Insurer okayed out-of-network care for heart patient but family faces huge bill
Published: 2010-01-19 16:44:16By: Jordan Rau | Kaiser Health News | January 19, 2010
RICHMOND -- Five months into pregnancy, Jodi Lemacks discovered that her unborn son had a severe heart defect and would require a complex operation as soon as he was born. But the local pediatric heart surgeons didn't inspire confidence.
One surgeon "had just lost a baby with the same defects," Lemacks says, "and he only did six of these surgeries a year, which is not a really good number."
So Lemacks and her husband, Mark, selected a Philadelphia surgeon who was one of the most experienced in the nation at performing the challenging operation. It involved draining the heart of blood while the surgeon reconstructed the aorta, which in a newborn is thin as a string. Even in the best of hands, Joshua had only a 5 percent chance of surviving to the second surgery he would need six months later, several specialists told the Lemackses.
The initial surgery in 2003 was a success. But what the relieved parents didn't realize was that their financial life would be drastically impaired. They ended up with $70,000 in doctors' bills that their insurer, Anthem Blue Cross and Blue Shield of Virginia, refused to pay -- even though it had approved the couple's choice of surgeons. After the second surgery, they were responsible for $15,000 more. Debt collectors have been calling ever since.
"We'll be in collections forever," says Mark Lemacks, who runs his own office-supply business. The family's credit rating is so low that when they tried to buy a mattress recently, the store would not provide financing.
What ensnared the Lemackses was something called "balance billing," which occurs when doctors, hospitals or medical labs bill their patients the difference between what they charge and what insurers pay for their services. It comes into play when patients use providers who aren't part of their insurers' networks and thus haven't agreed to prearranged payment rates.
For patients who voluntarily chose an independent caregiver over in-network options, the additional bills, while often unwelcome, are generally considered justifiable. But consumer advocates want the government to protect people who unwittingly end up out of network because of an emergency, such as when they are taken to the nearest hospital after a car crash; or who get an insurer's permission to see a specialist out of network; or who were unknowingly treated by out-of-network doctors while at an in-network facility. The Lemackses fell into the last two of those three categories.
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