Reasons why medical bills are out of control

If you ever wondered why you might receive a blockbuster medical bill even if you have health insurance, the reporting of Kaiser Health News (KHN) can help. KHN, a nonprofit news service that reports on how the health care system works, is editorially independent of another well-known nonprofit, the Kaiser Family Foundation, and not affiliated with the health insurance company, Kaiser Permanente. It can be accessed online at https://khn. org and has taken on a daunting project which is documenting and explaining in English what is happening with hospital, medications and other medical bills. Each month it publishes a “Bill of the Month” with explanations why.

The “Bill of the Month” for August, for example, published on August 27, 2018, reports on “A Jolt To The Jugular! You’re Insured But Still Owe $109K For Your Heart Attack.” Here are the facts as reported by them.

Drew Calver, a popular high school history teacher and swim coach in Austin, Texas, suddenly collapsed from a heart attack at his home and was rushed to St. David’s Medical Center on April 2, 2017 where doctors confirmed he needed emergency stents implanted to open his clogged artery.

Drew asked whether his health insurance would cover since the Medical Center was “out-of-network” on his school district health plan. He was assured by the hospital that he was ok and the surgery was performed.

The hospital charged $164,941 for the surgery and four days in the hospital. AETNA, the administrator for the health benefits for the school district, paid the hospital $55,840. At that time the hospital billed Drew for $108,951.31. See update below. What happened?

Surprise Bills and Out-ofNetwork

Although the out-of-network issue was raised in this situation initially, it turned out not to be the primary problem since it was emergency care where he did not have a choice.

This kind of bill is referred to as a surprise bill.

One point recently being stressed is that, even when you go to a hospital or a provider that is in-network, another outof-network party could become involved such as, for instance, if you receive surgery from a team and someone involved is out of network.

Medical plans are becoming increasingly complicated and you cannot always determine who is and who is not in-network.