STEVE INSKEEP, HOST:
Recovering from complex surgery is hard. And it's worse if you also get a bill that is nine times more than you expected. Dr. Elisabeth Rosenthal is editor-in-chief of our partner, Kaiser Health News, regularly brings us the medical bill of the month and has one more for us. Hey there, Elisabeth.
ELISABETH ROSENTHAL: Hi. Great to be here again.
INSKEEP: So who got this giant bill?
ROSENTHAL: It's a bill for Ely Bair. He's an analyst for a biotech company in Seattle. And he was shocked to learn he owed $27,000 for a surgery similar to one he'd had before when the earlier one - same doctor, same hospital, same insurer - he only had to pay 3,000.
INSKEEP: Wow, and reasonably would have expected about the same again. So what happened here? Let's turn to reporter Stephanie O'Neill, who got the full story.
STEPHANIE O'NEILL, BYLINE: During a routine visit to his dentist a few years back, Ely Bair learned why migraine headaches, jaw pain and high blood pressure had plagued him for years. He had a misaligned jaw. Surgery could fix it, he was told. But it would be a big job and quite a commitment on Bair's part.
ELY BAIR: My surgeon was very good at explaining this. And he was like, you know, once you start down this path, we have to do both jobs separately. And once you start, you can't really jump ship.
O'NEILL: That's because once the upper jaw is fixed, the doctor has to go back in and surgically reshape the lower jaw so it fits properly. The procedure would be expensive. But Bair's employee health insurance would cap his out-of-pocket cost at $3,000. So in July, 2018, the 35-year-old moved forward.
BAIR: So I had top jaw surgery and what's called SARPE, which is surgically accelerated rapid palate expansion.
O'NEILL: The procedure requires that the surgeon break the top jaw, then install a metal expander within the palate to widen it. And almost immediately, Bair says, he got relief.
BAIR: As soon as I had my airways opened by the first surgery, my blood pressure shot straight down. And it's been pretty much perfect ever since.
O'NEILL: His recovery, including extensive orthodontic work to realign his teeth, took about 18 months. Then in July, 2020, he went in for Phase 2, the lower jaw surgery. At the end of it all, he says, success. No more migraines. No more jaw pain. No more blood pressure meds. Bair was pretty darn pleased until he got the bill. Instead of $3,000 out of pocket, he was on the hook for $27,000.
BAIR: I thought, there must have been some sort of mistake, some sort of, like, coding mistake or, you know, billing mistake on the hospital's end that would get resolved.
O'NEILL: He thought that because the procedure was done by the same surgeon at the same hospital and paid for by the same insurance company. The only difference was that he'd switched jobs a year earlier. He didn't realize his benefits could change so much.
BAIR: I was (laughter) probably overwhelmed with emotion at that point. I was still recovering. And, you know, recovery from jaw surgery, it's a major surgery. And so just trying to deal with, you know, being healthy, especially during COVID - I was in quarantine by myself for five weeks in our, like, upstairs bedroom, couldn't even see my boyfriend. You know, it was rough. And, you know, trying to think about financials during all that time was not exactly (laughter) what I wanted to do.
O'NEILL: When he called his insurance company, Premera Blue Cross, to find out what happened, they told him his new plan had a lifetime limit for the surgery of $5,000. But that limitation didn't show up when his surgeon reviewed Bair's new benefits through Premera's online portal. Bair appealed. And Premera responded that Bair should have read his member booklet more closely. The payment cap, they said, was listed under something called maxillofacial orthognathic surgery.
BAIR: The assumption from insurance was that I could find this limitation in this 80-page booklet and know the medical terminology of what procedure I'm having done. And obviously, that wasn't the case because I did look in the booklet. But obviously, I did not look deep enough.
O'NEILL: Ultimately, Ely Bair says he contacted the state attorney general's office. After they got involved, the hospital cut the bill to $7,000.
For NPR News, I'm Stephanie O'Neill.
INSKEEP: Well, let's talk about this with Dr. Elisabeth Rosenthal. And first, it's remarkable there that the insurance company can say, you were told but just not in a form that you were able to really absorb it. That must be really common.
ROSENTHAL: Yeah. I mean, there are a few problems Ely hit. One is that insurance is really, really unpredictable when it comes to health care for our mouth and teeth.
INSKEEP: Oh, is there something especially difficult with insurance for that?
ROSENTHAL: Well, health insurance and dental insurance are really different beasts that work differently. Dental insurance, as we all know, is very limited. It usually has a yearly cap. And health care involving the mouth is in a gray area, which health insurers sometimes do and sometimes don't cover. In Washington, where Ely lives, this kind of jaw surgery is not considered an essential benefit under the Affordable Care Act. So Ely's two different insurance plans treated his surgery totally differently. And that's totally legal.
INSKEEP: Well, but that raises another question. Why would these insurance companies that are in the same market and paying the same health care system give such a very different benefit?
ROSENTHAL: This is a really common misunderstanding. The same brand of insurance can offer many different plans. And if you have employer-provided insurance, what benefits you get depends far more on what benefits your company elects to give you rather than the brand name that's on your card. So you could have a Blue Cross plan from one job that's really great, a Cadillac plan, and a Blue Cross plan from a second job that was really kind of minimal.
INSKEEP: I wonder what he possibly could have done in advance to avoid that giant bill.
ROSENTHAL: Well, the thing is, he assumed that the two plans would act similarly. And, in fact, the second plan had a cap on what it paid for that kind of surgery, a lifetime cap. And my first thought is, you know, sure, that was true. But you shouldn't have to read through 80 pages of fine print to learn, you know, whether you're going to be out of pocket for nearly 30,000 bucks. So that's why I always tell people it's advisable - though, it's a total, total pain - to get pre-certification and an estimate of cost from your insurer. You know, doctors' offices, they want you to be covered. And, you know, I've heard a million times, don't worry, your insurance should cover this. And then it doesn't. So, you know, ask your insurer. It's a total pain. But kudos to Ely for making a complaint to the attorney general's office. And patients should know they can also seek redress from a state consumer protection board.
INSKEEP: Elisabeth Rosenthal of Kaiser Health News. Thanks so much, always a pleasure talking with you.
ROSENTHAL: Thanks for having me.
INSKEEP: And remember, if you have a surprising or outrageous medical bill you'd like us to look into, go to NPR's Shots blog and tell us all about it.
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