美国国家公共电台 NPR--A surprise-billing law loophole? Her pregnancy led to a six-figure hospital bill

A surprise-billing law loophole? Her pregnancy¹ led to a six-figure hospital bill

Transcript²

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

A registered nurse, Laskey called her OB-GYN back home in Seattle, who said to seek immediate³ care. Staff members at a nearby emergency department found no leakage⁴. But her OB-GYN still wanted to see her as soon as possible.

Laskey and her husband, Jacob, made the three-hour trip to the Swedish Maternal⁵ & Fetal Specialty⁶ Center-First Hill. Laskey had sought the clinic's specialized⁷ care for this pregnancy, her second, after a dangerous complication with her first: The placenta had become embedded⁸ in the uterine muscles.

Back in Seattle, doctors at the clinic found Laskey's water had broken early, posing a serious risk to her and the fetus⁹, and ordered her immediate admission to Swedish Medical Center/First Hill. She delivered her son after seven weeks in the hospital. Though she was treated for multiple postpartum complications, she was well enough to be discharged the next day. Her son, who is healthy, went home a month later.

Laskey soon developed a fever and body aches, and she was told by her OB-GYN to go to Swedish's emergency department. She said doctors there wanted to admit her when she arrived Aug. 20 and scheduled a procedure for Aug. 26 to remove a fragment of placenta that her body had not eliminated on its own.

Laskey, who had already spent weeks away from her 3-year-old daughter, chose to go home. She returned for the procedure, which went well, and she was home the same day.

Then the bills came.

The Patient: Danielle Laskey, 31, was covered by a state-sponsored plan offered by her employer, a local school district, and administered by Regence BlueShield.

Medical Service: In-patient hospital services for 51 days, plus a one-day stay that included a second placenta removal procedure.

Service Provider: Swedish Medical Center/First Hill, part of Providence¹⁰ Health & Services, a large, nonprofit, Catholic health system.

Total Bill: Swedish, through Regence, billed about $120,000 in cost sharing for Laskey's initial hospitalization and about $15,000 for her second visit and procedure.

What Gives: The specialized clinic caring for Laskey before her hospital admission was in her insurance plan's network. The clinic's doctors admit patients only to Swedish Medical Center, one of the Seattle area's only specialized providers for Laskey's condition — which, given that connection, she assumed was also in the network.

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

It turned out Swedish Medical Center was out of network for Laskey's plan and, at first, Regence determined¹¹ that Laskey's hospitalizations were not emergencies. Jacob said that in November a Regence case manager initially¹² told him that his wife's lengthy¹³ hospitalization was an emergency admission and out-of-network charges would not apply. But then he said the case manager called back and said the charges would apply after all, because Danielle had not come in through the emergency department.

Both Washington state and federal laws prohibit insurers and providers from billing patients for out-of-network charges in emergency situations. The couple said neither Swedish nor Regence told them before or during the two hospitalizations that Swedish was out of network, and that they never knowingly signed anything agreeing to accept out-of-network charges.

Jacob, who works as a psychiatrist¹⁴ at a different hospital, said he mentioned the surprise-billing laws to the Regence case manager, but she replied that the laws did not apply to his family's situation.

It was only after Regence was contacted by KHN that the insurer explained its reasoning to the reporter: Regence said the Swedish hospital, while out of network for Danielle, had a broader contract with the insurer as a "participating provider" and so the insurer was not in violation¹⁵ of surprise-billing laws by approving Swedish's out-of-network coinsurance charges.

The broader contract allowed Swedish to bill members of any Regence plan who receive out-of-network services there 50% coinsurance — the patient's portion of the overall cost the insurer allows the provider to charge — with no out-of-pocket maximum for the patient.

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

Setting the terms with an insurer for providing its members emergency or other care appears to allow hospitals to sidestep new surprise-billing laws that prevent out-of-network providers from charging high, unpredictable rates in emergencies, according to government and private-sector medical billing experts.

Experts said they had not heard of out-of-network providers evading¹⁶ surprise-billing laws by being contracted as "participating providers" until KHN asked about Laskey's case.

Ellen Montz, director of the Center for Consumer Information and Insurance Oversight¹⁷ at the Centers for Medicare & Medicaid Services, said that under the federal No Surprises Act, the definition of a "participating" emergency facility that's subject to the law's surprise-billing protections depends on whether the facility has a contract with the insurer specifying¹⁹ the terms and conditions under which an emergency service is provided to a plan member.

Matthew Fiedler, a senior fellow at the University of Southern California-Brookings Schaeffer Initiative for Health Policy who studies out-of-network billing, said Laskey's case seems to fall into a "weird²⁰" gray area of the state and federal laws protecting patients from out-of-network charges in emergency situations.

If there had been no contract between Regence and Swedish, the laws clearly would have prohibited those charges. But since there was a contract specifying a 50% coinsurance rate when Swedish was out of network for a particular Regence plan, those laws may not apply, Fiedler said.

After he declined to apply for the hospital's financial assistance program, Jacob said Swedish also notified them in November that they had two months to pay or be sent to collections.

Natalie Kozimor, a spokesperson for Providence Swedish, said the hospital disagreed with "some of the details and characterizations of events" presented by the Laskeys, though she did not specify¹⁸ what those were. She said Swedish assisted Danielle with her appeal to Regence.

"We had no luck with Swedish taking any role or responsibility with regard to our billing or advocating on our behalf," Jacob said. "They basically just referred us to their financial department to put us on a payment plan."

The Resolution: In December, the couple appealed Regence's approval of Swedish's out-of-network charges for the 51-day hospitalization, claiming it was an emergency and that there was no in-network hospital with the expertise²¹ to treat her condition. They also filed a complaint with the state insurance commissioner²²'s office.

The office told KHN that the "participating provider" contract does not override²³ the laws barring out-of-network charges in emergency situations. "Danielle had an emergency and Regence acknowledges it was an emergency, so she cannot be balance-billed," said Stephanie Marquis, public affairs director for the Washington state Office of the Insurance Commissioner.

On Jan. 13, Regence said it would grant the Laskeys' appeal to cover the first hospitalization as an in-network service, erasing²⁴ the biggest part of Swedish's bill but still leaving the family on the hook for the $15,000 bill for Danielle's second visit and procedure.

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

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

"Under the Washington state and federal balance-billing laws, the definitions of whether a provider is considered in network hinges on whether there is a contract with a specific provider," Bach said.

The Takeaway: More than a year after the federal surprise-billing law took effect, patients can still get hammered by surprise bills resulting from health plans' limited provider networks and ambiguities²⁵ about what is considered emergency medical care. The loopholes are out there, and patients like Danielle Laskey are just discovering them.

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

Fiedler said policymakers need to consider addressing what looks like a gap in the new laws protecting consumers from surprise bills, since it's possible that other insurers across the country have similar contracts with hospitals. "Potentially this is a significant loophole, and it's not what lawmakers were aiming for," he said.

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

Bruce Alexander, a CMS spokesperson, said the Departments of Health & Human Services, Labor²⁶, and Treasury²⁷ are looking into this issue. While the agencies can't predict whether a new rule or guidance will be needed to address it, he said, "they remain committed to protecting consumers from surprise medical bills."

In the meantime, patients, even in emergencies, should ask their doctors before a hospital admission whether the hospital is in their plan network, out of network, or (watch for these words) a "participating provider."

As the Laskeys discovered, hospital billing departments may offer little help in resolving surprise billing. So, while it is worth contesting questionable²⁸ charges to the provider, it's also usually an option to quickly appeal to your state insurance department or commissioner.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism²⁹ 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.

1 pregnancy   

n.怀孕，怀孕期

参考例句：

• Early pregnancy is often accompanied by nausea.怀孕早期常有恶心的现象。
• Smoking during pregnancy increases the risk of miscarriage.怀孕期吸烟会增加流产的危险。

2 transcript   

n.抄本，誊本，副本，肄业证书

参考例句：

• A transcript of the tapes was presented as evidence in court.一份录音带的文字本作为证据被呈交法庭。
• They wouldn't let me have a transcript of the interview.他们拒绝给我一份采访的文字整理稿。

3 immediate   

adj.立即的；直接的，最接近的；紧靠的

参考例句：

• His immediate neighbours felt it their duty to call.他的近邻认为他们有责任去拜访。
• We declared ourselves for the immediate convocation of the meeting.我们主张立即召开这个会议。

4 leakage   

n.漏，泄漏；泄漏物；漏出量

参考例句：

• Large areas of land have been contaminated by the leakage from the nuclear reactor.大片地区都被核反应堆的泄漏物污染了。
• The continuing leakage is the result of the long crack in the pipe.这根管子上的那一条裂缝致使渗漏不断。

5 maternal   

adj.母亲的，母亲般的，母系的，母方的

参考例句：

• He is my maternal uncle.他是我舅舅。
• The sight of the hopeless little boy aroused her maternal instincts.那个绝望的小男孩的模样唤起了她的母性。

6 specialty   

n.(speciality)特性，特质；专业，专长

参考例句：

• Shell carvings are a specialty of the town.贝雕是该城的特产。
• His specialty is English literature.他的专业是英国文学。

7 specialized   

adj.专门的，专业化的

参考例句：

• There are many specialized agencies in the United Nations.联合国有许多专门机构。
• These tools are very specialized.这些是专用工具。

8 embedded   

a.扎牢的

参考例句：

• an operation to remove glass that was embedded in his leg 取出扎入他腿部玻璃的手术
• He has embedded his name in the minds of millions of people. 他的名字铭刻在数百万人民心中。

9 fetus   

n.胎，胎儿

参考例句：

• In the fetus,blood cells are formed in different sites at different ages.胎儿的血细胞在不同时期生成在不同的部位。
• No one knows why a fetus is not automatically rejected by the mother's immune system. 没有人知道为什么母亲的免疫系统不会自动排斥胎儿。

10 providence   

n.深谋远虑，天道，天意；远见；节约；上帝

参考例句：

• It is tempting Providence to go in that old boat.乘那艘旧船前往是冒大险。
• To act as you have done is to fly in the face of Providence.照你的所作所为那样去行事，是违背上帝的意志的。

11 determined   

adj.坚定的；有决心的

参考例句：

• I have determined on going to Tibet after graduation.我已决定毕业后去西藏。
• He determined to view the rooms behind the office.他决定查看一下办公室后面的房间。

12 initially   

adv.最初，开始

参考例句：

• The ban was initially opposed by the US.这一禁令首先遭到美国的反对。
• Feathers initially developed from insect scales.羽毛最初由昆虫的翅瓣演化而来。

13 lengthy   

adj.漫长的，冗长的

参考例句：

• We devoted a lengthy and full discussion to this topic.我们对这个题目进行了长时间的充分讨论。
• The professor wrote a lengthy book on Napoleon.教授写了一部有关拿破仑的巨著。

14 psychiatrist   

n.精神病专家；精神病医师

参考例句：

• He went to a psychiatrist about his compulsive gambling.他去看精神科医生治疗不能自拔的赌瘾。
• The psychiatrist corrected him gently.精神病医师彬彬有礼地纠正他。

15 violation   

n.违反(行为)，违背(行为)，侵犯

参考例句：

• He roared that was a violation of the rules.他大声说，那是违反规则的。
• He was fined 200 dollars for violation of traffic regulation.他因违反交通规则被罚款200美元。

16 evading   

逃避( evade的现在分词 )； 避开； 回避； 想不出

参考例句：

• Segmentation of a project is one means of evading NEPA. 把某一工程进行分割，是回避《国家环境政策法》的一种手段。 来自英汉非文学 - 环境法 - 环境法
• Too many companies, she says, are evading the issue. 她说太多公司都在回避这个问题。

17 oversight   

n.勘漏，失察，疏忽

参考例句：

• I consider this a gross oversight on your part.我把这件事看作是你的一大疏忽。
• Your essay was not marked through an oversight on my part.由于我的疏忽你的文章没有打分。

18 specify   

vt.指定，详细说明

参考例句：

• We should specify a time and a place for the meeting.我们应指定会议的时间和地点。
• Please specify what you will do.请你详述一下你将做什么。

19 specifying   

v.指定( specify的现在分词 )；详述；提出…的条件；使具有特性

参考例句：

• When we describe what the action will affect, we are specifying the noun of the sentence. 当描述动作会影响到什么时，我们指定组成句子的名词。 来自About Face 3交互设计精髓
• Procurement section only lists opportunistic infection drugs without specifying which drugs. 采购部分只说明有治疗机会性感染的药物，但并没有说明是什么药物。 来自互联网

20 weird   

adj.古怪的，离奇的；怪诞的，神秘而可怕的

参考例句：

• From his weird behaviour,he seems a bit of an oddity.从他不寻常的行为看来，他好像有点怪。
• His weird clothes really gas me.他的怪衣裳简直笑死人。

21 expertise   

n.专门知识(或技能等)，专长

参考例句：

• We were amazed at his expertise on the ski slopes.他斜坡滑雪的技能使我们赞叹不已。
• You really have the technical expertise in a new breakthrough.让你真正在专业技术上有一个全新的突破。

22 commissioner   

n.（政府厅、局、处等部门）专员，长官，委员

参考例句：

• The commissioner has issued a warrant for her arrest.专员发出了对她的逮捕令。
• He was tapped for police commissioner.他被任命为警务处长。

23 override   

vt.不顾，不理睬，否决；压倒，优先于

参考例句：

• The welfare of a child should always override the wishes of its parents.孩子的幸福安康应该永远比父母的愿望来得更重要。
• I'm applying in advance for the authority to override him.我提前申请当局对他进行否决。

24 erasing   

v.擦掉( erase的现在分词 )；抹去；清除

参考例句：

• He was like a sponge, erasing the past, soaking up the future. 他象一块海绵，挤出过去，吸进未来。 来自辞典例句
• Suddenly, fear overtook longing, erasing memories. 突然，恐惧淹没了渴望，泯灭了回忆。 来自辞典例句

25 ambiguities   

n.歧义( ambiguity的名词复数 )；意义不明确；模棱两可的意思；模棱两可的话

参考例句：

• His reply was full of ambiguities. 他的答复非常暧昧。 来自《现代汉英综合大词典》
• Fortunately, no ambiguities hang about this word or about its opposite, indeterminism. 值得庆幸的是，关于这个词和它的反义词，非决定论都不存在多种解释。 来自哲学部分

26 labor   

n.劳动，努力，工作，劳工；分娩；vi.劳动，努力，苦干；vt.详细分析；麻烦

参考例句：

• We are never late in satisfying him for his labor.我们从不延误付给他劳动报酬。
• He was completely spent after two weeks of hard labor.艰苦劳动两周后，他已经疲惫不堪了。

27 treasury   

n.宝库；国库，金库；文库

参考例句：

• The Treasury was opposed in principle to the proposals.财政部原则上反对这些提案。
• This book is a treasury of useful information.这本书是有价值的信息宝库。

28 questionable   

adj.可疑的，有问题的

参考例句：

• There are still a few questionable points in the case.这个案件还有几个疑点。
• Your argument is based on a set of questionable assumptions.你的论证建立在一套有问题的假设上。

29 journalism   

n.新闻工作，报业

参考例句：

• He's a teacher but he does some journalism on the side.他是教师，可还兼职做一些新闻工作。
• He had an aptitude for journalism.他有从事新闻工作的才能。