By Adam Schrager
Channel3000.com (WISC-TV, Madison, WI), November 10, 2014
MADISON, Wis. – Megan Rothbauer would rather be discussing an impending engagement, her future marriage and eventually, children. However, the 30-year-old Madison resident is instead scouring the Internet looking for solutions to stave off bankruptcy.
A project manager for a manufacturing company, she is one year removed from a cardiac arrest and the subsequent physical recovery is being dwarfed by a near-impossible fiscal recovery. She was sent last Sept. 9 to the emergency room at St. Mary’s Hospital, which was out of her insurance network, instead of to Meriter Hospital, three blocks away, which was covered by her insurance. It’s the difference between a $1,500 maximum out-of-pocket expense and the now-$50,000-plus she’s facing in bills.
“I was unconscious when I was taken to the hospital,” she said. “Unfortunately, I was taken to the wrong hospital for my insurance.
“I was in a coma. I couldn’t very well wake up and say, ‘Hey, take me to the next hospital.’ It was the closet hospital to where I had my event, so naturally the ambulance took me there. No fault to them. It’s unfortunate that Meriter is in network and was only three blocks away from St. Mary’s,” Rothbauer said.
A News 3 investigation revealed Rothbauer’s situation — what’s called “balance billing,” where patients receive the balance between the hospital charge and what insurance companies will cover — is not unique. While the local insurance companies that represent roughly 80 percent of those who have insurance in our area will offer out-of-network patients in-network rates during emergency room visits, there remains no guarantee they won’t face hefty bills on the back end depending on the treatment they receive.
“My strong suspicion is this happens more frequently than you think,” said Meg Gaines, who runs the Center for Patient Partnerships, a consumer health care advocacy group at the University of Wisconsin-Madison Law School. “I mean every time someone goes down, they don’t have someone around who knows what their insurance is.”
In Rothbauer’s case, her insurer, Blue Cross Blue Shield, said it paid St. Mary’s 100 percent of its in-network rate or $156,000 to cover part of the original $254,000 bill that she incurred during 10 days in a medically-induced coma and another six days in the cardiac unit. St. Mary’s negotiated with Rothbauer to reduce the remainder of her $98,000 bill by 90 percent. This is separate from the bills she received from the doctors, the ambulance, the therapist and others.
Gaines said consumers have little chance to negotiate against the parties in the health care industry as they don’t have the necessary tools.
“I mean, I know this business. I’ve been doing this for a while, knocking on doors, trying to understand this data and I have no ability to do it. None,” Gaines said. “When they don’t even disclose the cost (of services), there’s the cost. There’s the price. There’s the charge. There’s the accepted payment. Lions, tigers and bears, oh my. How do you even know what’s what in this world?”
“It is totally random, and it is the problem with saying consumers have to go to the right hospital and you say, ‘What if you’re unconscious?'” Gaines said.
Rothbauer’s insurance company placed the blame for her situation on St. Mary’s Hospital and its cost for services.
“(Megan) received care by a hospital that is not in our Wisconsin network,” Scott Larrivee, public relations director for Anthem Blue Cross Blue Shield, wrote in an email to News 3. “Since we have no contract with this hospital, we have very little influence over what the hospital is charging in this situation.”
The hospital, meanwhile, said it empathizes with Rothbauer’s situation, but that it already wrote off tens of thousands of dollars in costs and that the conversation should also focus on the fact its doctors and nurses saved Rothbauer’s life.
“When you’re looking at saving a life, you’re not looking at whether or not you can save them money,” said Cyn Gunnelson, manager for Managed Care Contracting for the Wisconsin region of SSM Health Care. “I can only do so much. The hospital can only do so much. And I think the best outcome is the person walked away from the emergency room.”
Rothbauer credits the doctors and nurses at St. Mary’s for the work they did on her behalf. However, her feelings toward the hospital’s accounting department and her insurance company are much different. As she sits at her kitchen table with her eventual fiancé, Ben Johnsen, the bills are spread out, covering much of the surface. Her frustration is matched solely by the fear that this could happen to any one of us.
She and Johnsen are holding off getting engaged until her economic situation has more clarity. She is waiting to hear back about her latest appeal to Blue Cross Blue Shield before she can negotiate further with Dean to see if the doctors’ bills will be reduced and whether she and Johnsen need to get second jobs, cash out retirement accounts, take a loan from the hospital or file for bankruptcy.
“My hardest issue is I had no control and I still have no control over what is my future,” she said. “I don’t want this to happen to anyone else. I don’t know if this can be fixed for me at this point, but I think it’s unfortunate that it can happen to anyone.”
The Affordable Care Act specifically addressed emergency room visits for out-of-network patients by requiring insurers to pay the greater amount between the in-network rate and what Medicare would cover. However, balance billing is expressly permitted and Gaines said its results, like what’s happened to Rothbauer, are far too common.
“It’s devastating for people who plan, who get insurance, get coverage, do everything they can and then, at 29, have a heart attack and get taken to the wrong hospital, and can’t get married, can’t do anything because they have to declare bankruptcy because they can’t afford to have gone to the hospital,” she said. “I mean, it’s not enough to worry about having a heart attack at 29, you end up with a secondary one or a stroke because of your medical bills. I mean, it’s just ridiculous. The level of frustration is astronomical.”