Casey Trumble’s case for pregnancy complications: Medical billing at the Prentice Women’s hospital before the No Surprises Act went into effect
Her husband, Casey Trumble, drove her from their Chicago home to her OB-GYN’s office at Northwestern Medicine Prentice Women’s Hospital downtown. With suddenly elevated blood pressure and protein in her urine, she was diagnosed with preeclampsia, a potentially fatal but treatable pregnancy complication. Doctors admitted her to the hospital, saying she could expect to stay up to six weeks and have an induced delivery.
A sudden decline in her blood platelet count, which was a sign she was experiencing a rare, dangerous type ofeclampsia, required an immediate delivery by caesarean section.
Kearney’s daughter, Joey, born at 31 weeks, was placed on a ventilator and moved to the hospital’s neonatal intensive care unit. Small but healthy, she slowly began breathing on her own and eating normally. She was discharged in late January 2020, after 36 days in the NICU.
The Patient: Danielle Laskey, 31, was covered by a state-sponsored plan offered by her employer, a local school district, and administered by Regence BlueShield.
Ann & Robert H. Lurie Children’s Hospital of Chicago had the staff physicians that treated Joey. The location of Lurie is independent of Northwestern Medicine, but still connected to Prentice Women’s through an enclosed walkway. Lurie has a collaboration agreement with Northwestern Medicine to provide neonatology and pediatric physician services to Prentice Women’s patients.
The resolution: After KHN contacted Blue Cross, a Lurie representative called to offer to accept payment at the in-network rates.
Many patients agree to sign financial agreements when they’re admitted into a hospital because they believe they’ll pay for almost anything they don’t have insurance for. They’re asked to sign on a screen, without looking at the document.
Joey’s 36-day stay in the NICU happened before the federal government implemented the No Surprises Act barring surprise out-of-network billing. A state law prohibiting it, though, was in effect.
The No Surprises Act went into effect last year, prohibiting medical providers and insurers from billing patients for out-of-network doctor’s services at in-network hospitals unless there is an explicit consent from the patient. To be safe, patients should ask treating doctors whether they are in or out of network, even at an in-network hospital.
“It definitely appears that under the 2011 law, Brenna can only be billed for in-network cost sharing,” said Kathy Mikos, a registered nurse and patient advocate with the Navocate Group in Woodridge, Illinois, who is not involved with Kearney’s case.
Lurie, Blue Cross, and Northwestern Medicine did not respond to numerous requests from KHN for comment. Lurie cited patient privacy, despite receiving a release from Kearney regarding the federal Health Insurance Portability and Accountability Act, or HIPAA, which authorized the hospital to discuss Joey’s case with KHN.
A day later — following additional requests by KHN for comment — Spicer called Kearney and said she would remove all physician charges for her daughter’s care. Spicer did not return KHN’s call seeking comment.
The attorney general’s office told KHN it will investigate Kearney’s complaint, including whether Lurie violated the state Consumer Fraud and Deceptive Business Practices Act by telling her it was extending a “courtesy” by charging her only in-network rates, when that is what the 2011 law required. The insurance department also said it would investigate the complaint.
Gillespie, the state senator, said Lurie, Northwestern Medicine, and Blue Cross should have known about the state law. She said if patients feel they have been charged unfairly, they can file complaints with their state’s insurance department.
The Takeaway: More than a year after the federal surprise-billing law took effect, patients can still get hammered by surprise bills resulting from health plans’ limited provider networks and ambiguities about what is considered emergency medical care. Danielle Laskey is a patient that is discovering loopholes.
Danielle Laskey’s emergency medical care at Swedish Medical Center: A case study on out-of-network charges in the case of a pregnant woman
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). The KFF is a nonprofit organization that provides information on health issues.
It was the first day of her family’s vacation in the San Juan Islands last June when Danielle Laskey, who was 26 weeks pregnant, thought she was leaking amniotic fluid.
Laskey made a call to the OB-GYN back in Seattle who told her to seek immediate care. No leaks were found by the staff at the emergency department. The OB-GYN wanted her to see him as soon as possible.
In Seattle, Laskey’s water broke early, posing a serious risk to her and her fetus, and doctors ordered her admission to Swedish Medical Center/First Hill. She delivered her son after seven weeks in the hospital. Though she was treated for multiple postpartum complications, she was well enough to be discharged the next day. Her son went home a month later.
Laskey chose to go back to her home after a long time away from her daughter. She was home the same day after she came back for the procedure.
So after being urgently admitted to Swedish, Laskey believed her bills would be largely covered, with the couple expected to pay $2,000 at most for their portion of in-network care because of her plan’s out-of-pocket cost limit.
What Gives: The specialized clinic caring for Laskey before her hospital admission was in her insurance plan’s network. The clinic’s doctors admit patients only to Swedish Medical Center, one of the Seattle area’s only specialized providers for Laskey’s condition — which, given that connection, she assumed was also in the network.
Jacob said the Surprise-Billing laws were mentioned to the case manager of Regence, but that they did not apply to his family’s situation.
The office told KHN that there are laws against out-of-network charges in emergency situations. “Danielle cannot be balance-billed because she had an emergency, and Regence acknowledges it and is willing to pay for it,” said the public affairs director of the insurance commissioner.
In the meantime, patients, even in emergencies, should ask their doctors before a hospital admission whether the hospital is in their plan network, out of network, or (watch for these words) a “participating provider.”
Setting the terms with an insurer for providing its members emergency or other care appears to allow hospitals to sidestep new surprise-billing laws that prevent out-of-network providers from charging high, unpredictable rates in emergencies, according to government and private-sector medical billing experts.
Experts had not heard of out of network providers being contracted as “participating providers”, until KHN brought up Laskey’s case.
Matthew Fiedler, a senior fellow at the University of Southern California-Brookings Schaeffer Initiative for Health Policy who studies out-of-network billing, said Laskey’s case seems to fall into a “weird” gray area of the state and federal laws protecting patients from out-of-network charges in emergency situations.
Source: https://www.npr.org/sections/health-shots/2023/02/28/1159786893/a-surprise-billing-law-loophole-her-pregnancy-led-to-a-six-figure-hospital-bill
A Resolution to “Localizing Out-of-Network Medical Billing Surprises”: Danielle Laskey’s Elusive Hospitalization
After he declined to apply for the hospital’s financial assistance program, Jacob said Swedish also notified them in November that they had two months to pay or be sent to collections.
Natalie Kozimor, a spokesperson for Providence Swedish, said the hospital disagreed with “some of the details and characterizations of events” presented by the Laskeys, though she did not specify what those were. She said Danielle was assisted with her appeal by Swedish.
“We had no luck with Swedish taking any role or responsibility with regard to our billing or advocating on our behalf,” Jacob said. We were referred to their financial department to put us on a payment plan.
The Resolution: In December, the couple appealed Regence’s approval of Swedish’s out-of-network charges for the 51-day hospitalization, claiming it was an emergency and that there was no in-network hospital with the expertise to treat her condition. They also filed a complaint with the state insurance commissioner’s office.
On Jan. 27, two days after KHN contacted Regence and Swedish about Danielle Laskey’s case, a Regence representative called and informed her that her second hospitalization also would be reclassified as an in-network service.
“Under the Washington state and federal balance-billing laws, the definitions of whether a provider is considered in network hinges on whether there is a contract with a specific provider,” Bach said.
Washington state Rep. Marcus Riccelli, chair of the House Health Care and Wellness Committee, said he will ask the state’s public and private insurers what steps they could take to avoid provider network gaps and out-of-network billing surprises like this. He said he will also review whether there is a loophole in state law that needs to be closed by the legislature.
Congress might have to fix the problem, since the federal agencies that administer the No Surprises Act may not have authority to do anything about it, he added.
The Departments of Health & Human Services, Labor, and Treasury are looking at this issue, according to Bruce Alexander. While the agencies can’t predict whether a new rule or guidance will be needed to address it, he said, “they remain committed to protecting consumers from surprise medical bills.”
As the Laskeys discovered, hospital billing departments may offer little help in resolving surprise billing. It’s usually an option to appeal to your state insurance department or commissioner if you don’t want to contest questionable charges to the provider.