Michigan Association of Health Plans

Surprise medical bills upset patients, engage lawmakers

Amy Brooks flew by air ambulance from Ashland to Madison last year to be treated for seizures. Then the Madison woman got the transport bill: $41,000.

Quartz, her health insurance plan, denied coverage, even though doctors in Ashland and at UW Health, co-owner of Quartz, said she needed to be flown to UW Hospital. She had surgery there to remove a brain tumor the previous year.

“I felt helpless,” Brooks, 50, who ran a cleaning business and now works seasonal jobs, said of the $41,000 bill. “I would have possibly had to file for bankruptcy.”

Surprise medical bills, which have been around for years, have recently caught the attention of state and federal lawmakers. Wisconsin legislators, who introduced a bill to curb unexpected medical tabs in July, plan to introduce a new measure this month. Congress drafted bipartisan proposals last year and could act soon, after President Donald Trump called for action last spring.

Typically, surprise medical bills are defined as out-of-network charges for care provided at in-network facilities. An emergency room is in a health plan’s network, for example, but the ER doctors work for a company that isn’t. The plan rejects the doctor charge and the patient gets stuck with the bill.

Nationwide, 18% of ER visits and 16% of stays at in-network hospitals in 2017 triggered surprise bills for patients with health insurance through large employers, according to a study last year by the Kaiser Family Foundation.

Wisconsin fared better, with 12% of ER visits and 7% of hospital stays resulting in surprise bills, the study found.

Other situations can result in surprise medical bills, said Sachin Gupte, legal advocacy coordinator at UW-Madison’s Center for Patient Partnerships.

Sometimes lab tests or specialists such as anesthesiologists aren’t covered because they’re out of network, said Gupte, an attorney. In one case, a patient who received a treatment every six months got a much larger bill because the health system rescheduled an appointment at a different site, he said.

Bobby Peterson, executive director of ABC for Health, a nonprofit law firm in Madison that helps people get health care, said insurers sometimes cap payments for procedures, regardless of what providers charge, and bill patients for the remainder. Or they use little-known rules to deny coverage, leaving patients on the hook, Peterson said.

Surprise medical bills “come in many different shapes and forms,” he said. “Unless you’re a very active and engaged consumer, or you have legal representation — if you can afford it, of if you’re low-income enough that you can get the services — you’re really going to be out of luck.”

This article appeared in the Wisconsin State Journal. Read more here.