Dang appealed the remaining $20,243.71 to her insurer, the company said that it had already paid an appropriate amount.
Andrew, the ZSFG spokesperson, emphasized that the hospital's billing practices are focused on "supporting people who don't have insurance." Still, he acknowledged that Zang is facing a difficult situation.
"I do understand that situation is a problem for individuals who come in here who are insured," he said. "She may feel like she didn't have a choice in coming here, and she might not have" (Kliff, Vox, 1/7).
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