Rachel Bluth: Battling another surprise exorbitant medical bill
Main entrance of Hartford Hospital.
From a planning perspective, Wolfgang Balzer, of Wethersfield, Conn., is the perfect health-care consumer.
Balzer, an engineer, knew for several years he had a hernia that would need to be repaired, but it wasn’t an emergency, so he waited until the time was right.
The opportunity came in 2018 after his wife, Farren, had given birth to their second child in February. The couple had met their deductible early in the year and figured that would minimize out-of-pocket payments for Wolfgang’s surgery.
Before scheduling it, he called the hospital, the surgeon and the anesthesiologist to get estimates for how much the procedure would cost.
“We tried our best to weigh out our plan and figure out what the numbers were,” Wolfgang said.
The hospital told him that the normal billed rate was $10,333.16 but that Cigna, his insurer, had negotiated a discount to $6,995.56, meaning his 20% patient share would be $1,399.11. The surgeon’s office quoted a normal rate of $1,675, but the Cigna discounted rate was just $469, meaning his co-payment would be about $94. (Although the Balzers made four calls to the anesthesiologist’s office to get a quote, leaving voicemail, no one returned their calls.)
Estimates in hand, they budgeted for the money they would have to pay. Wolfgang proceeded with the surgery in November, and, medically, it went according to plan
Then the bill came.
The bill for Wolfgang’s surgery turned out to be $2,304.51, $800 higher than he and his wife, Farren, had budgeted for, based on the estimates. “That’s a huge hit,” Farren says.
Total Bill: The estimates the Balzers had painstakingly obtained were wildly off. The hospital’s bill was $16,314. After the insurer’s contracted discount was applied, the bill fell to $10,552, still 51% over the initial estimate. The contracted rate for the surgeon’s fee was $968, more than double the estimate. After Cigna’s payments, the Balzers were billed $2,304.51, much more than they’d budgeted for.
What Gives: “This is ending up costing us $800 more,” said Farren, 36. “For two working people with two children and full-time day care, that’s a huge hit.”
When the bill came on Christmas Eve, the Balzers called around, trying to figure out what went wrong with the initial estimate, only to get bounced from the hospital’s billing office to patient accounts and finally ending up speaking with the hospital’s “Integrity Department.”
They were told “a quote is only a quote and doesn’t take into consideration complications.” The Balzers pointed out there had been no complications in the outpatient procedure; Wolfgang went home the same day, a few hours after he woke up.
The couple appealed the bill. They called their insurer. They waited for collection notices to roll in.
Hospital estimates are often inaccurate and there is no legal obligation that they be correct, or even be issued in good faith. It’s not so in other industries. When you take out a mortgage, for instance, the lender’s estimate of origination charges has to be accurate by law; even closing fees — incurred many months later — cannot exceed the initial estimate by more than 10%. In construction or home remodeling, while estimates are not legal contracts, failure to live up to them can be a basis for liability or “a claim for negligent misrepresentation.”
In this case, Hartford Hospital produced an estimate for Balzer’s laparoscopic hernia repair, CPT (current procedural terminology) code 49650
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The hospital ran the code through a computer program that produced an average of what others have paid. Cynthia Pugliese, Hartford HealthCare’s vice president of revenue cycle, said the hospital uses averages because more complicated cases may require additional supplies or services, which would add costs.
“Because it was new, perhaps the system doesn’t have enough cases to provide an accurate estimate,” Pugliese said. “We did not communicate effectively to him related to his estimate. It’s not our norm. We look at this experience and this event to learn from this.”
Efforts to make health care prices more transparent have not managed to bring down bills because the different charges and prices given are so often inscrutable or unreliable, said Dr. Ateev Mehrotra, an associate professor of health care policy and medicine at Harvard Medical School
“The charges on there don’t make any sense. All it does is, people get pissed off,” Mehrotra said. “The charge has no link to reality, so it doesn’t matter.”
Resolution: “Because I roll over more easily than my wife does, I’m of the mindset to pay it and get done with it,” Wolfgang said. “My wife says absolutely not.”
Investigating prices, dealing with billing departments and following up with their insurer was draining for the Balzers
“I’ve been tackling this since December,” Wolfgang said. “I’ve lost two or three days in terms of time.”
For the Balzers, there’s a happy ending. After a reporter made inquiries about the discrepancy between the estimate and the billed charges — six months after they got their first bill — Pugliese told them to forget it. Their bill would be an “administrative write-off,” they were told.
“They repeatedly apologized and ended up promising to adjust our bill to zero dollars,” Wolfgang wrote in an email.
Most patients aren’t as proactive as the Balzers in getting estimates for the cost of health care, and most wouldn’t know that the hospital, surgeon and anesthesiologist would each bill separately.
The Takeaway: It is a good idea to get an estimate in advance for health care if your condition is not an emergency. But it is important to know that an estimate can be way off — and your provider probably is not legally required to honor it.
Try to request an estimate that is “all-in” — including the entire set of services associated with your procedure or admission. If it’s not all-inclusive, the hospital should make clear which services are not being counted.
Having an estimate means you can make an argument with your provider and insurer that you shouldn’t be charged more than you expected. It could work.
Laws requiring some degree of accuracy in medical estimates would help. In a number of other countries, patients are entitled to accurate estimates if they are paying out-of-pocket.
Most patients aren’t as proactive as the Balzers, and most wouldn’t know that the hospital, surgeon and anesthesiologist would each bill separately. And most wouldn’t fight a bill that they could afford to pay.
The Balzers say they wouldn’t have changed their medical decision, even if they’d been given the right estimate at the beginning. It’s the principle they fought for here: “There’s no other consumer industry where this would be tolerated,” Farren wrote in an email.
Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!
Rachel Bluth is a journalist with Kaiser Health News.
Don Pesci: Political monopoly and the plight of young men
Hartford, Connecticut’s capital city, has been a one-horse town since 1971, when the last Republican mayor, Ann Uccello, was recruited by then President Richard Nixon to serve in the U.S. Department of Transportation. Since that time, more than 44 years, Hartford has languished in the grip of the Democratic Party hegemon. Hegemony always has and always will produce aberrant and corrupt government, largely because in one-party systems there are no political checks and balances, the administrative state is captive to an easily manipulable single party, and there are fewer eyes looking through the windows.
Former Bridgeport Mayor Joe Ganim, convicted and sent to prison on numerous corruption counts, once again is running for mayor in his old bailiwick; and three years after former Hartford Mayor Edie Perez had been convicted of corruption, an appellate court has overturned his hastily arrived at conviction.
The Perez case now lies before Connecticut’s Supreme Court, three of whose justices have been appointed by Gov. Dannel Malloy, the nominal head of Connecticut’s Democratic Party.
In addition, Mr. Malloy has appointed three justices to Appellate courts and thirty-nine judges to Superior Courts. The wheels of justice in Connecticut grind exceedingly slow, and so there is little chance that Mr. Perez will any time soon follow in the footsteps of Mr. Ganim and announce his candidacy for his old mayoralty seat.
More than four decades is a longtime for any hegemon. It seems proper at this late date – better late than never – to ask what progress, or regress, Hartford has made during these years of one-party rule?
Although Mr. Malloy and his crime czar, Under Secretary for Criminal Justice Policy and Planning Mike Lawlor, lately have tried to take credit for a national drop in crime rates, Connecticut cities need much improvement.
Based on the FBI’s Uniform Crime Report statistics released in September 2013, three Connecticut cities were listed among the top 10 most dangerous cities in the United States with populations fewer than 200,000: New Haven was second, Hartford fourth and Bridgeport sixth. Among the Top 101 cities with the highest percentage of single-parent households in a population of 50,000 plus, Hartford ranked number two, and we know from reliable studies that single parent households in urban areas link with disruptive social pathologies such as teenage pregnancies and the incarceration of young males.
Researcher Sara McLanahan, at Princeton University, suggests that boys are much more likely to end up in jail or prison by the time they turn 30 if they are raised by single mother. Her study shows that even after controlling for differences in parental income, education, race, and ethnicity, boys raised in single parent households are more than twice as likely to be incarcerated than boys raised within a traditional intact two parent household. Hartford is now the murder capital of New England. As July gave way to August, Everett Scott, 47, was brought to Hartford Hospital with a hole in his chest, apparently another drug-related murder. He did not survive. The usual meeting was held, attended by the usual politicians, who promised to do something. In 2014, there were 19 homicides in Hartford; in the first seven months of the 2015, the death toll was 19.
From the back of the room, Pastor Sam Saylor called out, “We stand at the number 19... In 2012, on Oct. 20, a 20-year-old boy, my son, died. Here we are now at the end of July facing number 20." For the benefit of the politicians seated at a table at the front of the room, Mr. Saylor asked his audience, “How many of you have lost a loved one to gun violence?" Twenty five hands were raised.
The politicians -- among them U.S. Representatives John B. Larson, and Elizabeth Esty -- no doubt well intended, nodded empathetically. Fewer illicit guns among drug dealers might be helpful; the General Assembly already had promulgated to little purpose new gun laws regulating sales among the sort of people in Connecticut who do not join drug gangs, and such regulations obviously had not diminished the death tally in Hartford. More cops might help. Call in the National Guard?
For obvious political reasons, one is not likely to find among Democratic or Republican Party campaign planks measures that will redress this problem; the war on young blacks in cities is a hard political nut to crack, because it would require a courage and honestly politicians find it difficult to muster. It would require, among other things, an acknowledgement that all the palliatives we have over the years thrown at the problem have worsened the lot of young blacks and Hispanic boys.
The black protagonist of Ralph Ellison’s Invisible Man, published in 1952, was a specter because people refused to see him. The plight of boys and young men in early 21st Century is likewise invisible.
Don Pesci (donaldpesci@comcast.net) is a Vernon, Conn.-based political writer.