She felt a pain in her sinuses and sought a quick resolution.

Covid-19 couldn’t be ruled out, so rather than risk passing on an unknown infection to others in a waiting room, the New Yorker booked a telehealth visit through her usual health system, Mount Sinai — a perennial on best-hospitals lists.

That proved an expensive decision. She remembers the visit as taking barely any time. The doctor decided it was likely a sinus infection, not covid, and prescribed her fluticasone, a nasal spray that relieves congestion, and an antibiotic, Keflex. (The Centers for Disease Control and Prevention says antibiotics “are not needed for many sinus infections, but your doctor can decide if you need” one.)

Then the bill came.

The Patient: Elyse Greenblatt, now 38, had insurance coverage through Empire BlueCross BlueShield, a New York-based insurer.

Medical Services: A telehealth urgent care visit through Mount Sinai’s personal record app. Greenblatt was connected with an urgent care doctor through the luck of the draw. She was diagnosed with sinusitis, prescribed an antibiotic and Flonase, and told to come back if there was no improvement.

All this meant a big bill. The insurer said the telehealth visit was deemed an out-of-network service — a charge Greenblatt said the digital service didn’t do a great job of warning her about. It came as a surprise. “In my mind, if all my doctors are ‘in-insurance,’ why would they pair me with someone who was ‘out-of-insurance’?” she asked. And the hospital system tried its best to make contesting the charge difficult, she said.

Service Provider: The doctor was affiliated with Mount Sinai’s health system, though where the bill came from was unclear: Was it from one of the system’s hospitals or another unit?

Total Bill: $660 for what was billed as a 45- to 59-minute visit. The insurer paid nothing, ruling it out of network.

What Gives: The bill was puzzling on multiple levels. Most notably: How could this be an out-of-network service? Generally, urgent care visits delivered via video are a competitive part of the health care economy, and they’re not typically terribly expensive.

Mount Sinai’s telehealth booking process is at pains to assure bookers they’re getting a low price. After receiving the bill, Greenblatt went back to the app to recreate her steps — and she took a screenshot of one particular part of the app: the details. She got an estimated wait time of 10 minutes, for a cost of $60. “Cost may be less based on insurance,” the app said; this information, Mount Sinai spokesperson Lucia Lee said, is “for the patient’s benefit,” and the “cost may differ depending on the patient’s insurance.”

A $60 fee would be in line with, if not a bit cheaper than, many other telehealth services. Doctor on Demand, for example, offers visits from a clinician for $79 for a 15-minute visit, assuming the customer’s insurance doesn’t cover it. Amazon’s new clinic service, offering telehealth care for a wide range of conditions, advertises that charges start at $30 for a sinus infection.

The Health Care Cost Institute, an organization that analyzes health care claims data, told KFF Health News its data shows an urgent care telehealth visit runs, on average, $120 in total costs — but only $14 in out-of-pocket charges.

So how did this visit end up costing astronomically so much more than the average? After all, one of the selling points of telemedicine is not only convenience but cost savings.

First, there was the length of the visit. The doctor’s bill described it as moderately lengthy. But Greenblatt recalled the visit as simple and straightforward; she described her symptoms and got an antibiotic prescription — not a moderately complex visit requiring the better part of an hour to resolve.

The choice of description is a somewhat wonky part of health care billing that plays a big part in how expensive care can get. The more complex the case, and the longer it takes to diagnose and treat, the more providers can charge patients and insurers.

Greenblatt’s doctor billed her at a moderate level of care — curious, given her memory of the visit as quick, almost perfunctory. “I think it was five minutes,” she recalled. “I said it was a sinus infection; she told me I was right. ‘Take some meds, you’ll be fine.’”

Ishani Ganguli, a doctor at Brigham and Women’s Hospital in Boston who studies telehealth, said she didn’t know the exact circumstances of care but was “a bit surprised that it was not billed at a lower level” if it was indeed a quick visit.

That leaves the out-of-network aspect of the bill, allowing the insurer to pay nothing for the care. (Stephanie DuBois, a spokesperson for Empire BlueCross BlueShield, Greenblatt’s insurer, said the payer covers virtual visits through two services, or through in-network doctors. The Mount Sinai doctor fit neither criteria.) Still, why did Mount Sinai, Greenblatt’s usual health care system, assign her an out-of-network doctor?

“If one gets their care from the Mount Sinai system and the care is within network, I don’t think it is reasonable for the patients to expect or understand that one of the Mount Sinai clinicians is suddenly going to be out of network,” said Ateev Mehrotra, a hospitalist and telehealth researcher at Beth Israel Deaconess Medical Center.

It struck the doctors specializing in telehealth research whom KFF Health News consulted as an unusual situation, especially since the doctor who provided the care was employed by the prestigious health system.

The doctor in question may have been in network for no insurers whatsoever: A review of the doctor’s Mount Sinai profile page — archived in November 2022 — does not list any accepted insurance. (That’s in contrast to other doctors in the system.)

Lee, Mount Sinai’s spokesperson, said the doctor did take at least some insurance. When asked about the doctor’s webpage not showing any accepted plans, she responded the site “instructs patients to contact her office for the most up-to-date information.”

Attempting to solve this billing puzzle turned into a major league headache for Greenblatt. Deepening the mystery: After calling Mount Sinai’s billing department, she was told the case had been routed to disputes and marked as “urgent.”

But the doctor’s office would seemingly not respond. “In most other professions, you can’t just ignore a message for a year,” she observed.

The bill would disappear on her patient portal, then come back again. Another call revealed a new twist: She was told by a staffer that she’d signed a form consenting to the out-of-network charge. But “when I asked to get a copy of the form I signed, she asked if she could fax it,” Greenblatt said. Greenblatt said no. The billing department then asked whether they could put the form in her patient portal, for which Greenblatt gave permission. No form materialized.

When KFF Health News asked Mount Sinai about the case in mid-October of this year, Lee, the system’s spokesperson, forwarded a copy of the three-page form — which Greenblatt didn’t remember signing. Lee said the forms are presented as part of the flow of the check-in process and “intended to be obvious to the patient as required by law.” Lee said on average, a patient signs two to four forms before checking into the visit.

But, according to the time stamp on the forms, Greenblatt’s visit concluded before she signed. Lee said it is “not standard” to sign forms after the visit has concluded, and said that once informed, patients “may contact the office and reschedule with an ‘in-network provider.’”

“If it was provided after the service was rendered, that is an exception and situational,” she concluded.

The business with the forms — their timing and their obviousness — is potentially a vital distinction. In December 2020, Congress enacted the No Surprises Act, designed to crack down on so-called surprise medical bills that arise when patients think their care is covered by insurance but actually isn’t. Allie Shalom, a lawyer with Foley & Lardner, said the law requires notice to be given to patients, and consent obtained in advance.

But the legislation provides an exception. It applies only to hospitals, hospital outpatient facilities, critical access hospitals, and ambulatory surgery centers. Greenblatt’s medical bill variously presents her visit as “Office/Outpatient” or “Episodic Telehealth,” making it hard to “tell the exact entity that provided the services,” Shalom said.

That, in turn, makes its status under the No Surprises Act unclear. The rules apply when an out-of-network provider charges a patient for care received at an in-network facility. But Shalom couldn’t be sure what entity charged Greenblatt, and, therefore, whether that entity was in network.

As for Mount Sinai, Lee said asking for consent post-visit does not comply with the No Surprises Act, though she said the system needed more time to research whether Greenblatt was billed by the hospital or another entity.

The Resolution: Greenblatt’s bill is unpaid and unresolved.

The Takeaway: Unfortunately, patients need to be on guard to protect their wallets.

If you want to be a smart shopper, consider timing the length of your visit. The “Bill of the Month” team regularly receives submissions from patients who were billed for a visit significantly longer than what took place. You shouldn’t, for example, be charged for time sitting in a virtual waiting room.

Most important, even when you seek care at an in-network hospital, whose doctors are typically in network, always ask if a particular physician you’ve not seen before is in your network. Many practices and hospitals offer providers in both categories (even if that logically feels unfair to patients). Providers are supposed to inform you that the care being rendered is out of network. But that “informed consent” is often buried in a pile of consent forms that you auto-sign, in rapid fire. And the language is often a blanket statement, such as “I understand that some of my care may be provided by caregivers not in my insurance network” or “I agree to pay for services not covered by my insurance.”

To a patient trying to quickly book care, that may not feel like “informed consent” at all.

“It’s problematic to expect patients to read the fine print, especially when they feel unwell,” Ganguli said.

Emily Siner reported the audio story.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).

It was January and Ahmed was at an OB-GYN’s office near her home in Venus, Texas, for her first prenatal checkup. After an ultrasound, getting anti-nausea medication, and discussing her pregnancy care plan, she said, a nurse made a convenient suggestion: Head to the lab just down the hall for a standard panel of tests.

The lab was inside Texas Health Hospital Mansfield, which opened in December 2020 in a Dallas-Fort Worth suburb. Ahmed, just eight weeks pregnant, said the doctor told her everything about the visit was routine. “Nothing really stood out,” Ahmed said. “And, of course, there’s just a lot of excitement, and so I really didn’t think twice about anything.”

Her blood tests checked for multiple sexually transmitted infections, her blood type, and various hormones. Within days, Ahmed began bleeding and her excitement turned to fear. A repeat ultrasound in early February showed no fetus.

“My heart kind of fell apart at that moment because I knew exactly what that meant,” she said. She would have a miscarriage.

Then the bills came.

The Patient: Reesha Ahmed, 32, has an Anthem Blue Cross and Blue Shield policy through her employer.

Medical Services: An analysis of Pap smear results and several blood tests in tandem with Ahmed’s initial prenatal visit, including complete blood count, blood type, and testing for STIs such as hepatitis B, syphilis, and HIV.

Service Provider: Ahmed got her tests at Texas Health Mansfield, a tax-exempt hospital jointly operated by Texas Health Resources, a faith-based nonprofit health system, and AdventHealth, another religious nonprofit.

Total Bill: The hospital charged $9,520.02 for the blood tests and pathology services. The insurer negotiated that down to $6,700.50 and then paid $4,310.38, leaving Ahmed with a lab bill of $2,390.12.

What Gives: Ahmed’s situation reveals how hospital-based labs often charge high prices for tests. Even when providers are in network, a patient can be on the hook for thousands of dollars for common blood tests that are far cheaper in other settings. Research shows hospitals typically charge much more than physicians’ offices or independent commercial labs for the same tests.

The situation was particularly difficult for Ahmed because she had lost the pregnancy.

“To come to terms with it mentally, emotionally, physically — dealing with the ramifications of the miscarriage — and then having to muster up the fighting strength to then start calling your insurance, and the billing department, the provider’s office, trying to fight back a bill that you don’t feel like you were correctly sent? It’s just, it’s a lot,” she said.

In Texas, the same lab tests were at least six times as expensive in a hospital as in a doctor’s office, according to research from the Health Care Cost Institute, a nonprofit that examines health spending.

The markup can be even higher depending on the test. HCCI data, based on 2019 prices, shows the median price for a complete blood count in Texas was $6.34 at an independent lab and $58.22 at a hospital. Texas Health charged Ahmed $206.69 for that test alone.

“It is convenient to get your lab done right in the same building,” said Jessica Chang, a senior researcher at HCCI, but “many patients are not thinking about how highly marked up these lab tests are.” Chang said she suspects many hospitals tack on their overhead costs when they bill insurance.

Anthem also charged Ahmed for at least four tests that most insurance plans would consider preventive care and therefore covered at no cost to patients under the Affordable Care Act’s requirements for covering preventive care, which includes aspects of prenatal care. Her EOBs, or “explanation of benefits” notices, show she paid out-of-pocket for a test identifying her Rh factor — which detects a protein on the surface of red blood cells — as well as for tests for hepatitis B, hepatitis C, and syphilis.

Asked to review Ahmed’s tests, Anthem spokesperson Emily Snooks wrote in an email to KFF Health News that the claims “were submitted as diagnostic — not preventive — and were paid according to the benefits in the member’s health plan.”

There “definitely shouldn’t be” out-of-pocket costs for those screenings, said Sabrina Corlette, co-director of Georgetown University’s Center on Health Insurance Reforms.

The Centers for Disease Control and Prevention recommends screening pregnant patients for several infectious diseases that pose major risks during pregnancy. Ina Park, a professor of family community medicine at the University of California-San Francisco and an expert on STIs, said the tests Ahmed received didn’t raise red flags from a clinical perspective. “It’s really more what the actual lab charged based on what the tests actually cost,” Park said. “This is a really exorbitant price.”

For example, Ahmed paid $71.86 in coinsurance for a hepatitis B test for which the hospital charged $418.55. The hospital charged $295.52 to screen for syphilis; her out-of-pocket cost was $50.74.

“You just wonder, is the insurance company really negotiating with this provider as aggressively as they should to keep the reimbursement to a reasonable amount?” Corlette said.

The Resolution: Ahmed refused to pay the bills and Texas Health sent the debt to collections. When she tried to get answers about the costs, she said she was bounced between the doctor’s office and the hospital billing department. Ahmed submitted a complaint to the Texas attorney general’s office, which passed it to the Texas Health and Human Services Commission. She never heard back.

According to Ahmed, a hospital representative suggested her bloodwork might have been coded incorrectly and agreed the charges “were really unusually high,” Ahmed said, but she was told there was nothing the hospital could do to change it. The hospital did not comment on the reason behind the high charge. And in a March 7 email, an AdventHealth employee told Ahmed the doctor’s office had “no control” over the hospital’s billing.

Ahmed filed an appeal with Anthem, but it was denied. The insurance company stated the claims were processed correctly under her benefits, which cover 80% of what the insurer agrees to pay for in-network lab services after she meets her deductible. Ahmed has a $1,400 deductible and a $4,600 out-of-pocket maximum for in-network providers.

“We depend on health care providers to submit accurate billing information regarding what medical care was needed and delivered,” Snooks said. Asked about reimbursements to the Texas Health lab, she added, “The claim was reimbursed based on the laboratory’s contract with the health plan.”

After a KFF Health News reporter contacted Texas Health on Oct. 9, the hospital called Ahmed on Oct. 10 and said it would zero out her bills and remove the charges from collections. Ahmed was relieved, “like a giant burden’s just been lifted off my shoulders.”

“It’s just been fighting this for 10 months now, and it’s finally gone,” she said.

Texas Health Resources and AdventHealth declined to respond to detailed questions about Ahmed’s charges and the tests she was directed to obtain.

“We are sorry Ms. Ahmed did not get clarity on her care with us. Our top priority is to provide our patients with safe, effective and medically appropriate care,” Laura Shea, a spokesperson for the hospital, said in an emailed statement.

The Takeaway: Ahmed’s problem demonstrates the pitfalls of using a hospital lab for routine testing.

For standard bloodwork “it’s really hard to argue that there’s a quality difference” between independent labs and hospitals that would warrant higher prices, Chang said. That holds true for other services, too, like imaging. “There’s nothing special about the machines that hospitals use for a CT or MRI scan. It’s the same machine.”

More from Bill of the Month

• When That Supposedly Free Annual Physical Generates a Bill
• She Received Chemo in Two States. Why Did It Cost So Much More in Alaska?
• She Paid Her Husband’s Hospital Bill. A Year After His Death, They Wanted More Money.

Broadly, state and federal lawmakers are paying attention to this issue. Congress is considering legislation that would equalize payments for certain services regardless of whether they are provided in a hospital outpatient department or a doctor’s office, although not lab services. Hospitals have tried to fend off such a policy, known as “site-neutral payments.”

For example, the Lower Costs, More Transparency Act would require the same prices under Medicare for physician-administered drugs regardless of whether they’re given in a doctor’s office or an off-campus hospital outpatient department. That bill also would require labs to make public the prices they charge Medicare for tests. Another bill, the Bipartisan Primary Care and Health Workforce Act, would ban hospitals from charging commercial health plans some facility fees — which they use to cover operating or administrative expenses.

According to the National Conference of State Legislatures, Colorado, Connecticut, Ohio, New York, and Texas have limited providers’ ability to charge privately insured patients facility fees for certain services. Colorado, Connecticut, Maryland, and New York require health facilities to disclose facility fees to patients before providing care; Florida instituted similar requirements for free-standing emergency departments.

Patients should keep copies of itemized bills and insurance statements. While not the only evidence, those documents can help patients avoid out-of-pocket costs for recommended preventive screenings.

For now, patients can proactively avoid such extreme bills: When your doctor says you need blood tests, ask that the requisition be sent to a commercial lab like Labcorp or Quest Diagnostics that is in your network and have the tests done there. If they can’t do it electronically, ask for a paper requisition.

“Don’t always just go to the lab that your doctor recommends to you,” Corlette said.

Emily Siner reported the audio story.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

Her answers on the form led her primary care doctor to ask about depression and her mood, and Rogers said she answered honestly.

“It was a horrible year. I lost my mom,” Rogers said she told her physician.

After what Rogers estimates was a five-minute conversation about depression, the visit wrapped up. She said her doctor did not recommend treatment nor refer her for counseling.

“It’s not like anything I told her triggered, ‘Oh my goodness, I’m going to prescribe you medication,’” she said.

Then the bill came.

The Patient: Christine Rogers, 60, a public relations/communications worker who is insured by Cigna Healthcare through her job.

Medical Services: An annual wellness visit, which included typical blood tests, as well as a depression screening and discussion with a physician.

Service Provider: WakeMed Physician Practices, part of WakeMed Health & Hospitals, a Raleigh-based, tax-exempt system with three acute care hospitals, outpatient centers, and hundreds of physicians across a range of specialties.

Total Bill: $487, which included a $331 wellness visit and a separate $156 charge for what was billed as a 20- to 29-minute consultation with her physician. Her insurer paid $419.93, leaving Rogers with a $67.07 charge related to the consultation.

What Gives: Rogers said the bill came as a surprise because she knows annual wellness checks are typically covered without patient cost sharing as preventive care under the Affordable Care Act. And as part of an annual physical, patients routinely fill out a health questionnaire, which may cover mental health topics.

But there is a catch: Not all care that may be provided during a wellness visit counts as no-cost preventive care under federal guidelines. If a health issue arises during a checkup that prompts discussion or treatment — say, an unusual mole or heart palpitations — that consult can be billed separately, and the patient may owe a copayment or deductible charge for that part of the visit.

In Rogers’ case, a brief chat with her doctor about mental health triggered an additional visit charge — and a bill she was expected to pay.

Rogers said she didn’t broach the subject of depression during her checkup. She was asked when she checked in to fill out the questionnaire, she said — and then the doctor brought it up during her exam.

The Affordable Care Act requires insurers to cover a variety of preventive services without a patient paying out-of-pocket, with the idea that such care might prevent problems or find them early, when they are more treatable and less costly.

The federal government lists dozens of services that are classified as no-cost-sharing preventive care for adults and children, such as cancer screenings, certain vaccinations, and other services recommended by either of two federal agencies or the U.S. Preventive Services Task Force, an independent group of experts in disease prevention.

Depression screening is covered as preventive care for adults, including when they’re pregnant or in the postpartum phase.

Rogers requested an itemized bill from her doctor’s practice, which is part of WakeMed Physician Practices. It showed a charge for the wellness visit (free for her), as well as a separate charge for a 20- to 29-minute office visit. Earlier, Rogers said, she had discussed the initial bill with the office manager at her doctor’s office, who told her the separate charge, roughly $67, was for discussing her questionnaire results with her doctor.

For Rogers, it wasn’t so much about the $67 she owed for the visit, as it was a matter of principle. The separate change, she said, was “disingenuous” because she was specifically asked about her mental health.

Also, annual physicals are intended to nip health problems in the bud, which sometimes requires a few more minutes of attention — whether to discuss symptoms of depression or palpate an abdomen for digestive issues.

Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University, agrees the charge seemed a bit over-the-top: Depression screening “is now a recommended part of the annual physical,” she said. “Implicit in that is someone looks at answers and makes an assessment, and you should not be charged for that.”

Beyond the confusion of being charged for what she thought would be free preventive care, Rogers wondered how the bill was calculated: Her conversation with her doctor about depression did not last that long, she said.

A 20- to 29-minute-visit billing code is commonly used in primary care, reflecting not just the time spent, but also the complexity of the condition or diagnosis, said Yalda Jabbarpour, a family physician in Washington, D.C. She also directs the Robert Graham Center for Policy Studies, which researches primary care in the U.S.

Billing codes exist for other, shorter time frames, though those are rarely used except for the most minimal of services, such as a quick question about a test result, she said.

Physicians said Rogers did the right thing, emphasizing that patients should be honest with their doctors during preventive visits — and not keep silent about issues because they are concerned about potential cost sharing.

“If you have a condition like depression, not only does it affect mental health, but it can have significant impact on your medical health overall,” said Stephen Gillaspy, senior director for health and health care financing at the American Psychological Association.

The Resolution: Confused by getting billed for a visit she thought would have no charge, Rogers initially called her doctor’s office and spoke with the office manager, who told her the claim submitted to her insurer was coded correctly for her visit. She then called her insurer to question whether a mistake had been made. She said her insurer said no, agreeing that the physician had billed properly.

Rogers paid the bill.

After being contacted by KFF Health News, and with Rogers’ permission, the WakeMed health system investigated the bill and said it was handled correctly.

“We do split bills when a service is provided that is above and beyond the preventive components of a physical — in this case, beyond a positive screening for depression,” WakeMed spokesperson Kristin Kelly said in an email.

By contrast, Cigna Healthcare, Rogers’ insurer, sent her a new explanation of benefits statement after being contacted by KFF Health News. The EOB showed Cigna had zeroed out any cost to Rogers associated with the visit.

Cigna spokesperson Meaghan MacDonald, in a written statement, said the “wellness visit was initially billed incorrectly with two separate visit codes, and has now been resubmitted correctly so there is no cost-share for Ms. Rogers. We are working with the physician to ensure she is refunded appropriately.”

The insurer’s website says Cigna covers a variety of preventive services without copayment and encourages doctors to counsel patients about depression.

Not long after receiving the new EOB, Rogers said she received a refund of $67.07 from WakeMed.

The Takeaway: While many preventive services are covered under the ACA, the nuances of when a patient pays can be complicated and open to interpretation. So, it is not uncommon for medical practices to narrowly interpret the term “preventive service.”

That creates a billing minefield for patients. If you respond on a questionnaire that you sometimes experience heartburn or headaches, most physicians will inquire about your responses to assess the need for treatment. But should that come with an extra charge? Other patients have written to KFF Health News and NPR expressing frustration over being billed for conversations during a checkup.

Additional time spent during a wellness exam discussing or diagnosing a condition or prescribing medication can be considered beyond preventive care and result in separate charges. But if you receive a bill for a preventive service that you expected would be free, request an itemized bill with billing codes. If something seems off, ask the physician’s office.

If you’re billed for time spent on extra consultation, question it. You know how long the provider spent discussing your health issue better than a billing representative does. Next, reach out to your insurer to protest.

Most important, be honest with your primary care provider during your annual physical.

Stephanie O’Neill reported the audio story.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

Gebel, a mother of two, went to her primary care doctor in Juneau, Alaska, who referred her for testing, she said.

Her 9-month-old was asleep in her arms when she got the results.

“I got the call from my primary care nurse telling me it was cancer. And I remember I just sat there for probably at least another half an hour or so and cried,” Gebel said.

Juneau, the state capital, has about 31,700 residents, who are served by the city-owned Bartlett Regional Hospital. But Gebel said she has several friends who have also had cancer, all of whom recommended she seek treatment out of town because they felt bigger cities would have better care.

She opted for treatment in Seattle, the closest major American city to Alaska. She underwent surgery at Virginia Mason Medical Center in September 2022. In January, she began chemotherapy at Lifespring Cancer Treatment Center, a stand-alone clinic that she said she selected because it offers a lower-dose chemotherapy.

During chemo, she learned she had stage 4 breast cancer, she said.

Commuting to Seattle for chemo every week — nonstop flights that lasted as long as two hours and 45 minutes — became tiring. So Gebel began treatment at Bartlett Regional Hospital after her Seattle doctor taught hospital staffers there how to administer her chemo regimen.

Then the bill came.

The Patient: Emily Gebel, 37, insured through her husband’s employer by Premera Blue Cross. She was previously covered by Moda Health.

Medical Service: One round of metronomic chemotherapy, which involves regular infusions at lower but more frequent doses and over a longer period than traditional chemotherapy.

Service Provider: Bartlett Regional Hospital and Lifespring Cancer Treatment Center. The hospital is a tax-exempt facility owned by the city and borough of Juneau, though most of its revenue comes from the services it provides, according to hospital officials. Lifespring is a stand-alone, doctor-owned cancer clinic in Seattle.

Total Bill: The prices for Gebel’s chemo infusions at Bartlett Regional Hospital varied week to week. A hospital bill showed one infusion in July was listed at $5,077.28 — more than three times the price for a similar mix of drugs at the Seattle clinic, $1,611.24.

What Gives: In the United States, the price for the same medical service can vary based on where it is received. And for those living in remote areas like Alaska, the price difference can put care further out of reach.

Gebel’s firsthand experience with this disparity began after her husband, Jered, requested a cost estimate from Bartlett Regional Hospital. It said Gebel’s chemo would cost around $7,500 per weekly infusion, more than 4½ times what she had been charged in Seattle.

“The email came through with the bill estimate, and it’s like, ‘Oh my goodness, this has to be wrong,” Jered said.

Jered said Emily had met her annual out-of-pocket maximum, meaning her insurance would cover the costs of her treatment, but from the start, the disparity just bothered him.

When Emily received a bill for a few rounds of her weekly chemo treatments, it showed the hospital charged more than triple what the Seattle clinic did for a round of chemo, asking higher prices for every related service and medication she received that week.

The hospital charged about $1,000 for the first hour of chemo infusion, which is more than twice the rate at the Seattle clinic. One of the drugs cost $714, more than three times the price at the clinic.

It was even the tiniest things: The hospital charged $19.15 for Benadryl, about 22 times the clinic’s price of 87 cents.

Staff at Lifespring Cancer Treatment Center, the Seattle clinic, did not reply to requests for comment.

Sam Muse, the hospital’s former chief financial officer, who no longer works there, said Bartlett Regional Hospital officials determined prices by looking at average wholesale prices and what other facilities in the region charge. Muse said the hospital had to account for high operating costs.

“Anything that we charge certainly has to take into consideration … the cost of just supplying health care in a rural setting like Juneau,” Muse said. “We’re not accessible by road at all, only ferry or plane.”

Juneau’s isolated geography makes reaching many resources a challenge. The city is part of the Alaska Panhandle, a narrow, island-speckled sliver of the state wedged between Canada, the Pacific Ocean, and Glacier Bay National Park & Preserve. Neither Anchorage nor Vancouver, its nearest major cities, is close by.

The hospital — the only one in the city and largest in the panhandle — treats a small number of cancer patients, at least a few hundred last year, Muse said. Its two oncologists live outside the city and fly into Juneau six times a month, said Erin Hardin, a hospital spokesperson.

Bartlett spent nearly $11 million last year to pay and fly in nurses, doctors, and other staffers who live outside the city, Muse said.

We’re “trying to find that happy medium between keeping care here and keeping costs down and how do we do that in a sustainable way for the long term,” Muse said.

Even though research shows Alaskans seek emergency care and are admitted to the hospital less often than many Americans, they had the third-highest health care expenditures per capita in 2020.

“Alaska is special in that it’s small, it’s remote, therefore it’s more expensive,” said Mouhcine Guettabi, an associate professor of economics at the University of North Carolina-Wilmington who studied health care costs in Alaska when he taught there.

Guettabi said hospitals often need to offer higher wages to recruit doctors and nurses willing to live in Alaska, which has a higher cost of living than that of most states.

Towns or entire regions may have few specialists and only one hospital, creating a dearth of competition that may drive up costs, Guettabi said. It’s also more expensive to ship items there, including medical supplies.

But Alaska’s costs are higher even when taking all those factors into account, Guettabi said. In Anchorage, for instance, prices for medical items increased nearly three times as fast from 1991 through 2017 than prices overall.

Alaska also has a unique policy that may be increasing prices. Its “80th percentile rule” was enacted in 2004 to limit the amount of money patients pay when treated by providers outside their health insurers’ network. But like many experiments meant to rein in costs, the rule has instead been increasing health care spending, according to a study by Guettabi.

“Critics think the rule may be adding to that soaring spending, partly because over time providers could increase their charges — and insurance payments would have to keep pace,” the study noted.

The Resolution: Emily received a bill from the hospital in September, more than five months after beginning treatment there.

It said Emily owed about $3,100 even though a previous explanation of benefits said she’d met her out-of-pocket limit.

Jered said he contacted hospital billing officials, who discovered that a medicine had been incorrectly coded and told Jered that Emily’s charge was zero.

“We know how hard it is to pay these ridiculous medical bills,” Jered said. “If I’m able to push back a little bit against this massive system, well, hey, maybe other people can, too. And who knows, maybe eventually health care prices can come down.”

Emily said she’s glad Jered knows how to handle the financial aspects of her care. Like many Americans, she could have just paid or ignored the incorrect bills, risking being sent to collections.

“I can’t imagine the amount of time I would have to spend on it while juggling parenting and also dealing with completing treatment, going through the sickness that goes along with that, and just generally feeling very run down,” she said.

The Takeaway: Alaska government officials, nonprofits, and experts have suggested methods to lower the cost of health care. The state is considering repealing the 80th percentile rule and implementing value-based care, which emphasizes paying providers based on health outcomes.

But what should Alaskans and other patients do in the meantime? If you live in a high-cost state, you might check out prices at a health care system in a state next door.

In any case, get ready to advocate for yourself.

Jered learned about medical billing by following the Bill of the Month series and reading “Never Pay the First Bill,” a book by Marshall Allen, a former ProPublica reporter.

Request itemized bills and make sure the codes match the services you received, Jered said. Note any prices that seem outrageous. If you have concerns, arrange an in-person meeting with an official in the provider’s finance department. If that’s not possible, a phone call is better than email. Make sure to document all conversations, so you have a record.

Come prepared with your documents and evidence, including the rate paid by Medicare, the federal insurance system for those 65 and older. Ask the official to explain the reasons for the codes and pricing before contesting anything. You can sometimes negotiate high-priced services down. And remember that the person you’re speaking with isn’t to blame for your health care costs.

“Don’t come at them angry, don’t come at them as viewing them as the enemy — because they’re not,” Jered said. “They are working within the same broken system.”

This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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In February 2022, doctors said that Kent, her husband of 33 years, was too weak for the routine chemotherapy that had kept his colon cancer at bay since 2018. He was admitted to Barnes-Jewish Hospital in St. Louis, not far from their home in Olivette, Missouri.

Doctors discovered a partial blockage of his bowel, Reynolds said, but she remained hopeful that his treatment would soon resume.

“I remember calling our kids and saying, ‘OK, this is all really good news. We just need to get him kind of bolstered back up and feeling well,’” she said.

But years of chemotherapy had taken a toll on his body, and he told his wife that he couldn’t go on any longer.

Kent was discharged and began hospice care at home. He died the next month at age 62.

When Reynolds received the bill for the hospital stay, she paid the $823.15 it said her husband owed. She scribbled “paid” on the bill, memorializing the date, June 30, 2022 — the financial endpoint, she thought, of Kent’s years of treatment.

Then the bill came (again).

The Patient: Kent Reynolds, deceased, had been covered by Blue Cross and Blue Shield of Illinois through his Illinois-based employer.

Medical Service: A 14-day hospital stay related to complications from colon cancer, including a partially blocked bowel.

Service Provider: BJC HealthCare, a tax-exempt health system that operates 14 hospitals, mostly in the St. Louis area, including Barnes-Jewish Hospital.

Total Bill: The hospital charged $110,666.46 for the stay before any payments or adjustments. The insurer negotiated that price down to $60,348.77, and Reynolds paid the $823.15 the hospital said the patient owed. Then, a year after her husband’s death, she received a new version of the bill from the hospital, charging her an additional $1,093.16.

What Gives: Reynolds encountered a perplexing reality in medical billing: Providers can — and do — come after patients to collect more money for services months or years after a bill has been paid.

The new bill said Kent Reynolds had been enrolled in a payment plan and that the first “monthly installment” on the nearly $1,100 balance was soon due.

She said she called both the hospital and Blue Cross and Blue Shield of Illinois in search of answers but didn’t get an explanation that made sense to her.

According to Reynolds, a BJC HealthCare representative told her that the insurer had paid more than it owed, meaning the health system had to reimburse the insurer and charge the patient more.

Reynolds said she grabbed a yardstick to use as a straight edge and went line by line, comparing both bills, to see what had changed, a task that evoked painful memories of her husband’s last days. The amount for each individual charge — medications, lab tests, supplies, and more — was the same on both bills. The total had not changed.

Only three aspects of the bill had changed: the adjustments; the amount paid by the insurance company; and what the patient owed.

Adjustments, or discounts, are amounts that may be subtracted from a medical bill, typically under the provider’s pre-negotiated contract with an insurer. Insurers and providers agree to lower, in-network rates for services provided to patients covered by the insurer.

Reynolds also received an EOB, or “explanation of benefits,” notice showing the insurer reviewed the bill again in February, a year after the hospital stay. The document said the hospital’s charges for her husband’s private room — amounting to nearly $77,000 — were more than his health plan’s negotiated room rates, which did not cover the full cost.

The EOB noted that the patient could still owe the hospital $50,216.31 for the room charges — a startling amount — although Reynolds ultimately received no bill indicating she owed that much.

Reynolds said she spent hours trying to understand the items on the hospital and insurance paperwork, since they used medical abbreviations and were grouped differently on the documents.

“It shouldn’t be this hard for a widow to figure out what the medical bills were,” said Erin Duffy, a research scientist at the University of Southern California’s Schaeffer Center for Health Policy and Economics.

Blue Cross and Blue Shield of Illinois declined to comment despite receiving a signed release from Reynolds waiving federal privacy protections.

The Resolution: Unclear about what had changed and how much she owed, Reynolds held off on paying the second bill. After KFF Health News contacted BJC HealthCare, Laura High, a media relations manager for the system, said the charges were the result of a “clerical error.” Reynolds no longer has a balance, High said in an email in May.

“I was shocked by it,” Reynolds said. “I’m convinced most of the people I know would have paid this.”

High did not answer questions about the cause of the billing error or how often such errors occur.

However, Duffy provided a different explanation for the charges. “This doesn’t seem like an error,” she said. “It seems consistent with their insurance plan design.”

She said it appeared the additional $1,100 charge — assessed a year later — represented Kent’s coinsurance share of the private room charges, which she found as a recurring line item on each page of the bill under the heading “Oncology/PVT.”

While his coinsurance responsibility could have amounted to 10% of what the insurer paid in room charges — potentially a huge amount — Kent had met his out-of-pocket payment maximum for the year, so the charges did not reach the full 10% of the room costs, Reynolds said.

The Takeaway: In the United States, medical bills and insurance statements create a burdensome puzzle for patients to sort through to determine what is actually owed. The first rule of thumb is: “Don’t pay the bill before you’ve gotten the EOB,” which is the insurer’s accounting of what you owe and what the insurer will pay, said Kaye Pestaina, co-director of KFF’s Program on Patient and Consumer Protections.

In addition, ask for an itemized breakdown of charges and compare it against the EOB.

Medical billing experts said standardizing terms and other details on medical bills and EOBs would help patients enormously in this undertaking.

A few states have taken steps toward giving patients more information about health care charges, including by simplifying medical bills. In 2019, New York state lawmakers proposed requiring hospitals to provide patients with bills in plain language, including an itemized list of services labeled as paid by the insurer or owed by the patient. The proposal, which did not advance, required hospitals to send patients a single bill within seven days of leaving the hospital.

Reynolds’ experience highlights the lack of laws and standards around how long providers have to bill — and review bills — for medical services. Insurers may dictate in their contracts how long providers have to submit claims; the Medicare program has a 12-month limit to file claims, for instance. However, Dave Dillon, a spokesperson for the Missouri Hospital Association, said no laws restrict how long providers have to send a bill to patients.

Creditors may seek payment from a deceased person’s estate to collect whatever they can, said Berneta Haynes, a senior attorney at the National Consumer Law Center. In Missouri, a living spouse can be held responsible for a deceased spouse’s medical bills in certain instances, said Terry Lawson, a managing attorney for Legal Services of Eastern Missouri.

Experts said they did not pinpoint anything Reynolds could have done differently, noting that it is the system that needs to change.

“When can she move on from these hospital bills?” Duffy asked.

Stephanie O’Neill Patison reported the audio story.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Retired from a career as an electrician and HVAC technician, he had an outpatient procedure in April 2021 to alleviate his pain by dilating the clogged artery using a balloon snaked into his blood vessel.

Greene, who lives in Oxford, Pennsylvania, came through the procedure without any problems, and it reduced his discomfort, said his wife, Bluizer Greene. She spoke with KFF Health News on behalf of Greene, who is recovering from other health problems.

Greene is covered by Medicare and a supplemental policy through Humana and did not expect to pay anything for the care, Bluizer said.

Then the bills came.

The Patient: Thomas Greene, 74, who is covered by original Medicare and a Medicare supplement policy sold by Humana.

Medical Service: Peripheral artery bypass surgery on Greene’s right leg.

Service Provider: The operation was performed at Jennersville Hospital in West Grove, Pennsylvania, which closed in December 2021. Anesthesia services were provided by two providers who work for North American Partners in Anesthesia, which is private equity-owned and, with thousands of providers operating in 21 states, identifies itself as among the nation’s largest anesthesia staffing companies.

Total Bill: For the anesthesia care, North American Partners in Anesthesia billed $2,965.58: $1,334.51 for a certified nurse anesthetist and $1,631.07 for an anesthesiologist.

What Gives: North American Partners in Anesthesia, or NAPA, pursued Greene to pay for his anesthesia care instead of billing Medicare on time, sending the debt to collections before the couple discovered the problem.

Medicare eventually received the claims from NAPA, months after the couple started receiving collection letters, Bluizer said. But Medicare denied them because they were filed late — nearly 17 months after the surgery. Humana also denied the claims.

Medicare requires providers to submit claims within a year of providing their services. And Medicare supplemental policies, like Greene’s plan from Humana, generally do not pay for services if Medicare doesn’t cover them, whether because Medicare has not paid its part yet or because the program denied the claim.

A year after Greene’s surgery, in spring 2022, the couple opened a letter from a collection agency working on behalf of the anesthesia group. It demanded Greene pay about $3,000.

“Something has to be wrong, because this is the first time my husband has ever been asked to pay out-of-pocket and we’ve had the same insurance for years,” Bluizer said.

She said for several months she called NAPA and the collection agency, C.tech Collections, of Mount Sinai, New York, to determine why it was billing her husband.

Greene was also contacted by the Faloni Law Group, a second organization working on behalf of NAPA to collect the debt, and Bluizer said she followed its instructions to respond by mail, disputing the debt on the grounds that it should be billed to insurance.

But her communication attempts did not resolve the issue, and she said her husband continued to receive collection notices.

Neither debt collector responded to requests for comment.

“We were angry, and it was very upsetting because we had never had a bill put into a collection agency for any of his hospitalizations, and it was money we did not feel that we owed,” Bluizer said.

She said they may have received some letters from the anesthesia group in 2021 and 2022 that they discarded without opening because they believed her husband’s medical bills would be covered by insurance, as the rest of his surgery bills were.

Worried about the situation, including its potential impact on their credit, the couple reached out late last year to Harold Ting, a volunteer counselor for Pennsylvania’s MEDI program, which provides free assistance to Medicare beneficiaries. Medicare generally covers anesthesia services.

“This is totally unfair that a beneficiary ends up having to pay for what should be a totally covered service, when the provider is at fault,” Ting said.

Two explanation of benefits statements from Humana show the insurer received claims from NAPA in April 2021, shortly after Greene’s surgery. The statements said the claims could not be considered at that time, though, because Humana had not yet received Medicare EOBs for the services.

Kelli LeGaspi, a Humana spokesperson, declined to comment on Greene’s case. She said a Medicare EOB — a coverage statement generated when the program processes a claim — is required for the supplement carrier to consider a claim. Without it, a claim for secondary coverage cannot be considered and is denied, she said.

Supplement plans deny claims for benefits that are denied by Medicare, she said.

“If Original Medicare declines to pay the claim, then the Medicare supplement plan is required to decline the claim as well,” she said in an email.

In December 2022, a NAPA representative told Bluizer in an email that NAPA billed Medicare after the April 2021 surgery and that Medicare denied the claims in August 2021. The representative provided an account statement showing the claims were sent to collections that month.

But Bluizer said a Medicare representative told her in late 2021 that the program had received no claims from NAPA.

Greene’s Medicare account shows NAPA filed claims in September 2022, about 17 months after his surgery and about five months after he received his first collection letter. Both claims were denied.

A quarterly summary notice said while the time limit for filing the claims had expired, Greene also could not be billed.

Meena Seshamani, director of the federal Center for Medicare, said in an email to KFF Health News that if a Medicare provider sends a claim a year or more after a service is provided, it is denied except in very rare circumstances.

There is no exception for provider error, she said.

A spokesperson for NAPA declined to be interviewed on the record, despite receiving a signed release waiving federal privacy protections.

Martine G. Brousse, a billing expert and founder of the patient advocacy firm AdviMedPRO, said Greene’s Medicare notice should have reassured the couple that he did not owe anything, despite the several overdue-bill notices they received.

If the Medicare statement “shows a zero balance to the member, then the provider cannot legally go after the patient,” said Brousse, who is not involved in Greene’s case. “The patient has zero liability because it is not their fault” the provider billed Medicare a year after the surgery. “That is the end of the story.”

Another mystery about the claim is why NAPA billed separately for a nurse anesthetist and an anesthesiologist. Bluizer said her husband was not told why NAPA billed individually for the two medical professionals — a practice some insurers believe constitutes double billing.

Brousse said there could be a simple explanation, such as if the nurse anesthetist started the procedure and the anesthesiologist finished it or if the company charged for the anesthesiologist to work in a supervisory role.

But the Medicare claims document shows each provider billed for the same amount of time — a little over an hour.

“As far as I can tell, this looks like two providers billed with the same ‘I did the job’ Medicare procedure code,” she said. “Medicare cannot accept that without an explanation.”

The Resolution: Unable to get answers, Ting connected Greene to the nonprofit, Pennsylvania-based Center for Advocacy for the Rights and Interests of Elders.

In March, Ariel Rabinovic, an advocate with the center, contacted NAPA on Greene’s behalf and explained that federal law does not allow the group to bill Medicare patients for services Medicare does not cover. He said he was told the company would stop billing Greene.

Bluizer said the couple has not received any collection notices since then.

Rabinovic said he has seen other situations in which health providers who agree to accept Medicare try to bill patients for services Medicare does not cover, which is not allowed.

“Older folks have a lot of things going on, and dealing with this can be very confusing for them,” he said. “A lot of people end up paying because they don’t want to deal with it.”

Greene has faced several health issues and spent time in a rehabilitation hospital this winter. His wife said she was happy the billing issue had been resolved without their having to pay anything.

The Takeaway: When a Medicare statement says the patient may not be billed anything for a health service, that’s the bottom line. Don’t write a check, but also don’t ignore bills and collection notices, because they could ultimately hurt your credit.

Read your mail, the experts said. While Greene was not responsible for paying the anesthesia bill given that Medicare said he did not owe anything, the couple may have prevented the debt from being sent to collections if they had responded to the anesthesia group’s communications and confirmed it had Greene’s insurance information, Brousse said.

Keep copies of bills and insurance statements, especially Medicare EOB documents, or follow them on an online portal.

The couple was smart to reach out to advocates for help resolving the issue when they could not do so on their own, Rabinovic said.

“This is why people need to read their notices from Medicare even when it says ‘This is not a bill,’” he said.

Also, when an anesthesia bill includes charges for both a nurse anesthetist and an anesthesiologist, question the charges. Many insurers will not pay for both.

The Centers for Medicare & Medicaid Services recommend beneficiaries call 800-MEDICARE with questions about their care or bills or file a complaint online.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).

She knew it was triggered by food, so she said she tried taking an antacid. That helped a little, but, eventually, she avoided eating altogether. She estimated she lost 25 pounds in that time.

One night that September, the pain would not go away for hours. It was so severe she went to the emergency room at Indian Path Community Hospital in Kingsport, Tennessee, where she lives. An ultrasound revealed she needed her gallbladder removed right away. She was able to get into surgery quickly because she hadn’t eaten in over 12 hours due to her food avoidance.

At the time, Birch was 23 and uninsured. Once she was released from the hospital, however, she lost her housing and spent months without a permanent mailing address while crashing with family.

“It was a pretty rough situation because, at the time, I didn’t have a job, I didn’t have a driver’s license or anything,” Birch said.

For fear of bills she couldn’t afford, she said, she had often avoided seeking care for emergencies, including a broken finger, asthma attacks, and a sprained ankle. She didn’t expect her gallbladder surgery — which cured her pain — to be free.

But she said she never received a bill. She got engaged and moved in with her husband after they married at the end of 2017. Then, in 2018, there was a knock on her door, and she was served a lawsuit.

The Patient: Bethany Birch — née Bethany Allison — now 30, a stay-at-home mom. She lacked health coverage at the time of her surgery.

Medical Services: Emergency gallbladder removal in 2016, plus a previous visit to the emergency room at the same hospital the same year. A bill later obtained for that visit showed she received treatments consistent with an asthma attack, and while Birch said she could not recall that specific visit, she added that she has gone to the ER so many times for asthma attacks she finds it hard to keep track.

Service Provider: Indian Path Community Hospital, which in 2018 became part of Ballad Health, a health system in Tennessee and Virginia.

Total Bill: $11,749.60 plus interest, for two hospital visits and additional court costs associated with the lawsuit Ballad Health pursued against Birch. According to an affidavit of debt, she owed the hospital $9,986.40 for gallbladder removal surgery and $1,603.70 for the previous visit. The court judgment ultimately tacked on $159.50 in court costs and an interest rate of 7%. As of May 2023, she had accumulated $2,715.97 in interest.

What Gives: In October 2018, Birch was served papers at her home in Kingsport informing her that Ballad Health was suing her for $11,590.10 for two unpaid hospital bills from 2016 — including $9,986.40 for her gallbladder removal.

An executive with the health system later said the hospital attempted to contact her for payment and to discuss charity care. But Birch — who had neither a permanent mailing address nor reliable phone service at the time and could not recall whether she provided the hospital with her email address — said she never received their communications.

Under the Affordable Care Act, hospitals must take certain measures to notify patients of an outstanding bill before pursuing “extraordinary collection actions,” like filing a lawsuit. But experts said the law does not account for individual circumstances that can complicate a patient’s receipt of a bill.

And when interest is added to a repayment plan, medical debt can balloon even more. Ballad Health sued more than 6,700 patients over medical debt in 2018, according to an analysis by The New York Times.

Birch brought her father along for support when she showed up to her court date that November, but she did not have an attorney representing her.

“I would never be able to afford one,” Birch said.

At the courthouse, she said, she met with a representative from Wakefield & Associates — now known simply as Wakefield — the debt collection and revenue firm representing the health system. Birch signed an agreement to pay the full $11,590.10, plus $159.50 in court costs, in monthly installments of $100 beginning in January 2019.

The court tacked on a 7% interest rate, the default interest rate under Tennessee law at the time of the judgment.

Karen Scheibe Eliason, general counsel at Wakefield, declined interview requests despite Birch’s offer to give permission for a representative of the company to speak with KFF Health News about her case.

Anthony Keck, an executive vice president at Ballad Health, reviewed Birch’s case with KFF Health News after Birch signed a release waiving federal privacy protections. The health system’s timeline indicates a screening of Birch found she was single, uninsured, and unemployed at the time of the visit.

Given those circumstances, Birch might have qualified for free or reduced-cost care under the hospital’s financial assistance policy for low-income patients if she had applied.

Information about the financial assistance option was included in the bills the hospital mailed in September, October, and December 2016, Keck said.

But Birch said she never received the bills, likely because they were sent to an address where she no longer lived. She said she filed a change of address form with the post office in 2017 listing her grandmother’s house, where she was staying, but that change would have occurred after the hospital said it sent her bills. She didn’t initially update her address, she said, because she didn’t have a permanent place to live.

Ballad Health’s timeline also indicates a financial counselor left a voicemail for Birch soon after she left the hospital, which Birch said she also did not receive, likely because her pay-as-you-go phone plan was not paid at the time.

Keck said Ballad Health has since changed its financial assistance program to screen and help people like Birch who have barriers in life that could prevent them from applying for financial assistance, such as financial, housing, and food insecurity.

“If we had had that system in place” when Birch was being treated, Keck said, “this wouldn’t have happened.”

The hospital where Birch was treated became part of Ballad Health in 2018, when two competing hospital systems in eastern Tennessee merged, creating one of the largest health systems in the country. According to recent public filings, Ballad Health had an operating revenue of $2.3 billion in 2022 and paid its CEO $2.8 million in 2021.

The Resolution: Birch was originally sued for $11,590.10. Since her court-ordered payment plan began, Birch had paid $5,270.20 as of May.

But her balance was still $9,299.82 — $6,583.85 on the principal amount, for her hospital debt and court costs, plus $2,715.97 of accrued interest. After more than four years of payments, she had barely made a dent in her debt.

A KFF Health News-NPR investigation showed many hospitals now commonly use aggressive collection tactics, including selling unpaid medical debt to third-party companies that handle collections, like Wakefield, and pursuing lawsuits against patients.

Keck said Ballad Health does not receive the interest payments. “Interest is mandated by the courts and is directed towards legal fees incurred by the agency collecting on the unpaid patient debt,” he said.

In February, Birch started receiving assistance from Ashley Beasley, a patient advocate her grandmother knew from church. Beasley agreed to help Birch as a favor and suggested she reach out to NPR and KFF Health News.

Birch and Beasley said they asked Ballad Health twice that month to settle her debt, but representatives told them Birch needed to work with Wakefield, the debt collector. When they called Wakefield, they said they were told Birch had to work with Ballad Health.

In May, on a phone call with Wakefield representative Anna Elrick, Birch and Beasley again asked to settle the debt, offering to pay an additional $500 on top of what Birch had already paid. Elrick said she would take the offer to Ballad Health. Three days later, Elrick called Beasley to say their offer had been accepted, Beasley said. Birch has since paid the $500 and received a letter from Wakefield acknowledging her account has been paid in full.

Birch called her settlement “bittersweet.” On one hand, she said, she feels relief.

“But it’s bitter because I know I’m not the only person who’s fallen prey to this,” she said. “I’m not going to forget that there are other people in my situation, too.”

The Takeaway: The ACA requires hospitals to make “reasonable efforts” to determine if a patient qualifies for financial assistance before taking them to court. Those efforts specifically include notifying a patient about a financial assistance policy and waiting at least 120 days after providing the first billing statement before initiating a legal process, for instance. Ballad Health’s timeline of Birch’s case indicates the health system followed those steps.

Zack Buck, a University of Tennessee associate professor who specializes in health law, said the ACA standards leave gaps that patients living in unstable circumstances can fall through.

“What does it mean to provide someone with a bill if it’s someone who is not easily reachable and does not have a home?” he said. “It’s almost as if the regulations don’t even ponder that possibility.”

Berneta Haynes, a senior attorney with the National Consumer Law Center, said some states have moved to cap or even ban certain interest charges on medical debt. In Arizona, for example, voters approved a 3% cap on medical debt last year. A Maryland law passed in 2021 prohibits hospitals from charging interest payments for patients who qualify for free or discounted care.

But Haynes said policy initiatives should also focus on how to prevent medical debt in the first place.

“Because once it happens, it seems like the situations get more and more complicated and people get left in these gaps,” Haynes said.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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“I tried to gut it out for three hours because of the insurance situation,” said Comfort, a retired teacher and American citizen who has Swiss insurance.

When the pain became unbearable, Comfort called his brother, who drove him and his wife, Nazuna, a few miles to the nearest emergency department, at the University of Pittsburgh Medical Center’s hospital in Williamsport, Pennsylvania.

Every bump of the drive was “like someone taking something and just jabbing it into my abdomen,” he said.

At the hospital, Nazuna Konishi Comfort handed over her husband’s Swiss insurance card, which confirmed coverage by Groupe Mutuel. Jay recalled the staff making copies of his insurance card and then treating his acute appendicitis. Doctors performed emergency surgery to remove the inflamed appendix.

Diagnostic tests confirmed he had a rare cancer, which doctors in Switzerland later removed with another surgery after he returned home. “It was a miracle,” Comfort said, adding that the cancer was completely removed.

After his appendectomy, Comfort recalled vomiting and then waiting in a recovery room. In all, he spent about 14 hours at UPMC Williamsport before being released. He attended his daughter’s wedding and, eventually, traveled back to Switzerland.

Then the bill came.

The Patient: Leslie “Jay” Comfort, 66, a retired educator who worked in Japan and Switzerland. Comfort pays a monthly fee and deductible for Switzerland’s mandatory basic health insurance, which he has with the Swiss-based Groupe Mutuel. His benefits — and the prices for procedures — are defined by the Swiss government.

Medical Service: Emergency laparoscopic appendectomy and diagnostic tests, which showed Comfort had a rare subtype of cancer called goblet cell adenocarcinoma.

Service Provider: University of Pittsburgh Medical Center Williamsport, which is about 3½ hours northeast of Pittsburgh. The UPMC health system is one of the state’s largest employers, with 40 hospitals.

Total Bill: $42,156.50, covering emergency surgery, scans, laboratory testing, and three hours in a recovery room. His insurer has said it will pay him about $8,184 (7,260.40 in Swiss francs), which is double the procedure’s price in Switzerland. This left him to cover the remaining roughly $34,000.

What Gives: Although Comfort has health coverage, his Swiss insurance had no contract with the U.S. hospital where he underwent emergency surgery — or with any other provider outside Switzerland.

With what is considered an excellent health system, Switzerland has the highest prices for medical care in Europe. As in the U.S., the country relies on private insurers and hospitals. But the cost of care in Switzerland is substantially lower than what is charged in the U.S., so the reimbursement his insurer offered is a fraction of what Comfort owes the U.S. hospital.

“I’m trying to do the right thing and say I’m willing to pay my responsibility,” he said.

Groupe Mutuel does not have agreements with foreign providers, such as UPMC, and does not deal with them directly, said Lisa Flückiger, a spokesperson for Groupe Mutuel. The insurer originally agreed to reimburse Comfort what would have been paid in Switzerland for the same treatment in a public hospital and then double that because it was an emergency in a foreign country — a total of 4,838 in Swiss francs, or about $5,460.

While helpful, Comfort said, that amount wouldn’t pay off the $42,156.50 he owes UPMC.

UPMC has expanded its reach throughout Pennsylvania and is now the largest provider of care in many parts of the state. In 2016, it purchased a smaller health system and now runs two major hospitals, UPMC Williamsport and UPMC Williamsport Divine Providence Campus.

Studies show that in areas where hospital consolidation is high, prices go up. Because there is less competition, hospitals have more power to charge what they want when patients have private insurance or are paying out-of-pocket.

In the U.S., the amounts charged for medical care are “all over the map,” said Johnathan Clarke, vice president of strategy and business development at Penfield Care, a medical cost-containment company in Canada. The company negotiates medical bills on behalf of individuals, including international visitors to the U.S., but is not involved in Comfort’s case.

Clarke said he would expect an appendectomy to be priced between $6,500 and $18,800, based on his analysis of Medicare payments in the Pittsburgh area. Healthcare Bluebook — which evaluates insurers’ claims data to provide cost estimates based on what insurers have paid, rather than what providers charge — says a fair price for a laparoscopic appendectomy in Williamsport is about $14,554.

Comfort said a “reasonable price estimate” based on his own internet research would be between $7,500 and $12,000.

Comfort’s care included an X-ray and an EKG, or electrocardiogram for his heart, because “there was no information relating to past medical/surgical history for this patient,” wrote Susan Manko, vice president of public relations at UPMC. The staff also conducted pathology work that identified cancer.

But those additional services did not fully explain the gap between cost estimates and what the hospital charged. For instance, UPMC charged $8,357 for Comfort’s three-hour stay in the recovery room.

Manko said Comfort’s total bill aligns with UPMC’s standard charges.

The cost disparities highlight the stark difference in international pricing. Cost estimates last year showed the average amount paid for an appendectomy in the U.S. was “nearly exactly double” that paid in Switzerland, said Christopher Watney, chief executive of the International Federation of Health Plans, an industry association whose members include health insurers on six continents.

Health care in Switzerland, though, is often expensive compared with other European countries, Watney said. The Swiss pay double for an appendectomy compared with Germans, and more than three times that of those in Spain, he said. Across the globe, Watney said, many countries include an overnight stay in the cost of an uncomplicated appendectomy in contrast to Comfort’s experience, which was billed as outpatient care.

Comfort, who has dual residency in Switzerland and Japan after nearly three decades working abroad, said he worked in the U.S. long enough to qualify for Social Security benefits and Medicare. He said he had previously tried to gain Medicare coverage at one point but still is not enrolled, after being transferred to a couple of offices and “playing phone tag.”

Still, unlike many patients dealing with a five-figure medical bill, Comfort said he is not concerned about UPMC harming his financial reputation. The health system doesn’t “seem to put bad marks against people’s credit record — and I don’t have credit in the United States. I’ve been out for 30 years.”

Manko confirmed that, saying UPMC reviewed and updated its collection policy last year; it states the health system will not engage in “extraordinary collection actions” such as lawsuits, liens on homes, arrests, or reporting to credit agencies.

She said the health system — which, as a nonprofit system, is tax-exempt — maintains a “robust financial assistance program” for patients unable to pay. But “to our knowledge” Comfort has not applied for financial assistance, Manko told KFF Health News.

The Resolution: Comfort said he spent months waiting for a bill and finally reached out to UPMC because, if the bill had arrived this year, he would have had to pay his insurance deductible again on top of the charges.

Comfort received a full UPMC bill six months after his surgery. Manko said there was “confusion” at the time of Comfort’s ER registration. Comfort’s wife provided the insurance information, she said, “but there was no documentation in the patients record for address, policy number or policy holder information.”

Once Comfort received his bill, he realized it was much higher than his Swiss insurance reimbursement and, frustrated, contacted KFF Health News.

Flückiger said the original payment amount Comfort’s insurer calculated was by episode and did not include the scan or laboratory costs. After receiving questions from a KFF Health News reporter, Groupe Mutuel “realized that we have not included the laboratory analysis and the CT scan,” which are not routinely part of an appendectomy, Flückiger wrote.

After KFF Health News provided a detailed summary of the UPMC bill, the insurer increased the amount it would pay Comfort. In all, the insurer said, Comfort should receive 7,260.40 in Swiss francs, or about $8,184.

Comfort still hopes to negotiate directly with UPMC to reduce what he owes.

“I don’t want to try to walk away, saying I don’t owe you anything,” Comfort said. “That’s not right. We’re moral people, you know. But if you’re going to try to gouge me and play the power trip and think you’re going to try to get everything you can out of me, I won’t play that game.”

The Takeaway: Though the Affordable Care Act was meant to provide insurance to more Americans and bring down the cost of care, hospital bills remain extraordinarily high and highly variable.

For a nonemergency, Comfort could have tried to compare prices at other hospitals. But most hospitals in the area where he fell ill are owned by UPMC. And an inflamed appendix can’t wait for comparison shopping.

Clarke, the cost-containment expert, said the “only thing” Comfort could have done differently was to purchase a travel health insurance policy before leaving Switzerland. While prices for health care in continental Europe are comparable to Switzerland, the high cost of care in the U.S. means Groupe Mutuel insurance is “insufficient.”

That is especially important for visitors to the U.S. since, as Robin Ingle, CEO of travel insurance company Ingle International, said: U.S. prices are “kind of crazy numbers.”

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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On Wednesday, a few days later, a maternal-fetal specialist near her home in Winter Haven, Florida, diagnosed Walsh with twin-to-twin transfusion syndrome, a rare complication that occurs when fetuses share blood unevenly through the same placenta. The doctor told her that the fetuses were experiencing cardiac issues and that she should prepare for treatment the following day, Walsh said.

Her OB-GYN told her that, without immediate surgery, her twins had a high chance of perinatal death, and she could also die.

Both doctors referred Walsh to a fetal surgeon about four hours away, describing him as an expert on the condition.

As Walsh prepared to leave, she received a call from the surgeon’s practice, the Fetal Institute. Walsh said a billing representative told her that before surgeon Ruben Quintero would see her, she needed to pay in full for the consultation, surgery, and postoperative care — a total estimate of $15,000.

Although Walsh had insurance, the biller said the surgeon was not in any private insurance networks nor did he offer payment plans.

“I burst into tears,” Walsh said. “’I don’t want to lose these babies.’”

Her mother agreed to give her money, and Walsh also called her insurer, who advised her to apply for a waiver that could allow them to reclassify the care as in network.

Late Wednesday, Walsh and her husband checked into a hotel near the practice’s office in Coral Gables. The next morning, she handed her credit card and then her mother’s credit card to the clerk at the Fetal Institute. Quintero said her case had advanced to stage 3, meaning there were problems that could cause heart failure in one or both fetuses.

He performed surgery later that day at a hospital about 90 minutes away. On Friday morning, she traveled back to his office for a follow-up. In the following weeks, she had two more consultations.

About five weeks after the surgery, Walsh gave birth to twin girls. They were premature but otherwise healthy.

Then she waited for her insurance reimbursement to come.

The Patient: Sara Walsh, 39, is covered by Blue Cross and Blue Shield of Texas through her employer, a national newspaper publisher.

Medical Service: Fetoscopic laser surgery for treatment of twin-to-twin transfusion syndrome, as well as pre- and postoperative evaluations and X-rays.

Service Provider: The Fetal Institute in Coral Gables, Florida, a practice that specializes in treating rare pregnancy complications.

Total Bill: $18,610 over multiple visits for surgery; pre- and post-surgical consultations; and two follow-up consultations for potential complications that didn’t ultimately require more treatment. Walsh ended up putting $14,472.35 on her and her mother’s credit cards. Her health plan eventually paid the Fetal Institute $5,419.44. Walsh was later partially reimbursed but ultimately paid more than $13,000 out-of-pocket.

What Gives: Walsh’s case falls into a gray area of medical billing between emergency and elective care. Despite being insured, Walsh paid most of the full charges upfront and out-of-pocket for care that three doctors said she urgently needed to save her twins. And she knew the surgeon was an out-of-network provider.

Within 20 hours, Walsh gathered the thousands of dollars she was told she needed to pay before the surgeon would meet with her and prepared to undergo surgery in an unfamiliar hospital. “That 20 hours was just insanity,” she said.

When Walsh called BCBS before her procedure, a representative told her that Quintero was in its network at a few facilities but not at his private practice, where he would evaluate her. Laura Kersey, a billing representative with the Fetal Institute, confirmed to KFF Health News that the practice accepts Medicaid — which covers nearly half of all births in Florida — but does not contract with private insurance.

“Our highly specialized practice sees patients from across the globe,” Quintero said in a statement to KFF Health News. “It would be impractical to join all health plans. If any patient is unable to pay in full for a procedure, we offer them CareCredit or an alternative payment plan, on a case by case basis.”

Neither option was available to Walsh. Approval for CareCredit, a medical credit card, would not have come in time for her next-morning procedure. Walsh said the Fetal Institute denied her request to pay half the bill upfront and the rest over time.

Kersey said requiring upfront payment is the Fetal Institute’s “normal practice.” She said they are transparent about their billing practices and disclose them to potential patients ahead of time. If someone cannot pay, she said, the Fetal Institute sends the person back to the referring physician to find another option.

Walsh said the BCBS representative advised her to complete a waiver intended for patients who receive urgently needed care from an out-of-network provider when it is not feasible to see an in-network provider. Walsh did not have the days or even weeks needed to undergo the insurer’s formal preauthorization process, which could have told her in advance whether BCBS would cover the claim.

Walsh and her mother had paid the Fetal Institute nearly $13,000 related to her surgery, hopeful that BCBS would reimburse them.

In the weeks before Walsh gave birth, the specialist in Winter Haven sent her back to Quintero twice. Both times Quintero evaluated Walsh and sent her home without further treatment. She paid nearly $1,475 more for those visits.

Walsh said she had trouble getting all the documentation BCBS said she needed. In early November, she received the letter of medical necessity explaining the diagnosis.

The letter, signed by Quintero, said that twin-to-twin transfusion syndrome, when left untreated, results in pregnancy loss in 95% of patients.

But Walsh’s situation didn’t count as the type of emergency that could have qualified her for federal billing protections, said Erin Fuse Brown, a law professor and the director of the Center for Law, Health & Society at Georgia State University.

Walsh sought care that was “knowingly out of network, even though there was a figurative gun to her head,” Fuse Brown said, referring to the potential loss of her twins or even her own life.

The federal No Surprises Act, which took effect last year, months after Walsh’s surgery, protects patients who receive emergency services inadvertently from out-of-network providers and only in certain settings — particularly emergency departments and urgent care centers. It also covers nonemergency services received from out-of-network providers, but only at in-network facilities.

Federal laws requiring public access to emergency services apply only to hospitals, not individual providers in their offices, Fuse Brown said. Physicians generally can refuse new patients and charge what they want, if they are transparent about costs, she added.

“It’s not a surprise medical bill if it’s not a surprise,” Fuse Brown said.

Only about 30 to 40 hospitals nationwide can perform fetoscopic laser surgery to treat twin-to-twin transfusion syndrome, Yale Medicine estimates.

Walsh said the specialist who referred her for a next-day surgical appointment gave her just two options for providers in the region, only one of whom practiced in her state. That was Quintero, who is renowned for his work on the condition. He is credited with pioneering the procedure Walsh needed and, with his colleagues, also developed a way to assess the condition’s severity, known as the Quintero staging system.

But it turns out there was another option in Florida. Neither the specialist nor BCBS told Walsh about the possibility of getting care at the University of South Florida, she said. At the time, USF was the only other facility in her state that could have performed the procedure, according to Alejandro Rodriguez, a maternal-fetal medicine physician and an assistant professor at the USF Health Morsani College of Medicine in Tampa. Rodriguez said that USF accepts private insurance, Medicaid, and Medicare and doesn’t require patients to pay upfront for care.

“There was no mention of shopping around,” Walsh said. And with her doctors telling her the lives of her children — and potentially her own — were urgently at stake, she said it seemed her only option was to pay up.

“No parent should face the choice of ‘How much money can I raise in the next 12 hours and is it enough to save the lives of my children?’” Walsh said.

The Resolution: Walsh has spent more than a year trying to get reimbursed by her health plan, repeatedly explaining her complicated case as representatives tried to sort out the proper billing codes for the rare, newer treatment. “No one understood how a doctor charged me more than $10,000 upfront to treat me,” she said.

Walsh also reached out to a medical advocate, who she said concluded that Quintero had billed correctly.

Walsh’s insurance covered Wellington Regional Medical Center, the in-network hospital where Quintero performed the procedure.

The Fetal Institute also filed claims for Walsh’s care with BCBS, telling her they were filing on her behalf. BCBS processed the claims — including for Quintero’s surgical services at the in-network hospital — as out-of-network care and reimbursed Walsh for just a fraction of the more than $18,000 charged.

Her “explanation of benefits” documents stated that Walsh was on the hook for the balance between what Quintero’s practice charged and the $5,419.44 that BCBS paid.

Walsh said BCBS covered her pregnancy-related visits to other, in-network providers, adding that her plan fully covers all diagnostic and laboratory maternity care.

In early 2022, the Fetal Institute forwarded Walsh a check for about $1,282. According to the practice’s records shared with KFF Health News, the check corrected an overpayment on the full charges, totaling $18,610 — which Walsh’s payments and BCBS’ reimbursements had together fulfilled.

Walsh said she had not received any other reimbursement.

BCBS declined to comment on Walsh’s case, citing privacy concerns even though Walsh waived federal health privacy protections, which would allow the insurer to speak to a reporter about the case.

After a KFF Health News reporter contacted the insurer, Walsh said, a BCBS representative called to inform her that her claims had been “escalated,” but eventually determined that the reimbursement was “appropriate” because the provider was out of its network.

The insurer said that the full amount of her balance doesn’t apply toward out-of-pocket maximums in her plan.

The Takeaway: Federal billing protections are not designed to protect patients who choose out-of-network care, even when they find themselves in an urgent situation with few options and little time for comparison shopping.

And often only a handful of specialized providers can treat rare conditions. While that dearth of options raises ethical questions about whether it is OK for a doctor to demand payment upfront for lifesaving surgery, it is legal to do so, experts say. Many Americans would be challenged to raise $15,000 overnight.

“The patient did everything she could,” said Fuse Brown.

Worse, still, she said: When a patient pays upfront, there’s little incentive for providers and insurers to negotiate a fair payment or even cooperate to help patients get reimbursement.

The case shows how consumer protections are still lacking in many situations. “This could still happen tomorrow,” Fuse Brown said.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Her family is insured through her husband’s employer, HCA Healthcare, a Nashville-based health system that operates more hospitals than any other system in the nation. So McLin knew that a nearby stand-alone emergency room, HCA Florida Lutz Emergency, would be in their plan’s provider network.

But McLin said a doctor there told her she couldn’t treat her son, Keeling, because he had second- and third-degree burns that needed a higher level of care. The doctor referred them to the burn center at HCA Florida Blake Hospital, about a 90-minute drive away.

McLin, who is a dentist, said the doctor told her the stand-alone ER would not charge for the visit because they did not provide treatment.

“I don’t remember exactly how she phrased it. But something along the lines of, ‘Well, we won’t even call this a visit, because we can’t do anything,’” McLin said.

At Blake Hospital, she said, a doctor diagnosed Keeling with a second-degree burn, drained the blisters, bandaged his hand, and sent them home with instructions on how to care for the wound.

“I didn’t think anything more of it,” McLin said.

Then the bills came.

The Patient: Keeling McLin, now 5, is covered by UnitedHealthcare through his father’s employer.

Medical Service: At the stand-alone emergency room, a physician assessed Keeling and sent him to another facility for treatment. “Keeling needs a burn center,” the doctor wrote in the record of his visit.

Service Provider: Envision Physician Services, which employed the emergency room physician at HCA Florida Lutz Emergency in Lutz, Florida, near Tampa, and HCA Florida Trinity Hospital, the main, for-profit hospital to which the stand-alone emergency room belonged.

Total Bill: For the emergency room visit, Envision Physician Services billed $829 to insurance and about $72 to the family. HCA Florida Trinity Hospital billed Keeling about $129, noting it had applied an “uninsured discount.” An itemization showed the original charge had been nearly $1,509 before adjustments and discounts.

What Gives: The stand-alone emergency room and ER doctor, who saw Keeling but referred him to another hospital, billed for his visit. But McLin soon learned she was unable to dispute some of the charges — because her young child’s name was on one of the bills, not hers.

Months after the ER visit, McLin received a bill addressed to the “parents of Keeling McLin” from Envision Physician Services, the provider staffing service that employed the ER doctor at Lutz. McLin recalled the doctor’s promise that they would not be billed. “I should have made them write something down to that effect,” she said.

She said she called her insurer, UnitedHealthcare, and a representative told her not to pay the bill.

She received an insurance statement that identified the bill from Envision’s doctor — an out-of-network provider working in an in-network emergency room — as a “surprise bill” for which the provider may charge only copays or other cost-sharing costs under federal law. McLin said she had not heard anything since then about the bill.

After being contacted by KHN, Aliese Polk, an Envision spokesperson, said in an email that Envision would waive the debt, apologizing to Keeling’s family “for the misunderstanding.”

She described the ER doctor’s evaluation, determination, and referral as a medical service. She said the bill was for cost sharing for the visit — not the difference between what the doctor charged and what insurance paid, as the law prohibits.

“We recognize the patient’s family may have understood at the time of treatment that there would be no charge for the visit, including the medical service provided by our physician,” Polk said. “Unfortunately, this courtesy adjustment was not captured when the claim was processed.”

Maria Gordon Shydlo, a UnitedHealthcare spokesperson, said the insurer believed the matter had been resolved and did not follow up on requests for an interview, even after McLin waived federal health privacy protections, which would allow the insurer to speak to the reporter about the case.

McLin also received a bill from HCA Florida Trinity Hospital for its stand-alone ER at Lutz and decided to dispute the charges.

But after calling the hospital to appeal, McLin said, the billing department would not discuss the debt with her because the statement was in her young son’s name.

“They had him as the guarantor,” McLin said. Unlike Envision, which billed Keeling’s parents and their insurance, McLin said the hospital listed the child as “unemployed, uninsured.”

The child’s ER record also included his date of birth and doctor’s notes referencing his age. McLin said she wrote to HCA in November asking to appeal the bill and that a billing representative told her over the phone that it would put the debt on hold and review the dispute.

“I never heard anything back and assumed we were good,” McLin said.

Then, in January, she received a letter from Medicredit, a collection agency and an HCA subsidiary, stating that Keeling owed $129 and that he had until mid-February to contest the debt. KHN was unable to make contact with Medicredit representatives, and HCA Healthcare did not respond to requests for comment from its subsidiary.

Once again, Sara McLin’s name was not on the debt collector’s letter, and she said Medicredit representatives refused to discuss the debt with her because it was in her son’s name. She said she called HCA, too. “They said, ‘We can’t help you. We don’t have the case anymore,’” she said.

Erin Fuse Brown, a law professor and director of the Center for Law, Health & Society at Georgia State University, said McLin did everything right and that it is unusual for a parent to be barred from discussing a debt related to their minor child.

“The fact that the hospital wouldn’t even talk to her strikes me as the part that is absurd. It’s absurd as a business matter. It’s absurd as a privacy matter,” Fuse Brown said, adding that federal health privacy laws allow a parent or legal guardian to access their dependent’s medical information.

Fuse Brown said the hospital should have been able to correct the error quickly with more information, such as a birth certificate or other document establishing that McLin was Keeling’s parent. At the very least, she said, it could have given McLin notice before sending the bill to collections.

“You get the feeling that it’s this large, automated process, that there’s no human to get through to, that there’s no human to talk to and override the mistake,” Fuse Brown said. “Maybe it’s routine, but she couldn’t even talk to someone to correct a correctable billing error, and then the system just steamrolls over the patient.”

The Resolution: When the collection agency’s deadline passed without resolution, McLin said she felt frustrated. “Nobody can explain to me who has to approve talking to me,” she said. “I don’t know who that person is or what the process is.”

After KHN contacted the health system, HCA Healthcare canceled the family’s debt. HCA representatives declined to be interviewed on the record despite also receiving a privacy waiver from McLin.

“We have attempted to contact Mrs. McLin to apologize to her for the inconvenience this has caused her and to let her know that there is a zero balance on the account,” Debra McKell, marketing director for HCA West Florida Division, said in an email on March 3. “We also will be sharing with her that we are reviewing our processes to ensure this does not happen again.”

McLin later received a letter from HCA stating that the account had been cleared. She also said she received a call from a customer service representative informing her that the debt had not been reported to any credit agencies.

She said she was pleased, but that patients should not have to struggle to correct a billing error before it is sent to a collection agency and potentially ruins their credit.

“It’s the principle of the thing that’s annoying me at this point,” she said.

The Takeaway: Though the notion of a debt collector pursuing a 4-year-old boy may seem farcical, it happens. When seeking medical care for a minor, it is important for the parent or guardian to ensure their name is listed as the responsible party.

Consumers who find themselves fighting a medical billing error need to “think like a lawyer,” Fuse Brown said, including documenting every interaction with the debt collector, getting any promises in writing, and recording phone calls. (State laws vary about how many parties on a call must give permission to record a conversation.)

Patients do not have to give up once a bill goes to collections, Fuse Brown said. “Once you hear from a debt collector, it’s not like the game is over and you lose,” she said. “Consumers do have rights.”

François de Brantes, a home health company executive and expert on how money flows through the health care system, said that hospital billing errors are not uncommon but that he had never heard of a situation like the one McLin experienced. He called it “puzzling” that HCA would issue a formal claim in a dependent child’s name.

De Brantes said those in a similar situation should also ensure that the collection agency removes any record of a debt against a minor to protect the child’s financial future.

“This stuff happens, where you have children who are improperly billed for stuff that they shouldn’t be billed, and they end up in collection,” he said. “Then the kid finds themselves with a collection record and they can’t get loans in the future, potentially student loans.”

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).