Refund for Vt. woman shows how 'really arbitrary' medical insurance is
Sarah Witter had to pay for a second surgery to repair her broken leg after a metal plate installed during the first surgery broke. On Friday, she got a more welcome break — a $6,358.26 refund from the hospital and her insurer.
Witter’s experience was the subject of December’s KHN-NPR “Bill of the Month” feature. She and her insurer, Aetna, had racked up $99,159 in bills from a Rutland, Vt., hospital and various medical providers after she fractured her leg in a skiing accident last February.
A surgeon at Rutland Regional Medical Center implanted two metal plates, attached to her leg bones to help them heal. Less than four months later, one of these plates broke, requiring her to have a second surgery to replace the plate. Witter, who is 63, ended up paying $18,442, mostly to the hospital, for her portion of the total cost for all her care from the hospital, doctors, emergency services and physical therapists.
After KHN contacted Aetna about these costs, the insurer noticed that Rutland Regional had billed Witter for the difference between what it charged for its services and what Aetna considered an appropriate price for the first surgery. Those additional charges are known as “balance bills” and occur when a medical provider is not in the insurer’s network and has no contract with the insurer. Rutland Regional is not in Aetna’s network. In our original story, KHN had calculated $7,410 in balance bills.
Aetna said it contacted the hospital and negotiated a compromise in which the insurer paid the hospital nearly $3,800 and the hospital waived the remainder of the charges to Witter that Aetna considered unreasonably high.
“As part of her benefits plan, Sarah’s claims in question went through a patient advocacy process that allows us to negotiate with the provider on the member’s behalf to resolve any balance billing issues,” a spokesman wrote.
Aetna said it will negotiate disputed bills for any of its customers who request assistance, and also help schedule appointments, get services authorized and deal with other non-medical complications. However, an Aetna spokesman wrote, “we weren’t fully aware of all of the bills that Sarah had received before we received them from you/her.”
Last week, Rutland Regional again declined to discuss Witter’s account. Witter said she learned of the refund during a meeting, at Rutland Regional’s invitation, with a hospital financial administrator.
“They went through all the costs and I guess treated it [the first surgery] more like it was a hospital service that was within my contract,” she said. The administrator told her they had “reprocessed” the charges from her second surgery, but that her portion of the bill did not change, she said.
“It’s good news — who doesn’t like getting money back? But I don’t quite understand,” she said. “If it’s that easy for them to reprocess this billing to get me this, then it’s obvious that everything is really arbitrary.”
One difference between the two surgeries was the first one was conducted during a crisis after Witter was admitted to the hospital through the emergency room. Balance bills in those circumstances are the most difficult to justify because patients with injuries that require immediate care, such as a heart attack or car accident, are usually taken to the closest medical facility. Patients are not in a position to figure out where the closest in-network alternative is.
Neither Witter’s hospital nor her insurer budged on her underlying complaint: that she shouldn’t have had to pay for second surgery, which cost $43,208, because one of the plates — known as a bone fixation device and manufactured by Johnson & Johnson’s DePuy Synthes — broke.
Device manufacturers generally do not offer warranties for hardware devices once they have been implanted, saying that device failure can be due to a variety of factors beyond the company’s control. Those include poor implantation by the surgeon; bones that fail to heal and subject the device to unremitting strain, causing metal fatigue; or patients who apply too much weight or movement on the bone despite instructions not to.
DePuy, which declined to comment for this story, earlier said that device failures occur in “rare circumstances.” In its instructions for surgeons, DePuy noted: “It is important to note that these implants may break at any time if they are subjected to sufficient stresses.”
Witter said her surgeon was present at her meeting at Rutland Regional and told her that “the fact the bone hadn’t completely healed yet was part of the problem.” She said she has not been able to find a contact for the device manufacturer so she can complain about it breaking.
Even after she receives her refund, Witter still will have paid $12,084 for her broken limb. Asked her advice for other patients dealing with bills they consider excessive, she said: “Don’t break your leg!’’
Jordan Rau: In Vermont, no break after big breaks
Sarah Witter couldn’t get a break even though her leg had gotten several.
As she lay on a ski trail in Vermont last February, Witter, now 63, knew she hadn’t suffered a regular fall because she could not get up. An X-ray showed she had fractured two major bones in her lower left leg.
A surgeon at Rutland Regional Medical Center screwed two gleaming metal plates onto the bones to stabilize them. “I was very pleased with how things came together,” the doctor wrote in his operation notes.
But as spring ended, the wound started to hurt more. In June, Witter returned to the doctor. “He X-rayed it and said it broke,” she said. “And I was thinking, what broke? And he said, the plate. He said they do sometimes.”
The doctor performed another operation, removing the cracked plate and replacing it with a larger one.
Witter said she had been dutifully following all the instructions for her recovery, including going to physical therapy and keeping weight off her leg.
“I was, of course, thinking, ‘What did I do?’” Witter said. “The doctor said right off the bat it was nothing I did.”
Then the bill came.
The two surgeries Sarah Witter had following her skiing accident last February led to almost $100,000 in bills. Witter paid more than $18,000 of that out-of-pocket.
Total bill: $99,159 for emergency services, therapy and hospital care, including $52,587 for the first surgery and $43,208 for the second surgery. Altogether, Witter’s insurer, Aetna, paid $76,783. Witter paid $18,442 — including $7,808 for the second surgery. About half of Witter’s total expenses were copayments; another $7,410 was the portion of hospital charges that Aetna considered unreasonably high and refused to pay.
Service provider: Rutland Regional Medical Center, the largest community hospital in Vermont, performed the surgeries. Emergency services, anesthesia and physical therapy were done by other providers.
Medical service: In February, two metal plates called bone fixation devices and manufactured by Johnson & Johnson’s DePuy Synthes division were surgically attached to two lower leg bones Witter had fractured in a skiing accident. These plates are long, narrow pieces of metal with holes drilled in them at regular intervals for screws to attach them to the bones. A crack had developed in one of the plates running from the side of one of those holes to the edge of the plate. A second surgery was required to remove the plate and replace it.
What gives: When devices or treatments fail and need to be replaced or redone, patients (and their insurers) are expected to foot the bill. That may be understandable if a first course of antibiotics doesn’t clear a bronchitis, requiring a second drug. But it is more problematic — and far more expensive — when a piece of surgical hardware fails, whether it’s a pacemaker, a hip that dislocates in the days after surgery or a fractured metal plate.
Warranties, standard features at an electronic store or a car dealership, are rare for surgeries and in the medical device industry.
Dr. James Rickert, an orthopedic surgeon in Indiana and president of the Society for Patient Centered Orthopedics, said a plate like the one implanted in Witter’s leg can fail if the surgeon does not line it up correctly with the bone, although usually that causes the screws to break or back out. A plate also can fail if the patient puts too much weight on it or doesn’t follow other recovery instructions.
“When the plate breaks, it’s usually from overworking it, or a defect in the plate itself,” Rickert said. “The vast majority of people follow their instructions and are honest about it. If a person comes in and tells you they’ve been following their instructions and the surgery’s done properly, to me that’s a hardware failure.”
Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association, said sometimes hospitals will not charge for a second surgery “if they were aware that it was something they did that caused the patient to need follow-up care.”
Rutland Regional, Witter’s hospital, would not discuss Witter’s care or bills, even though she gave it permission to do so. “The organization is not comfortable in getting into the specifics of an individual patient’s case,” a spokeswoman wrote. The hospital also declined to discuss under what circumstances, if any, it would discount a second surgery’s cost because of the first’s failure.
Hospitals do not consider it their responsibility if a medical device failure is the problem, Foster said. But manufacturers are reluctant to take the blame for an unsuccessful surgery.
Patients are usually out of luck when a second surgery is needed because of the failure of a medical device, like Sarah Witter’s broken plate. “The biggest annoyance with this whole thing, even though it took eight months out of my life,” Witter says, “is I hate to pay for it again, and the doctor clearly said it wasn’t anything I did.”
AdvaMed, the trade group for medical device manufacturers, said some companies will provide replacement devices if theirs failed, but others do not, especially if the failure of a procedure cannot “easily be attributeDed” to the device, the group said in a written statement.
“There are numerous factors outside of a manufacturer’s control — and unrelated to the safety of the device as designed — that could result in a device not performing as intended,” AdvaMed said.
These devices aren’t cheap: Witter’s hospital billed $9,706 for the first set of plates. It billed $12,860 for the replacement and an extra piece of equipment to attach it.
DePuy Synthes, which manufactured Witter’s plates, said in a written response that “in rare circumstances” metal plates “may fracture under normal weight-bearing or load-bearing in the absence of complete bone healing.” Even then, the company said, that is a chance patients have to take.
AdvaMed said it does not keep statistics on device performance, and DePuy did not respond to questions about how often its plates fail.
Resolution: The second surgery delayed Witter’s recovery by four months and prevented her from gardening, golfing, hiking, biking and motorcycling through the summer and fall, as she usually does. “I was pretty much chair-bound for 20 weeks,” she said.
In November, she was not able to join her husband and son on a trip to Iceland. Instead of volunteering at a nearby ski resort, as she had done for six years — and which carries the benefit of a free season pass — Witter said she tried selling hand warmers and lip balm out of a small kiosk and watching the skiers through a window. She said she had to quit after six days because of the pain in her feet.
“The biggest annoyance with this whole thing, even though it took eight months out of my life, is I hate to pay for it again, and the doctor clearly said it wasn’t anything I did,” she said.
Aetna said that while it does not allow providers to charge for indisputably inept medical mistakes such as leaving a surgical sponge in a patient or operating on the wrong limb, a broken plate does not qualify for such protection.
After reviewing Witter’s records, Aetna said it concluded the hospital had billed Witter for the portion of charges Aetna had considered excessive —a practice known as “balance billing.” While Aetna cannot reject those charges because the hospital does not have a contract with it, the spokesman said Aetna would try to negotiate with the hospital on Witter’s behalf to reduce the bill.
Rutland Regional, however, indicated in its statement that the only reason it would discount a bill was for people who had inadequate insurance or were suffering financial hardship from the size of the bills. Witter said she does not meet the hospital’s criteria.
The hospital invited her to meet with her surgeon and its chief financial officer.
The Takeaway: Witter brought up the seeming unfairness of the double charges to the hospital’s billing department as well as to her doctor, who, she said, was “charming,” but told her “he had no wiggle room to do anything.”
Patients are usually out of luck when a second surgery is needed because of the failure of a medical device or a surgeon’s mistake. A few places, most prominently the Geisinger Health System in Pennsylvania, offer warranties for hip and knee, spine and coronary artery bypass surgeries, among other procedures.
AdvaMed says that if a company provides a replacement, the hospital or surgeon is not supposed to bill Medicare or the patient for the equipment — even if the operation incurs charges.
Patients should scrutinize their bills and question their doctor and hospital or surgical center about charges for replacement devices.
If the doctor or hospital is partially at fault for the failure of the first procedure, request that part or all of the costs of the second surgery be waived. Get it in writing so you can make sure the billing department follows through. Also, in a medical market where insurers want to pay only for value-based care, let your insurer or employer’s human resources department know that you are being charged twice for the same surgery. Let them fight the battle for you.
Do you have an exorbitant or baffling medical bill? Join the KHN and NPR Bill-of-the-Month Club and tell us about your experience.
Jordan Rau: jrau@kff.org, @JordanRau
Ski trail in Stowe, Vt.