On Christmas Day in the Watiki Indoor Water Park, Hans Wirt was found to follow his son the stairs to the water slides.
Wirt’s breathing became more difficult when they returned to the nearby hotel where she and Wirt’s girlfriend stayed during a visit to the family in Rapid City, South Dakota.
Then he became nauseous and pale. Wirt thought that the cause might have changed between his house in Deltona, Florida – 33 feet above sea level – and Rapid City, on the edge of the Black Hills. But his 12-year-old son was worried and called for an ambulance.
“I could see from the look in his eyes that there was a little more about this,” said Wirt. “So I can thank my son a bit for saving my life.”
It turned out that the 62-year-old had a heart attack. A ‘worthless Christmas gift’, said Wirt.
Medici stabilized before they brought him to Monument Health – the only hospital in Rapid City with a first aid – where he was treated for two days.
Then the bill came.
The medical procedure
Paramedics used a defibrillator to restore a normal heart rhythm. Doctors in the hospital gave various medicines, used an electrocardiographer and other diagnostic and monitoring devices and caught stents in his arteries to improve blood flow to his heart.
The last bill
$ 95,523.73, including $ 32,998.90 for medical supplies, usually related to the stents, and $ 28,879 for treatment in a laboratory laboratory. After non -specific hospital adjustments from the account, WIRT $ 77,574.44 owed.
The invoicing problem: Medicaid about state lines
Wirt is covered by Florida’s Medicaid program via Sunshine Health, a managed care plan. But the South Dakota hospital refused to submit the bill to its Medicaid plan outside the State, instead to send to Wirt and eventually threatened to send the debt to a collection body.
Medicaid, the government’s health insurance program, mainly for people with a low income and people with disabilities, is jointly financed by the federal government and states. States are responsible for the management of Medicaid and most contract with private insurance companies such as Sunshine Health.
Federal Says that State Medicaid programs in emergencies in an emergency situations outside the state must reimburse hospitals for the care of beneficiaries.
Many hospitals bills outside the state of Medicaid plans in such situations. If they don’t do that, they run the risk of not being reimbursed at all, because Medicaid recipients probably cannot afford major accounts, said Katy Debriere, who was legal director of the Florida Health Justice Project when she spoke with KFF Health News in April.
But there is no federal law that requires them to do this, she said.
Federal Court Opinions to have noted that hospitals are not obliged to invoice Medicaid for each individual beneficiary they treat, even if they generally accept Medicaid.
Monument Health did not offer Wirt’s insurance because the hospital is not registered as a care provider at Medicaid in Florida, said hospital spokesperson Stephany Chalberg. She told KFF Health News that Monument Bills Medicaid only plans in South Dakota and four adjacent states: Wyoming, Montana, Nebraska and Minnesota.
The website of the hospital says Medicaid patients who are not registered in one of those states “are responsible for any costs.”
“Because of the important login requirements of our several hospitals and hundreds of doctors, we are not taking all states,” wrote a hospital representative in a message to Wirt.
According to the Medicaid website of FloridaOut-of-state providers who have treated one of the registered persons must submit five documents to invoice the program, including a request of six pages, a copy of the provider’s license and a claim form.
The process is different in every state, and many Medicaid programs reimburse out-of-state providers at lower rates than in the state, according to The Medicaid and Chip Payment and Access Commission, a federal agency that advises the congress.
Register barriers for provider ‘beneficiaries in an untenable situation, so that they do not have access to the coverage on which they have legal rights, “said Chalberg.
Wirt decided to submit his bill to his Medicaid plan. But he said that Sunshine Health told him that it can only process bills that have been received directly from providers.
Elizabeth Boyd, a spokesperson for Sunshine Health, told KFF Health News that his staff contacted the hospital on behalf of Wirt. She did not respond when he was asked why the plan cannot process bills that have been submitted by patients or what else it could have done to help Wirt.
The resolution
A few days after KFF Health News officials at Monument Health for this story e -mailed, Wirt noted that his balance due fell from more than $ 77,000 to $ 0.
Chalberg told KFF Health News that Monument Health Wirt’s account has treated through his charity care program. She said that “suitable patients” are told about the program and that “before an account is sent to collections, it is evaluated to determine whether the patient can be eligible for our financial assistance policy.”
To maintain tax-free status, non-profit hospitals Must have programs This offers free or discounts on patients who cannot pay their bills.
But Wirt said that when he first contacted Monument Health after receiving his account and said he could not afford to pay for it, officials did not mention the program. He said they did not share resources when he asked if there were outdoor groups who could help him pay the bill. Wirt said that hospital officials just recommended to set up a payment plan, but the monthly bills were still too high for him to afford it. “There is a reason why I am on Medicaid,” said Wirt. “It is just outside of me how they can expect someone who had Medicaid, think of that kind of money. It is unrealistic.”
The collection meals
Sarah Somers, legal director of the National Health Law Program, said that the different “Cogs in the Medicaid System” did not work correctly in the situation of Wirt. “Nobody has practiced enough to simply smooth the way for this person.”
States are responsible for managing Medicaid and are therefore the most important “COG,” Somers said. She said that Medicaid-Managed-Care companies should also intervene.
Somers and Debriere said that Medicaid receivers who receive accounts that they do not think should submit a complaint to the medicaid program of their state and, if they have one, their managed care plan. They can also ask if there is a Medicaid or Managed Care Caswerker who can argue on their behalf.
The lawyers said that patients should also contact a clinic for legal aid or a consumer protection company that specializes in medical debts. Debriere said that these organizations can help in submitting complaints and communicating with the hospital.
Debriere said that if she had helped Wirt, she would immediately have sent a letter to Monument Health to order it to stop invoicing and register with Florida Medicaid to submit his account or to offer him charity.
Wirt said that the doctors who treated him and the medical care he received at Monument Health were excellent. He said he spoke about the hospital’s invoicing practices because he does not want others to have the same experience.
“When I get sick and get a heart attack, I have to be sure that I now do that here in Florida instead of another state,” he joked.
Bill of the Month is a crowdsourced investigation by KFF Health News And The Washington Post’s Well+Being This dissects and explains medical accounts. Since 2018, this series has helped many patients and readers to reduce their medical accounts, and it has been cited in Statehouses, in Capitol and the White House. Do you have a confusing or shameful medical account that you want to share? Tell us about it!
#medicaid #patient #heart #attack #traveling #owed #KFF #Health #News