He put up $14,000 for surgery and waited for his reimbursement. It never came : Shots - Health News Agreeing to an out-of-network doctor's financial policy, which protects their ability to get paid and may be littered with confusing jargon, can create a binding contract that leaves a patient owing.

Sign here? Financial agreements may leave doctors in the driver's seat

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LEILA FADEL, HOST:

It's time for our April Bill of the Month. Dr. Elisabeth Rosenthal is a senior contributing editor with our partner, KFF Health News. Doctor, thanks for being here.

ELISABETH ROSENTHAL, BYLINE: Thanks for having me again.

FADEL: So whose medical bill are we examining today?

ROSENTHAL: This month, we're examining Cass Smith-Collins. He's a transgender man who was excited to find a highly specialized surgeon who could perform top surgery. That surgery removes breasts to better align the body with gender identity. But in order to do the surgery, the physician required thousands of dollars from the patient in advance. And two weeks before the surgery, the practice sent Cass an out-of-network physician-patient agreement. What's that, he thought. This month, our story is about those kinds of agreements that generally protect the physician's ability to get paid and can be full of confusing insurance and legal jargon that puts patients in a pickle.

FADEL: OK. Reporter Emily Siner has the rest.

EMILY SINER, BYLINE: Ever since he was a kid, Cass Smith-Collins was desperate to live in a different body. He didn't identify with the gender he was assigned at birth. And into adulthood, his body just never felt like it fit.

CASS SMITH-COLLINS: I always hid behind fat because the smaller I was, the more I looked like something I didn't want to be. And I was over 400 pounds at one point.

SINER: But after he and his wife moved to Nevada, a state that felt more welcoming than where they were living before, Cass came out as trans. He quickly started testosterone therapy and, at age 50, decided it was time to get top surgery. On Instagram and TikTok, he'd seen reviews of different surgeons. He knew he needed someone who specialized in helping bigger-bodied men and found a highly reviewed doctor in Florida.

SMITH-COLLINS: I'd waited 50 years for this. I had one shot to get it done.

SINER: The doctor didn't take Cass' insurance, so in order to get booked for the surgery, Cass needed to pay an upfront fee four weeks in advance. He dipped into his retirement savings and paid about $14,000 to the surgeon's practice.

SMITH-COLLINS: I would have probably sold my soul.

SINER: It was a lot of money, but in his reading of his health insurance information, Cass thought that he'd get reimbursed for part of the money he paid out. Plus, one of the documents from the surgeon's office said the practice would file a claim with Cass' health insurance company. The surgery went well. Cass was pleased. Later, a statement from his health plan arrived. Cass did not get a reimbursement, and it wasn't immediately clear why. But it turns out he misinterpreted his out-of-network insurance coverage. He says that between the physician's office agreement and all the insurance documents, he was buried in paperwork.

SMITH-COLLINS: And there should be some sort of disclaimer that's very, very obvious. As it is, sure, it's in there, but the language for it is super confusing. And I wasn't reading the fine print. Again, I was desperate.

SINER: Cass spent months trying to get UnitedHealthcare to reimburse him for some of his upfront payment. After Bill of the Month began asking about the charges, the insurance company said its initial determination was correct, but they reprocessed the claim and sent a large payment to the surgeon. When Cass learned that, he reached out to his insurance company again and got a representative on the line.

SMITH-COLLINS: So I asked her, I'm like, so - well, what does this mean for me? How do I get my money back?

SINER: Cass says he was told he'd get his refund from the doctor. After a more than $100,000 payment went from the insurance company to the surgeon, in mid-April, the doctor's office sent Smith-Collins $7,245. The surgeon did not respond to requests for comment. It was a monthslong billing headache. But the surgery was important to Cass, and he says he'd do it all again with the same out-of-network doctor, and he'd even dip into his retirement savings to pay for it. For NPR News, I'm Emily Siner.

FADEL: We're back with Dr. Elisabeth Rosenthal. So, Doctor, what's new here? Is there something patients need to be on the lookout for?

ROSENTHAL: Wow. There's so much going on here.

FADEL: Yeah.

ROSENTHAL: And yes, in the end, Cass got a portion of his upfront payment back. But all this took place after Bill of the Month came calling, as is so often the case. One big takeaway from Cass' experience is that when a patient signs doctors' - especially out-of-network doctors' financial agreements, that can put the doctor in the driver's seat steering any insurance reimbursement. Cass was fortunate to have received a reimbursement at all and no more bills. Patients should consider getting some outside legal help or expert help to understand how those agreements work with your out-of-network insurance benefits. It's very complicated.

FADEL: OK, so this patient was willing to pay before his surgery, but was hoping to get his money back or at least some of his money back. Did he contact the health insurance company ahead of time?

ROSENTHAL: Sure, he did. Cass Smith-Collins did get prior authorization from the health plan that said the surgery was, quote-unquote, "covered." But covered can mean a lot of things, right? If the provider is out of network, the two sides may have very different ideas of what a service is worth since they don't have mutually agreed-upon rates like the in-network doctors.

FADEL: OK. Say more about what needs to be considered when a patient decides to get care from a doctor who does not accept your insurance.

ROSENTHAL: Well, first of all, I should say this is really unfair that patients have to do all this kind of work. But the first step is, of course, try to find care that's in your network. But if you want or need to go out of network to someone who doesn't take your insurance. Try to make sure you know what's going on and what you're getting into. If you have a particular out-of-network doctor in mind, ask in advance to see and read the fine print of any and all financial agreements 'cause you'll be asked to sign those before you commit to the appointment.

Ask if your provider will accept whatever reimbursement your insurance plan offers. Unlikely, that's why the doctor's out of network, right? But it can't hurt to ask. And finally, emails show Cass had a couple of weeks to review a version of the practice's out-of-network agreement. But he actually signed it in the office the day before surgery. When you're facing serious or highly anticipated surgery, it's really hard to be careful and rational under those circumstances. Like I said, so hard for patients.

FADEL: Dr. Elisabeth Rosenthal, as usual, thank you so much.

ROSENTHAL: Thanks for having me.

FADEL: So if you have a confusing or outrageous medical bill that you want us to review, please go to NPR Shots blog and tell us all about it.

(SOUNDBITE OF FRAMEWORKS' SONG "DELPHINA")

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