NOEL KING, HOST:
All right, we're going to talk today about our medical bill of the month for the month of July. We have seen some pretty outrageous bills sent in by our listeners, but this is the biggest one we've seen yet.
Dr. Elisabeth Rosenthal is the editor-in-chief of our partner Kaiser Health News, and she's in the studio to tell us about it. Hi, Elisabeth.
ELISABETH ROSENTHAL, BYLINE: Good to be here. Yes, this one's a doozy.
KING: This month's bill went to a couple in the state of Montana.
ROSENTHAL: Yeah, this month, we meet Jessica and Sov Valentine. They've run into what can happen to you when you have to go out-of-network for kidney dialysis or any other procedure, frankly.
KING: So being in and out of network can be confusing for a lot of people. It was in this case. We sent reporter Nick Mott to visit the Valentines in their home in Plains, Mont.
NICK MOTT, BYLINE: Sov Valentine is in his garage-turned-gym doing some leg extensions. He's been a personal trainer for three decades. But right now, he's skinny as a rail.
SOV VALENTINE: When I first got sick, I - honestly, I was laying in bed with a two-pound dumbbell.
MOTT: He says he's doing everything he can to stay strong and fit so he can be ready for a kidney transplant when the time comes.
VALENTINE: After all these years, I know that if you don't maintain what you have, even if it's just doing two pounds, you're in trouble.
VALENTINE: Back in January, he'd been feeling weak and fatigued during his workouts. Then one day, he started vomiting. He knew something was seriously wrong, and he went to the hospital. But Plains, Mont. is a small town. And there was only one physician working when he got there. It was his wife, Jessica.
JESSICA VALENTINE: He just showed up at the front desk, so...
MOTT: What were you thinking?
VALENTINE: Oh, shoot.
MOTT: His kidneys were covered in cysts, and they were barely functioning. He'd need to start dialysis immediately.
VALENTINE: It's just shock. I mean, there's no other way to describe it.
MOTT: He's 50, really young for such a major health issue. It's a lot to deal with.
VALENTINE: What I do is just focus on what the one task is, whether it's big or small. Get through that, and don't worry about anything else.
MOTT: While Sov took it one day at a time, Jessica started doing the dirty work of figuring out what all this was going to cost.
VALENTINE: So I am pretty familiar with navigating the system because I have to do it for my work all the time. So I call insurance companies and try to get things authorized for patients as part of my job.
MOTT: Their insurance company said all the dialysis options in Montana were out-of-network. So Jessica called Fresenius, a dialysis center. The center said they couldn't give them an estimate and referred them back to their insurance, who referred them back to Fresenius and on and on.
Sov started treatments three times a week at Fresenius. As the time passed, the Valentines held their breath.
VALENTINE: While the bills were adding up, we didn't have any idea what the bills might be. So we didn't get any bills until he was essentially almost done at Fresenius.
MOTT: The first bill came in late March after 2 1/2 months of treatment. It was for $120,000. Jessica called Fresenius immediately. After several phone calls, all she found out is that they might be eligible for financial aid.
VALENTINE: That is ridiculous. I don't know who would be able to possibly do that. It's crazy.
MOTT: Then more bills came. That number grew to more than half a million dollars. They received a collection notice, too.
VALENTINE: It just doesn't seem real.
MOTT: Sov keeps taking things one step at a time. They kept digging and eventually found an in-network dialysis center at a fraction of the cost. They applied for financial aid from Fresenius and Medicare. The stress of being sick, of owing so much money, it compounds.
VALENTINE: I'm focusing on keeping my energy to heal. You know, I'm headed for a transplant. And I don't want to wear myself out, which is what this does.
MOTT: Sov's wife is a doctor, and he has good insurance. But he says he knows not everyone has the same luck.
KING: That was Nick Mott with Montana Public Radio. OK, Elizabeth, so Sov told Nick that he feels lucky. But he still has a half a million dollar bill that he's got to pay. Will Fresenius negotiate with him at all?
ROSENTHAL: Well, the company did come back to the Valentines and offered to cut it by 50%. But, you know, that's still more than Jessica owes in student loans for med school and, frankly, more than many kidney transplants would cost.
KING: This couple in Montana are not the only people in this country having problems with the cost of dialysis. The federal government has actually started paying attention to this, right?
ROSENTHAL: Yeah, I mean, dialysis has gotten some headlines because the Trump administration wants to make some changes that could result in taxpayers saving some money on dialysis care. It's mostly a cost to the federal government. And that's because the vast majority of people who need dialysis, people who develop end-stage renal disease like Sov, can get on Medicare under a 1973 bill.
But there's a catch to that, and they have to wait 90 days until they qualify. And that's where Sov gets really stuck.
KING: And once you're on Medicare, how much does it pay?
ROSENTHAL: Well, here's the crazy thing. Medicare pays about $235 per dialysis session. Meanwhile, Fresenius charged Sov $14,000 a session - huge gap there. And remember; end-stage renal disease is life-threatening. When you need dialysis, you need it, and you need dialysis three times a week.
KING: Could he have gone someplace other than Fresenius?
ROSENTHAL: Well, there aren't a lot of options. Fresenius and one other company, DaVita, control about 70% of the dialysis market in the U.S. And since Medicare picks up the tab after that 90-day wait, the companies play hardball with insurers for patients who have private insurance. It looks like they're simply trying to charge whatever they think they can get away with.
KING: So it sounds like what you're saying is there was not much they could have done to prevent this bill.
ROSENTHAL: Well, they were told there were no in-network options. He needed immediate dialysis. And when Jessica checked, that appeared to be the case. If there's no way to stay in network for needed care, under some state laws that could be considered a surprise bill, so fight it.
Also, President Trump's announcement earlier this month could have offered some help in that it's promoting alternative types of dialysis that can be done at home. But for now, the Valentines are in a tough position.
KING: So what's their plan? How are they doing now?
ROSENTHAL: Well, after discovering that there was an in-network provider in state that hadn't turned up in the directory, Sov is getting his dialysis there now. And pretty soon, he'll be eligible for Medicare. But what he's really hoping for is to get a kidney transplant soon.
Also, sadly, this hardworking couple is considering filing for bankruptcy if they have to pay that bill.
KING: Dr. Elisabeth Rosenthal from Kaiser Health News, thanks so much for being here.
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KING: If you have a baffling or surprising medical bill that you want us to take a look at, go to NPR's Shots blog and tell us all about it.
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