Health

Controversial 'Balance Billing' Practice Leaves Woman With $50,000 Medical Bill

| by Jared Keever

A 30-year-old Wisconsin woman is trying to figure out how to avoid bankruptcy after getting hit with a $50,000 medical bill after paramedics took her to the wrong hospital while she was unconscious. 

Megan Rothbauer suffered a heart attack last year. While she was unconscious, paramedics took her to the closest hospital — St. Marys of Madison, Wisconsin.

The problem is, St. Marys is outside of her insurance company’s billing network. Had she been taken to Meriter Hospital, which is only three blocks away, she would only be on the hook for $1,500. 

“I was unconscious when I was taken to the hospital,” Rothbauer told WISC. “Unfortunately, I was taken to the wrong hospital for my insurance. I was in a coma. I couldn't very well wake up and say, ‘Hey, take me to the next hospital.’ It was the closest hospital to where I had my event, so naturally the ambulance took me there. No fault to them.”

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“Since we have no contract with this hospital, we have very little influence over what the hospital is charging in this situation,” Scott Larrivee, a representative from Rothbauer’s insurance company, Anthem Blue Cross Blue Shield, said in an email. 

The hospital said it already reduced the bill as far as it could, and pointed out that people should be focused on the fact that Rothbauer’s life was saved.

Because the insurance company does not have a contract to negotiate lower prices with St. Marys, Rothbauer is liable for the difference between what the hospital billed and what the insurance was willing to pay. 

That’s referred to as “balance billing,” a phenomenon in the health industry that has been on the rise. 

A recent article from The New York Times claims some doctors and hospitals are using the out-of-network rates to circumvent price controls put in place by the Affordable Care Act. Insurance commissioners across the country, the article says, are working to reduce patient exposure to those costs.

“This has gotten really bad, and it’s wrong,” said James J. Donelon, Louisiana’s insurance commissioner. “But when you try to address it as a policy maker, you run into a hornet’s nest of financial interests.”

A story from the Los Angeles Times predicts the loopholes that allow for out-of-network billing will someday be closed. Until that time, the article says, patients need to work with doctors upfront to avoid surprise bills. 

But that wouldn’t have worked for Rothbauer, because she was unconscious.

Meg Gaines, of the Center for Patient Partnerships, a consumer health care advocacy group at the University of Wisconsin-Madison Law School, said that is another problem that needs to be addressed. It is unfair, Gaines said, to place the responsibility for life-and-death decisions on the patient. 

“My strong suspicion is this happens more frequently than you think,” she said. “I mean every time someone goes down, they don't have someone around who knows what their insurance is.

“It is totally random, and it is the problem with saying consumers have to go to the right hospital and you say, ‘What if you're unconscious?’” Gaines added.

Sources: WISC, The New York Times, Los Angeles Times

Photo Source: WISC, Flickr Creative Commons