DAVID GREENE, HOST:
Every month, NPR and Kaiser Health News take a close look at medical bills that you send us. And this week, you're going to be hearing the word surprise a lot. And that is never a word you actually want to hear in the same sentence as medical bill, especially if you are just coming back from emergency heart surgery and the bill is for a six-figure amount that you apparently owe. Elisabeth Rosenthal is the editor-in-chief of Kaiser Health News, and she is back in our studios. Hi, Elisabeth.
ELISABETH ROSENTHAL: Hi, great to be here.
GREENE: This is making me nervous just thinking about it. You have heart troubles. You go for emergency surgery. And now when you're just recovering, you're told that you owe a ton of money.
ROSENTHAL: Yeah, it's scary. Our August bill of the month is for a Texas man's medical costs after the insurance company has already reimbursed the hospital - crazy. His name is Drew Calver. He's a high school teacher and swim coach in Austin, Texas. And we'll hear Drew tell his story in a moment, but what he faced that day was a really common financial issue. When the hospital and insurer can't agree on a price, the patient is left holding the bag.
GREENE: And stressed out at a moment when he's recovering from a heart attack. I mean, that sounds unfair.
ROSENTHAL: Right, this insurer had already paid out $55,000, which from what we can tell is a very reasonable, generous price to pay for his procedure. But the hospital thought that his care was worth much, much more. And so they tried to bill about $150,000 and billed him for the difference. So that's called balance billing, the balance after insurance paid. We're talking about an amount that's double his teacher's salary. For him, it was an unexpected bill that, as far as he understood, was not covered under the terms of his insurance. So it was what we call surprise billing.
GREENE: OK. So these terms, just so I understand it, balance billing - when the hospital tries to make up for what they think they are owed. Once that balance billing ends up in Drew's mailbox, that's called surprise billing.
ROSENTHAL: Balance billing is one form of surprise billing.
GREENE: All right, well, let's actually meet Drew Calver. Ashley Lopez from member station KUT in Austin went to pay him a visit. And he took her back to the day of his heart attack.
ASHLEY LOPEZ, BYLINE: A little more than a year ago, Drew was taking out the trash on a Sunday morning. His wife, Erin, was heading to the store with one of their daughters. He remembers waving at them.
DREW CALVER: And then as I turned the corner from the driveway, I just had that back pain.
LOPEZ: Drew says he started to keel over. He then stumbled back inside the house where he saw Eleanor, his older daughter.
D. CALVER: And I literally said to her, Eleanor, I think I'm dying.
LOPEZ: Through waves of pain, Drew managed to reach his wife who then got a neighbor to drive him to a hospital that's less than a mile away. Turns out, Drew was having a particularly dangerous kind of heart attack known as the widow-maker. And this was a huge surprise because just a few months before, Drew was in a half-Ironman.
D. CALVER: I mean, I was a swimmer in college - high school and college, so always been in pretty good shape.
LOPEZ: Once Drew was stabilized at the hospital, doctors planned to put stents in to open up his blocked arteries. Before the actual procedure, he made sure to ask whether his insurance would cover all of that.
D. CALVER: And they said, yeah, with - your insurance is - accept it. You know, we've called them, and they've given us the OK.
LOPEZ: All together, Drew was in the hospital for four days.
ERIN CALVER: Those are from the ninja place.
LOPEZ: Life is pretty much back to normal these days, he says. Drew's wife, Erin, and his two daughters, Eleanor and Emory, ages 7 and 6, are getting ready to walk to school. He says surviving a heart attack has made him appreciate this time with his family even more. But there is one big thing that is still hanging over them. That's those hospital bills that came flooding in right after his heart attack.
D. CALVER: I've got some different sets in some of these.
LOPEZ: According to the hospital, Drew owes almost $109,000.
D. CALVER: It just kind of got real all of the sudden. They're like no. Hey, your insurance isn't going to pay this. You owe this.
LOPEZ: This medical debt is raising a lot of questions.
LOPEZ: While walking their daughters to school, Drew and Erin say they don't know how to plan their finances.
E. CALVER: Will we be able to get a car loan? Will they come after our 401(k)? You know, just all this stuff, and just thinking, like, this cannot be right.
LOPEZ: And for Drew, this massive hospital bill isn't making it any easier to recover from his heart attack.
D. CALVER: For me, I'm trying to reduce that stress in my life. That's part of my doctor's recommendations, you know, my doctor's orders.
LOPEZ: And Erin says they've been dealing with the worry of all this for a year now.
E. CALVER: I just think that the bill in itself is so reprehensible.
LOPEZ: In the meantime, they say there's just no way they can pay that bill.
GREENE: All right. The reporting there you just heard was from Ashley Lopez at NPR member station KUT in Austin. I am still with Elisabeth Rosenthal, the editor-in-chief of Kaiser Health News. Elisabeth, what can Drew Calver do here?
ROSENTHAL: Well, the first thing everyone should know is try to go to an in-network hospital. However, if you're having a heart attack...
ROSENTHAL: ...You're not Googling, you know, who's in network?
ROSENTHAL: You just go to the nearest place. So that's step one. The second step is don't just write the check. When you get a bill - a surprise bill or a balance bill that seems outrageous, fight back with this because in many states now, including Texas, there are laws that protect patients from surprise bills. And basically what those laws say is if the provider - in this case, the hospital - and the insurer can't agree on a price, then the patient cannot be held responsible. He is held harmless, and the two of them will have to work it out among themselves.
GREENE: So this is good news for Drew.
ROSENTHAL: Well, except there's a big loophole in those laws. And that is that about 60 percent of plans are what we call self-insured, meaning you may have a network like Cigna or Aetna, but they are really just administering the plan. And the problem is those state laws don't apply to those self-insured plans. So even though Texas has a great law, it did not cover Drew's situation and hold him harmless.
GREENE: OK. So, Drew Calver, the lesson is don't pay yet. Try and fight it, but it's not clear that you will win. You might be stuck paying this money somehow.
ROSENTHAL: Well, maybe, but one thing that I advise people to do is if your state has that law, download the forms. Send them to the hospital. Send them to your insurer. And say, hey, look, this is a weird loophole. You know this is the right thing to do, and it does work sometimes. I've used that, and it worked in New York for me.
GREENE: Elisabeth Rosenthal is the editor-in-chief of Kaiser Health News. Thanks as always for bringing these stories to us. They're really good lessons.
ROSENTHAL: Thanks for having me.
GREENE: Hey, if you have an interesting medical bill, we would love to take a look at it. You can go to NPR's Shots blog to share your bill with us and with Kaiser Health News.
(SOUNDBITE OF SYNTH4EVER'S "FLOATING THROUGH THE PLANES OF EXISTENCE")
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