By Jordan Rau, Kaiser Health News Sarah Witter had to pay for a second surgery to repair her broken leg after a metal plate installed during the first surgery broke. On Friday, she got a more welcome break — a $6,358.26 refund from the hospital and her insurer.
Witter’s experience was the subject of December’s KHN-NPR “Bill of the Month” feature. She and her insurer, Aetna, had racked up $99,159 in bills from a Rutland, Vt., hospital and various medical providers after she fractured her leg in a skiing accident last February.
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A surgeon at Rutland Regional Medical Center implanted two metal plates, attached to her leg bones to help them heal. Less than four months later, one of these plates broke, requiring her to have a second surgery to replace the plate. Witter, who is 63, ended up paying $18,442, mostly to the hospital, for her portion of the total cost for all her care from the hospital, doctors, emergency services and physical therapists.
After KHN contacted Aetna about these costs, the insurer noticed that Rutland Regional had billed Witter for the difference between what it charged for its services and what Aetna considered an appropriate price for the first surgery. Those additional charges are known as “balance bills” and occur when a medical provider is not in the insurer’s network and has no contract with the insurer. Rutland Regional is not in Aetna’s network. In our original story, KHN had calculated $7,410 in balance bills.
Aetna said it contacted the hospital and negotiated a compromise in which the insurer paid the hospital nearly $3,800 and the hospital waived the remainder of the charges to Witter that Aetna considered unreasonably high.
“As part of her benefits plan, Sarah’s claims in question went through a patient advocacy process that allows us to negotiate with the provider on the member’s behalf to resolve any balance billing issues,” a spokesman wrote.
Aetna said it will negotiate disputed bills for any of its customers who request assistance, and also help schedule appointments, get services authorized and deal with other non-medical complications. However, an Aetna spokesman wrote, “we weren’t fully aware of all of the bills that Sarah had received before we received them from you/her.”
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On Friday, Rutland Regional again declined to discuss Witter’s account. Witter said she learned of the refund during a meeting, at Rutland Regional’s invitation, with a hospital financial administrator.
“They went through all the costs and I guess treated it [the first surgery] more like it was a hospital service that was within my contract,” she said. The administrator told her they had “reprocessed” the charges from her second surgery, but that her portion of the bill did not change, she said.
“It’s good news — who doesn’t like getting money back? But I don’t quite understand,” she said. “If it’s that easy for them to reprocess this billing to get me this, then it’s obvious that everything is really arbitrary.”
One difference between the two surgeries was the first one was conducted during a crisis after Witter was admitted to the hospital through the emergency room. Balance bills in those circumstances are the most difficult to justify because patients with injuries that require immediate care, such as a heart attack or car accident, are usually taken to the closest medical facility. Patients are not in a position to figure out where the closest in-network alternative is.
Neither Witter’s hospital nor her insurer budged on her underlying complaint: that she shouldn’t have had to pay for second surgery, which cost $43,208, because one of the plates — known as a bone fixation device and manufactured by Johnson & Johnson’s DePuy Synthes — broke.
Device manufacturers generally do not offer warranties for hardware devices once they have been implanted, saying that device failure can be due to a variety of factors beyond the company’s control. Those include poor implantation by the surgeon; bones that fail to heal and subject the device to unremitting strain, causing metal fatigue; or patients who apply too much weight or movement on the bone despite instructions not to.
DePuy, which declined to comment for this story, earlier said that device failures occur in “rare circumstances.” In its instructions for surgeons, DePuy noted: “It is important to note that these implants may break at any time if they are subjected to sufficient stresses.”
Witter said her surgeon was present at her meeting at Rutland Regional and told her that “the fact the bone hadn’t completely healed yet was part of the problem.” She said she has not been able to find a contact for the device manufacturer so she can complain about it breaking.
Even after she receives her refund next week, Witter still will have paid $12,084 for her broken limb. Asked her advice for other patients dealing with bills they consider excessive, she said: “Don’t break your leg.”
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From:: KHN Insurance