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When you buy health insurance, you figure at the very least, if you had to go to the hospital in an emergency, that insurance will protect you from astronomical bills, right? But time and time again, patients with insurance do end up with huge bills, caught between what hospitals charge and what insurance companies will pay.
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It's called balance billing, and it's the topic of January's bill of the month - a project with NPR and Kaiser Health News. NPR health policy reporter Selena Simmons-Duffin has a story of one patient who says he's not sure which was worse - appendicitis or the billing nightmare that followed.
SELENA SIMMONS-DUFFIN, BYLINE: His name is Josh Bates, and he's quite tall.
JOSH BATES: Six-five.
SIMMONS-DUFFIN: He lives in Charlotte, N.C., with his roommate Nick and a very sweet German shepherd named Darko, as in Donnie Darko.
(SOUNDBITE OF DOG PANTING)
SIMMONS-DUFFIN: It's a pretty small apartment - very neat, interior design courtesy of his mom. This past October, Bates was getting ready to buy a house with a yard for Darko - the next step in adulthood, he says. He's 28.
BATES: We had a few picked out and one that we actually looked at. And then, you know, how it works is a week later is when I found out my credit score dropped by almost 200 points.
SIMMONS-DUFFIN: He called the credit agency, but he knew what they'd say. Twenty-eight thousand dollars in medical debt - a bill that he had been fighting for over a year had just hit his credit score. Let's back up to July 2018. Bates had been sick for days - high fever, couldn't eat anything, wasn't getting better.
BATES: It felt - you know, something was seriously wrong.
SIMMONS-DUFFIN: He called his roommate, who left work right away to take him to the nearest hospital emergency room. His mom drove up to meet him. A doctor pressed on his abdomen, and a scan confirmed he had appendicitis.
BATES: They said, yeah, you're probably minutes away from having your appendix rupture inside you, so we need to get you on the table as soon as possible.
SIMMONS-DUFFIN: He had surgery that night and was released from the hospital the next morning. A few months later...
BATES: When you see the $41,211.75, your life kind of flashes before your eyes. You're like, oh, my God.
SIMMONS-DUFFIN: He has insurance through his job, but the hospital was out of network. His insurance paid about $9,000. He paid 4,000 - a combination of his deductible and coinsurance for emergency care. That left a balance of $28,000, which is what just made his credit score take a nosedive.
MAANSA KONA: Balance billing primarily occurs in two scenarios.
SIMMONS-DUFFIN: Maansa Kona is a research professor at Georgetown University's Center on Health Insurance Reforms.
KONA: One is you have an emergency, and you go to an out-of-network facility.
SIMMONS-DUFFIN: That's what happened with Bates.
KONA: The second is you have a scheduled procedure at a facility that's in-network. But inadvertently or because there's no in-network provider available, you get treated by an out-of-network provider.
SIMMONS-DUFFIN: That is often called surprise billing. If that term sounds familiar, Congress got pretty close to passing a federal bill on this last year with bipartisan support and the president's backing. But in the end, nothing passed. Surprise bills are common. One study found 1 in 4 admissions from the emergency room results in one.
KONA: Because the insurer and the provider don't have a preexisting contract about what they're going to pay for their services, the insurer may not pay the full amount of what the out-of-network provider charges.
SIMMONS-DUFFIN: Then the provider puts the patient on the hook for whatever is left over. Kona says saddling patients with balance bills is illegal in some places.
KONA: Twenty-eight states have actually moved to protect patients in exactly these kinds of circumstances.
SIMMONS-DUFFIN: That includes North Carolina, where Bates lives. But there are holes in the law, and he fell through one of them. His health insurance is self-funded. He pays his premium to his employer, which then pays for employees' medical coverage. People with plans like this are not protected by state laws that cover balance bills, and they won't be protected until Congress passes a federal law. Until then, here are some tips. If you can check ahead and go to an in-network hospital, do that. If you get a balance bill, Kona says, you need to figure out three things.
KONA: First is whether you're in a state that has protections - second, if you're in a plan that can get those protections from the state; and third is if your situation is one that is covered by the protections offered in your state.
SIMMONS-DUFFIN: You can also do your own negotiating. Ask your insurer or employer to pay the bill. Ask the hospital or doctor to give you the in-network rate. You can use online tools like Healthcare Bluebook to find out what most insurers pay for services and then use that to negotiate. For an appendectomy in Josh Bates' zip code, that's around $12,000. He was charged three times that amount. Bates is still trying to get the hospital and insurer to work with him on the balance. But a year and a half in, he's losing hope.
BATES: You pay this money for insurance. You do everything right. And somehow, you still wind up in the crossfire between the two big corporations. I've made the joke, you know, God, if I would have known I had to go through all this, you know, I would have cut the thing out myself.
SIMMONS-DUFFIN: The search for a house with a yard is on hold for as long as this bill hangs over him.
Selena Simmons-Duffin, NPR News.
CHANG: And if you have a confusing or outrageous medical bill you would like us to take a look at, go to NPR's Shots blog.
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