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August 28, 2018

He's insured. But he still owes $108,951.31 for an ED visit. Here's why.

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    While several states have policies on the books to ensure patients' medical costs are covered when they're treated out-of-network during an emergency, a "loophole" in these laws can leave patients with unexpected high bills, Kaiser Health News (KHN) reports. That's what happened to Drew Calver of Texas after he received care for a heart attack—and found himself presented with a $108,951.31 ED bill.

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    The laws in place—and their limits

    California, New York, Texas, and several other states have enacted laws protecting patients from having to pay unexpected out-of-pocket costs for out-of-network care.

    Those state laws apply to "surprise bills"—those patients receive for care at an in-network hospital from an out-of-network doctor—and "balance bills"—which patients receive when an insurer agrees to pay for care but pays the hospital less than it bills for the services provided, leaving the patient to pay the remaining balance.

    But those state-level protections have "a huge loophole," according to KHN: They don't apply to health plans from self-insured employers that pay for insurance claims from their own funds, as such plans are regulated by federal law.

    About 60% of people with health insurance from their employers are covered by self-insured health plans—but many of them do not know, as their employers usually hire an insurer to administer the plan. That means employees receive member cards with the name of a health insurance company, KHN reports. 

    Calver's case

    According to Kaiser Health News, the loophole can leave patients seeking emergency care at an out-of-network facility with large—in some cases six-figure—bills.

    For example, in April 2017, Drew Calver, a high school teacher who is covered via the school district's self-insured plan administered by Aetna, suffered a heart attack at his home in Texas. His neighbor drove him to St. David's Medical Center—the closest ED, which was outside of Calver's health insurance network.

    ED physicians at St. David's confirmed Calver had suffered a heart attack, and they admitted him into the hospital's cardiac unit. The following day, physicians at St. David's implanted four stents into one of his arteries. Calver spent four days in the hospital. The total billed price of the care was $164,941, which included $42,944 for four stents and $10,920 for room fees.

    Because Calver's treatment qualified as emergency care, his insurance plan covered a portion of his bill—but ultimately Calver was subject to "balance billing" for the portion of the bill his insurer did not pay.

    His insurer paid the hospital $55,840, leaving Calver responsible for the remaining $108,951.31.

    Paying the bill

    Since his discharge from St. David's, Calver has been receiving notices from the hospital's billing company to pay the bill.

    After a KHN reporter contacted the hospital about Caver's case, St. David's said the hospital has paused its effort to collect the remaining balance on Calver's bill. A hospital representative contacted Calver to offer him financial assistance by applying for discount based on income as a teacher.

    Carol Lucas, a Los Angeles-based attorney with experience in health care payment disputes, said Calver's case "illustrates the dangers that even insured people face," especially because Calver was unconscious at the time he was treated and so could not ensure that he arrived at an in-network facility.

    An Aetna spokesperson said the insurer is "actively working to rectify the situation on behalf of the member." Calver's school district declined to talk about his case, according to KHN.

    St. David's in a statement said, "While we did everything right in this particular situation, the structure of the patient's insurance plan as a narrow network product placed a large portion of the financial responsibility directly on the patient because our hospital was not in-network."

    St. David's also said it makes efforts to transfer patients once they're considered stable. "However, this is not always possible because the patient’s health must come first," the hospital added (Terhune, Kaiser Health News, 8/27).

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