The baby spent over two months in the in-network hospital

A New Family Member’s Account of a Chicago Obstacle Center for Epidemiology and Preeclampsia. An Open Letter of Intent to Patients and the No Surprises Act

She took her husband from their home in Chicago to her OB- GYN’s office at the hospital. With suddenly elevated blood pressure and protein in her urine, she was diagnosed with preeclampsia, a potentially fatal but treatable pregnancy complication. Doctors admitted her to the hospital, saying she could expect to stay up to six weeks and have an induced delivery.

She needed an immediate delivery due to a rare, dangerous type of preeclampsia and her blood platelets count plummeted, she developed a bad headaches, and then her platelet count plummeted and she needed an immediate delivery.

Kearney’s daughter, Joey, born at 31 weeks, was placed on a ventilator and moved to the hospital’s neonatal intensive care unit. Small but healthy, she slowly began breathing on her own and eating normally. She was released from the NICU in January 2020.

Total bill: Aetna paid for nearly all of Joey and her mother’s hospital and physician charges in December, while Blue Cross picked up nearly all of Joey’s hospital charges in January. The family was asked to pay over $12k after Blue Cross made their payments.

Service rovider: Ann & Robert H. Lurie Children’s Hospital of Chicago, whose staff physicians treated Joey at Northwestern Medicine Prentice Women’s Hospital. Ownership-wise, Lurie is independent of Northwestern Medicine, but it is physically connected to Prentice Women’s by an enclosed walkway. Neonatology and child Psychiatrists are provided by Lurie andNorthwestern Medicine to patients at Prentice Women’s.

Blue Cross agreed to pay Lurie the in-network rate for the doctors’ services, reducing the bill to about $12,500 — which Lurie expected the family to pay.

It didn’t happen here, but many patients sign broad financial agreements in the chaos of a hospital and don’t even know it. In many cases, they are simply asked to sign on a screen, without seeing the document.

The No Surprises Act was implemented by the federal government before Joey’s 36 day stay in the NICU. A state law prohibiting it, though, was in effect.

The federal No Surprises Act, which took effect last year, prohibits medical providers or insurers from billing patients for out-of-network physician charges at an in-network hospital, unless the patient formally consents to an out-of-network doctor. To be safe, patients should ask treating doctors whether they are in or out of network, even at an in-network hospital.

Kathy Mikos, a registered nurse with the Navocate Group who is not involved with the case, said that it appears that under the 2011 law, in- network cost sharing can only be billed for.

Lurie, Blue Cross, and Northwestern Medicine did not respond to numerous requests from KHN for comment. The hospital was able to discuss Joey’s case with KHN despite receiving a release from Kearney about the federal Health Insurance Portability and Accountability Act.

A day later — following additional requests by KHN for comment — Spicer called Kearney and said she would remove all physician charges for her daughter’s care. Spicer did not return KHN’s call seeking comment.

The Illinois Attorney General’s Office and the Illinois Department of Insurance are where the complaints have been filed. The attorney general’s office told KHN it had never enforced the 2011 law barring certain out-of-network billing.

The state senator said that Blue Cross, Lurie, and Northwestern Medicine should have been aware of the state law. She said patients who believe they have been improperly charged should file complaints with their state’s insurance department, which can trigger a broader investigation.

Some physicians are still billing patients despite the new federal protections. Know your rights, so you can take action. Cite the new law. You should not write the check.

Kaiser Health News’ first day on a trip to the San Juan Islands: Danielle Laskey’s emergency medicine visits Swedish Medical Center/First Hill as an emergency service

Kaiser Health News is a national newsroom that reports on health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). The nonprofit organization KFF provides information on health issues to the nation.

It was the first day of her family’s vacation in the San Juan Islands last June when Danielle Laskey, who was 26 weeks pregnant, thought she was leaking amniotic fluid.

A registered nurse, Laskey called her OB- GYN back home in Seattle who said to seek immediate care. Staff members at a nearby emergency department found no leakage. But her OB-GYN still wanted to see her as soon as possible.

In Seattle, Laskey’s water had broken early and so doctors at the clinic ordered her to go to the Swedish Medical Center/First Hill because it posed a serious risk to her and the fetus. She delivered her son after seven weeks in the hospital. She was discharged the day after she was hurt, despite being taken to the hospital for multiple baby related problems. She had her son go home a month later.

Laskey had already gone away for a few weeks to care for her 3-year-old daughter. She returned for the procedure, which went well, and she was home the same day.

So after being urgently admitted to Swedish, Laskey believed her bills would be largely covered, with the couple expected to pay $2,000 at most for their portion of in-network care because of her plan’s out-of-pocket cost limit.

What’s more, the clinic caring for Laskey was in her insurance plan’s network. She assumed Swedish Medical Center was part of the network since it was one of the only specialized providers in the area for Laskey’s condition.

Jacob, who works as a psychiatrist at a different hospital, said he mentioned the surprise-billing laws to the Regence case manager, but she replied that the laws did not apply to his family’s situation.

Ashley Bach, a Regence spokesperson, confirmed to KHN that both stays now will be covered as emergency, in-network services, eliminating Swedish’s coinsurance charges. But in what appears to be contrary to the insurance commissioner’s stance, he said the bills had not violated state or federal laws prohibiting out-of-network charges in emergency situations because of the contract with Swedish covering all its plans.

A hospital that’s in network and one that’s a participating provider, what is the difference? In this case, by contracting with Regence as an out-of-network but also participating provider, Swedish straddled the line between being in and out of network — designations that traditionally indicate whether a provider has a contract with an insurer or not.

Ellen Montz is the director of the center for consumer information and insurance oversight and she said that a “participating” emergency facility is subject to the law’s surprise-billing protections.

Experts said they had not heard of out of network providers evading surprise billing laws by being contracted as participating providers, until KHN inquired about Laskey’s case.

Matthew Fiedler, a senior fellow at the University of Southern California-Brookings Laskey’s case seems to fall into a “weird” gray area of state and federal law that protects patients from out-of-network billing.

Source: https://www.npr.org/sections/health-shots/2023/02/28/1159786893/a-surprise-billing-law-loophole-her-pregnancy-led-to-a-six-figure-hospital-bill

Communication between Danielle Laskey and the State Insurance Commissioner: A Remark on Out-of-Network Billing Surprises and Medicaid Access in Washington State

Jacob said that Swedish gave them two months to pay or they would be sent to collections after they declined to apply for the financial assistance program.

Natalie Kozimor, a spokesperson for Providence Swedish, said the hospital disagreed with “some of the details and characterizations of events” presented by the Laskeys, though she did not specify what those were. She said Swedish assisted Danielle in her request to Regence.

Jacob said that Swedish did not take any responsibility or responsibility for their billing or advocating on their behalf. They referred us to the financial department for a payment plan.

The couple appealed Regence’s approval of Swedish’s out-of-network charges for their 51-day hospitalization because they claimed it was an emergency and there was no in-network hospital with the expertise to treat her condition. They filed a complaint with the insurance commissioner’s office.

On Jan. 27, two days after KHN contacted Regence and Swedish about Danielle Laskey’s case, a Regence representative called and informed her that her second hospitalization also would be reclassified as an in-network service.

“Because of the Washington state and federal balance-billing laws, if a specific provider is included in a network, then that provider is considered a provider in the network,” she said.

Washington state Rep. Marcus Riccelli, chair of the House Health Care and Wellness Committee, said he will ask the state’s public and private insurers what steps they could take to avoid provider network gaps and out-of-network billing surprises like this. He said he will also review whether there is a loophole in state law that needs to be closed by the legislature.

Congress might have to fix the problem, since the federal agencies that administer the No Surprises Act may not have authority to do anything about it, he added.

Bruce Alexander, a CMS spokesperson, said the Departments of Health & Human Services, Labor, and Treasury are looking into this issue. While the agencies can’t predict whether a new rule or guidance will be needed to address it, he said, “they remain committed to protecting consumers from surprise medical bills.”

Hospital billing departments may not be able to help resolve surprise billing. It is worth contesting certain charges but it is also an option to quickly appeal to the state insurance department.