Resources: Articles

How I Did It: Reporting on surprise medical bills Date: 10/17/18

Chad Terhune

Kaiser Health News and NPR have been collaborating on a series called Bill of the Month – including a particularly powerful  piece by KHN’s Chad Terhune about an insured high school teacher hit with a $108,951 bill after a heart attack at age 44. In this How I Did It essay, Terhune gives many detailed and specific hints on how to identify, verify, and report on these bills. 

By Chad Terhune

As a veteran business reporter, not much surprises me any more when it comes to medical bills. Then I met Drew Calver.

The high school teacher in Austin, Texas, got a bill for $108,951 from the local hospital that treated him for a heart attack last year. That was an astonishing amount, particularly since he had good health coverage through his employer and his insurer had already paid the hospital nearly $56,000.

I wrote about Calver in August for the “Bill of the Month” series, a joint crowdsourced investigation by Kaiser Health News and NPR. The story immediately went viral and national and local news outlets rushed to interview Calver and his family.

Within hours of my story running, St. David’s Medical Center – owned by the HCA hospital chain – offered to waive nearly the entire $109,000 bill. By week’s end, the hospital cut the amount due even further and Calver paid $332 to put the stressful saga behind him.

Three weeks later, a bipartisan group of U.S. senators unveiled a proposal to combat surprise bills, citing Calver’s story and others like it as impetus for federal action.

The Bill of the Month series kicked off in February with a story by Fred Schulte about a $17,850 urine test. Last month, NPR’s Alison Kodjak chronicled a radiologist’s ATV crash and his air ambulance bill of $56,603.

I also highly recommend Sarah Kliff’s Vox series on hospital ER fees and billing, as well as the New York Times’ coverage of out-of-network billing by physician staffing firms.

The details and dollar amounts vary, but these stories are happening all across the country. They’re increasingly relevant as state and federal officials wrestle with how to protect consumers from bills that could bankrupt them. Once published, these stories tend to generate more ideas from readers and offer a launching pad into other areas of inquiry on the health beat.

Image: Kaiser Health News via Creative Commons

Here are some tips for covering surprise medical bills:

Finding people

For Bill of the Month, Kaiser Health News and NPR put out a call for submissions and made it easy for people to share their bills. Consider some outreach online or through social media.

This also can be the opportunity to build a bigger story around that anecdote you already have in your reporting notebook. Another place to check is the county court docket. Look for cases in which area hospitals are suing patients over unpaid bills. Is one hospital more aggressive than others are? Even a small-dollar case could yield an interesting story about unusual charges or collection tactics.

Patient advocates, legal aid attorneys and medical billing experts can be a big help providing context and recommending cases that are worth pursuing.

Paperwork first, please

After an initial interview with a consumer, my first priority is gathering the key documents as soon as possible. This lays the foundation for future reporting and will flag any potential problems early on.

Some consumers already have a thick folder full of paperwork, and they have taken meticulous notes of every call with billing clerks and call-center workers. God bless those folks. In other cases, you might be missing a lot of crucial information.

I prefer the consumer to ask for these records initially. It often goes faster that way, and they are certainly entitled to their own information. Any obstacles they encounter could be part of the story.

Start with the bill itself. Most doctor’s offices and hospitals will send a total amount due with very few details of how they arrived at that number. You want an itemized bill with a listing of each charge and the medical coding that went with it. Ask the consumer to request this if they haven’t already.

Give me an E-O-B

Next, I want to understand the person’s insurance coverage and how their insurer handled the billed charges. Those list prices are the starting point in the reimbursement game.

You want the explanation of benefits form, or EOB. Most consumers get these online or in the mail. There can be multiple copies over time as more information becomes available so find the most recent versions.

The EOB should show how much of the billed charges the insurer paid the medical providers, as well as give some explanation. It will describe what the patient is responsible for in terms of copays, coinsurance or deductibles. This is what the patient generally owes.

Trouble ensues when out-of-network physicians or hospitals aren’t satisfied with an insurance company’s partial payment of the billed charges. Providers may have some legitimate complaints about low reimbursements and you should hear them out.

However, in most cases, that doesn’t justify going after patients for the unpaid balance, known as balance billing, and putting consumers in the middle of this business dispute. For emergencies, in particular, consumers have little or no control over whether the care they receive is in or out of network.

The records will help determine the focus of the story. In some instances, the insurance company may be to blame for improperly denying a claim for medically necessary care. That could have triggered a massive bill to the patient from the hospital or doctors.

The patient may have visited an in-network hospital, but the anesthesiologist or surgeon who was involved doesn’t contract with the health plan. Their medical group or staffing firm may be demanding a significant sum.

Another key fork in the road is whether federal or state law applies to the person’s health coverage. Several states, such as New York, Illinois and California, have passed laws aimed at shielding consumers from surprise bills, so you want to know whether some legal protections may apply to your case.

About 60 percent of people with employer health benefits are in self-insured plans, which means employers pay claims out of their own funds. Federal law governs most of those plans, and at the moment there’s no recourse for those consumers who get balance billed, no matter what state they live in. That’s a giant loophole that the proposed federal legislation seeks to close.

State rules on surprise billing tend to apply to coverage offered by smaller employers and policies purchased by individuals on the Affordable Care Act’s exchanges.

Consumers rarely know whether they are in a self-insured plan governed by federal law or a plan subject to state regulation. Their insurance card probably won’t help either. You’ll need to ask the health plan, the employer’s benefits office and possibly the state insurance department.

Breaking down the bill

Next, I want to get some outside analysis of the bills and the insurance company’s explanation of benefits. What’s a reasonable reimbursement for this hospitalization or treatment in a particular market? Are any of the billed charges excessive or unusual? What would Medicare generally pay for this service?

Before sharing any documents, remember to redact any personal information like names, addresses and Social Security numbers. The good news is there are a growing number of firms and websites available to help journalists scrutinize medical bills and find cost estimates.

For my story, I initially interviewed executives at WellRithms and Healthcare Bluebook. Both were able to analyze the bills within a day or two and offer immediate feedback. Other options include the Health Care Cost Institute, FAIR Health and Amino.

This round of interviews revealed that I needed to do more digging into the hospital’s charges for Calver’s heart stents. From there, I discovered a treasure trove of pricing data on medical devices collected by the ECRI Institute, a nonprofit research firm.

To broaden the scope of the story, reach out to some experts who study surprise billing. Loren Adler of the Brookings Institution and Yale University’s Zack Cooper have done significant research in this area.

There’s a lot of good polling available on the prevalence of surprise billing and consumers’ concerns about being exposed to unforeseen medical expenses, even with solid insurance coverage.

Sooner, the better

Don’t wait too long to reach out to the hospital, physician practice, insurance company and other involved parties. There’s a tendency to put off those calls because reporters worry that their involvement can begin to alter the story.

Faced with media scrutiny, a hospital may suddenly cancel out the bill or an insurer will overturn its denial of a claim. Whatever happens, it becomes another part of the story near the end of the chronology. Readers deserve to know that action was taken only after you raised questions.

A last-minute write off or change of heart doesn’t take away from the bills that were sent for months on end, the pleas for help that went unanswered and the anxiety this all caused for the family involved. It’s still a story.

One reason to avoid delay here is so you get the patient consent forms signed and delivered. This will allow medical providers and companies to discuss the specifics of the patient’s case without fear of violating the privacy restrictions under HIPAA (Health Insurance Portability and Accountability Act). I find it goes smoother if I get the necessary forms from the PR staff, ask the consumer to review and sign them and then return them so there’s no unnecessary delay.

Throughout the reporting, don’t hesitate to call back the consumer and other sources to clarify information or gather more details. This will improve the story and ensure accuracy. Be prepared to do a quick follow-up if the consumer’s situation is resolved or regulators and legislators get involved. More consumers may contact you with similar experiences to share.

I wrote about the drastic reduction in Calver’s bill and included an internal memo from the health system’s chief executive that was shared with me by a hospital employee. In his memo, the CEO defended the hospital’s charges and expressed regret at being unable to avoid media scrutiny.

“This is not the type of coverage any of us want,” C. David Huffstutler wrote in his Aug. 27 memo. "We had a number of circumstances that made it difficult to neutralize the coverage — a monthly news segment that seeks to empower patients to challenge their medical bills ... and, a compelling patient story."

Indeed, these patient stories can be powerful. They represent one more way journalists can fulfill their watchdog role and hold important institutions to account on behalf of consumers.

Chad Terhune (@chadterhune) is a senior correspondent at Kaiser Health News. He spent four years covering the business of health care for the Los Angeles Times. Before the Times, he was an award-winning reporter for The Wall Street Journal and Businessweek.