Erica Seryhm Lee for KHN
Mark Gottlieb’s life modified immediately when one other driver crashed into his automotive at an intersection in Hackensack, N.J., damaging 4 vertebrae in his higher backbone and smashing six enamel.
Within the months following that January 2019 crash, Gottlieb obtained the enamel topped and, for debilitating neck ache, tried injections, chiropractic care and bodily remedy. The remedies had been all coated by his automotive insurance coverage.
New Jersey legislation, as in 12 different states, requires drivers to purchase private harm safety protection as a part of their auto insurance coverage coverage, to pay for medical bills. Gottlieb had the utmost protection: $250,000.
Sadly, his ache endured. “Nothing was working. The one different factor was surgical procedure,” he says.
Although he needed his operation carried out close to his house, Gottlieb says, workers members on the Bergen Ache Administration clinic, the place he was receiving care, insisted he go to Hudson Regional Hospital in Secaucus. On April 3, 2020, Gottlieb underwent a posh kind of fusion surgical procedure on the herniated disks in his cervical backbone. He went house the identical day.
His ache improved a bit. Then the payments got here.
The affected person: Mark Gottlieb, 59, a advertising and marketing marketing consultant in Little Ferry, N.J., coated for $250,000 in medical prices by his Geico automotive insurance coverage coverage. He additionally has an Aetna medical insurance coverage, which is to offer secondary protection.
Medical service: anterior cervical discectomy and fusion, a sort of neck surgical procedure to interchange broken disks with bone grafts or implants to stabilize the backbone
Service supplier: Hudson Regional Hospital, a stand-alone, for-profit facility in Secaucus, N.J., and Bergen Ache Administration in Paramus, N.J.
Whole invoice: Taken collectively, the hospital and surgeon billed Gottlieb greater than $700,000. The hospital billed $445,995 for the surgical procedure, an quantity decreased to $133,778 by Geico, which finally paid $103,354. Bergen Ache Administration billed an extra $264,444 for the principle surgeon. Primarily based on a evaluate, Geico decreased that to $141,548. It paid $52,365 towards that earlier than Gottlieb’s medical protection in his auto coverage was exhausted. Then it was as much as his well being insurer or Gottlieb to take care of the remaining.
What offers: When accidents are the results of auto accidents, automotive insurance coverage is primarily accountable for negotiating and paying the insurance coverage portion of medical payments. That creates a bunch of monetary land mines for sufferers.
Gottlieb hit all of them.
With excessive expenses frequent within the U.S. for therapy, accident victims can simply exhaust the coverage limits of even beneficiant private harm protection, leaving some weak to large payments.
Though it is uncommon to listen to automotive insurers complain that they paid a hospital or physician an excessive amount of, auto insurers “sometimes pay extra for a few of the similar providers” than well being insurers do, says Robert Passmore, a vice chairman on the American Property Casualty Insurance coverage Affiliation, a commerce group.
That is partly as a result of, in contrast to well being insurers, auto insurers usually haven’t got broad networks of medical suppliers which have agreed to negotiated reductions off their billed expenses. So sufferers find yourself “out of community,” topic to no matter record worth the supplier expenses.
Gottlieb mentioned he checked with Geico earlier than his surgical procedure however was advised it had no data for him about networks. With about $190,000 remaining in his private harm safety fund on the time, he was not too frightened. He says efforts to get price estimates had been unsuccessful.
As an alternative of community charges, automotive insurers usually use different cost calculations. Some states set particular funds on charge schedules. However not each medical billing code is listed, and in these circumstances automotive insurers typically pay regardless of the supplier payments.
On this case, that was loads: Gottlieb’s hospital and surgeon’s expenses, even after being decreased by Geico, had been about eight instances as excessive as what Medicare would have paid.
Whereas Geico usually pays charges set by the state (that are dramatically decrease than what was charged), Gottlieb’s invoice included a bunch of billing codes not on the state’s schedule. For many, the insurer paid precisely what was charged. For instance, Geico allowed the complete worth of $65,125 charged by the surgeon for the removing of a broken disk and paid the hospital $39,195 for 9 surgical screws.
By September, with payments from his numerous suppliers nonetheless rolling in, Gottlieb’s private harm safety fund ran out after the remaining $52,365 was paid to Bergen Ache Administration — wanting the $141,548 Geico had really useful as reimbursement for the surgeon.
Insurance coverage pays payments as they’re submitted, which is usually not within the order by which the therapy was rendered.
“It seems that Bergen Ache Administration remains to be entitled to the $89,183.55 stability of the billing out of your process,” Geico wrote in a September letter to Gottlieb, which added that he may submit that stability to his well being insurer or pay it himself.
When he submitted the surgeon’s invoice to Aetna, he found that neither the physician nor the hospital was in his medical insurance community. He had not checked earlier than the operation since he by no means dreamed that outpatient surgical procedure would exhaust the auto coverage.
Meaning Aetna didn’t have a negotiated charge along with his suppliers, which could have knocked the costs down dramatically.
As an alternative, Aetna mentioned it will enable an out-of-network cost of $4,051 for the surgeon, in keeping with a Jan. 28 e-mail to Gottlieb. In a written assertion to Kaiser Well being Information, Aetna spokesperson Ethan Slavin mentioned that quantity was primarily based on Gottlieb’s coverage phrases, which set doctor funds about 10% above Medicare charges for out-of-network care.
As a result of he had not but met his annual out-of-network deductible, Gottlieb himself would have needed to pay the $4,051. He withdrew his request for Aetna to pay. As a result of out-of-network surgeons often go after sufferers to pay the stability of such payments, Gottlieb is ready to see if Bergen Ache Administration — which has already been paid $52,365 for the surgical procedure — will come after him for extra.
Up to now, neither the Bergen clinic nor the surgeon has despatched him to collections or sued for the quantity. Neither responded to a number of emails and cellphone calls positioned by KHN looking for remark.
In a written assertion, Hudson Regional Hospital spokesperson Ron Simoncini mentioned that the power “charged the state-mandated charge” the place relevant and that the place there was no such mandate, “the costs had been cheap.” The hospital just isn’t looking for extra cost.
Citing policyholder privateness, Geico declined to reply KHN’s questions, together with the way it determines what it can pay.
Did the auto insurer pay an excessive amount of?
Geico had set an allowable reimbursement of $141,548 because the surgeon’s charge.
“That’s an outrageously excessive surgeon’s charge for this sort of surgical procedure,” says Dr. Eeric Truumees, a professor at Dell Medical Faculty on the College of Texas at Austin.
“I do an incredible quantity of advanced cervical backbone surgical procedure and by no means had a charge that prime, even for advanced surgical procedure that takes 10 hours,” mentioned Truumees, president of the North American Backbone Society. He had no direct information of Gottlieb’s case.
Altogether, Geico really useful and partly paid practically $245,000 to the hospital and surgeon for the process.
In distinction, Medicare would have paid about $29,500 for your entire process, with about $1,800 of that going to the surgeon and the remaining to the hospital, in keeping with researchers at Rand Corp. who analyzed Gottlieb’s payments at KHN and NPR’s request.
The surgeon’s invoice was additionally excessive in contrast with what personal insurance coverage normally pays, in keeping with Barry Silver of Healthcare Horizons Consulting Group in Knoxville, Tenn. Silver in contrast Gottlieb’s payments with a whole lot of comparable claims from two carriers that administer employer-based medical insurance nationwide. The overall Geico paid the hospital was in keeping with what employers paid and was really lower than the 2 highest charges seen in his information. However the highest allowed cost in Silver’s database for the surgeon’s charge was $87,549 — far lower than the $141,548 Geico really useful.
Decision: Gottlieb stays at the hours of darkness about whether or not Bergen Ache Administration will search the remaining $89,000 towards his invoice.
Beforehand, Gottlieb sued the driving force who brought about the accident — and gained a considerable “ache and struggling” court docket settlement. He desires to protect it for future medical wants.
He has filed quite a few complaints about his payments with state regulators, lawmakers and his insurers. Aetna despatched his surgeon’s invoice to its inner Particular Investigations Unit following his criticism.
However “primarily based on our investigation, we decided there was no additional want for motion,” spokesperson Slavin says.
The takeaway: Most individuals are unaware that auto insurance coverage kicks in first after an accident and that it really works very in another way from medical insurance — so it’s a must to take note of how the insurance policies coordinate.
That is very true if the accident requires main therapy.
In case you have a low quantity of non-public harm protection in your car coverage, your medical payments might effectively kick over to your well being coverage. So whenever you join nonemergency therapy — particularly if it is in depth, like surgical procedure — it is essential to ensure the suppliers are categorised as “in community” by your well being insurer.
Some auto insurers even have networks. Ask whether or not yours does.
Attempt to get price estimates in writing for nonemergency care and examine that with what you might have left in your auto coverage protection.
“If it is greater than you might have left, it could be doable to barter with the hospital or physician to scale back their expenses,” says Silver at Healthcare Horizons.
KHN’s Stephanie O’Neill and Dr. Elisabeth Rosenthal contributed to the audio model of this story.
Invoice of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical payments. Do you might have an fascinating medical invoice you wish to share with us? Inform us about it.