She had spent a week in pain on the floor, curled up in a ball and crying, willing herself to believe her stomach hurt because she had the flu and unwilling to go to the hospital, partly because she was uninsured. Then her mom took her to the hospital, and that was the beginning of a rough ride through the health care system.
It turned out that she had appendicitis – and ultimately the result would be not just an appendectomy, but also months of treatment, several hospitalizations, and piles of bills, and long-lasting regrets — multiple applications for financial aid, lunch hours lost to endless attempts to resolve insurance problems and an errant Social Security number that caused multiple rejected claims.
We will call her P.W. She’s a Philadelphia woman, now 26. We met her because entered her information into our PriceCheck form as part of the WHYY The Pulse partnership with ClearHealthCosts.com. We reached out for the story behind the data. She sent me her bills and told her story, to help others. At her request, I agreed not to use her full name in writing about her, because if I did, her health history would follow her around the web forever.
She was uninsured at the beginning of her journey, then was insured by Tricare (which covers military personnel) via her father, and then finally covered by Aetna through work. So her switching coverage was a big issue.
It started with a stomachache
On March 8 of last year, she said: “I started to have a stomachache. I woke up later that evening and it was excruciating. In the center of my stomach, a horrible pain. I never thought of it as appendicitis, I thought of it as the flu.”
She was uninsured, she said, which factored into her decision to wait it out for almost a week before she went to the emergency room.
The hospital she went to, Barnes-Kasson in Susquehannah, Pa., decided to treat her initially for an eating disorder. She has always been petite, she said, weighing 100 pounds, but had dropped to 92 pounds. The early diagnosis was an eating disorder, but it then changed after a new doctor arrived the next morning.
“I went through a series of CT scans,” she said, but the hospital said its results weren’t clear enough, so she was transferred to another hospital, Robert Packer, in Sayre, Pa., where she stayed from March 15-17.
Ultimately, she said the doctors at Robert Packer decided that appendicitis was the correct diagnosis, and that “My appendix had started to leak toxins into my body.” They decided to put drains in her abdomen. She was released after a two-day stay, with the drains still in, where they remained for a little over a week. When she returned to Robert Packer for a follow-up, she said, “They determined the appendix had exploded, that there was nothing left, and recommended I not have surgery.”
She went home and – yes – filled out an application for insurance. She was eligible for Tricare under her father’s plan, she said, because she was under 26 and did not have insurance or access to insurance via work. She had the Tricare application before she got sick, but never filled it out completely. “I had never been sick,” she explained, adding that she now regrets that decision.
She went back to work, but a month later, she said, she started feeling sick again. She went to the emergency room at a different hospital, Roxborough Memorial in Philadelphia, after work on April 24, and explained the situation.
“They did a cat scan and said my appendix was very much intact,” she said. “They rushed me into emergency surgery at midnight and took it out. That was Friday, and I went back to work on Monday.”
One might hope that the story would end here, but she was not so lucky.
She began having pain in her stomach again. After a couple more visits to the emergency room, she ultimately underwent an endoscopy in June, to see if she had an ulcer or gastritis. “It turned out my stomach was inflamed,” she said. She had had an NG tube, and there were lasting aftereffects. She ultimately went on “a bunch of medications” for that, and eventually weaned herself off of them.
And then, the bills came
“I had bills totaling about $70,000 or $80,000,” she said.
At Barnes-Kasson, she had been seen initially by a nurse who knew her family, and who knew she was uninsured. That nurse made sure she was told how to apply for financial aid. She also applied for financial aid at the second hospital. At the same time, she was given an application for state financial aid, she said.
The two hospitals’ paperwork and applications were fairly transparent and quick, she said.
“Barnes Kasson was the first hospital I visited. My original bill was for $8,225 and was reduced by 40%,” she said, to a little over $5,000. “I’m currently paying a minimum of $100/month towards the remaining balance.
“Robert Packer was the second hospital I visited and my bills were reduced by 60% after filling out their financial assistance application. Because my bills are split between Robert Packer Hospital & the Guthrie Clinic at Robert Packer hospital, I receive two separate bills each month. The financial assistance was applied to the hospital and the clinic bills. Collectively I pay a minimum of $105/month towards my remaining balances.”
At Robert Packer, she said, the financial aid request dropped her bill from $16,098 to $7,253.55, and the associated clinic dropped her bill from $3,032 to $1,331.35.
At Roxborough Memorial, when she was covered by TriCare, her bill was $10,912.49. Her responsibility was $212.79.
When she went for the endoscopy, under Aetna coverage, “I was charged two times — $1,500 (member rate reduced to $761. My plan paid $684.90 and I paid $76.10) and $650 (member rate reduced to $332. My plan paid $298.80 and I paid $33.20). So, in total I paid $109.30. Both charges are listed as code 43239, but I’m not sure why there are two charges instead of one.”
An application for state aid
She filled out paperwork for state financial aid, in the event that the others did not work. But ultimately, she said, the state request was denied and is still on appeal.
That application, she said, was for multiple types of benefit: welfare, food stamps, medical assistance and so on. Some pages you could omit, or some sections, if you were pregnant or married. “They wanted three months of pay statements,” she said. “How much money do I have in savings, checking, cash on hand, savings bonds, where was I living, how much was I paying for utilities, how much was I paying to get to work?” The application took two weeks, she said, and she had decided to do both the hospitals’ form and the state form in case one or the other did not work out.
After the state form was filed, she said, it was declined “because I hadn’t submitted a piece of paperwork” with a doctor certifying that she couldn’t work, even though at that point she was working. She called and explained, and was told it wasn’t necessary – and then she was informed that the application was denied formally because that form was absent.
After months and months, she said recently, she appealed the request, and has been told that the appeal is under consideration.
“If I am granted financial assistance through the state, then they would work directly with each hospital to either pay 1. the full balance I was originally charged, or 2. the remainder of my balance that is currently on each account,” she wrote in an email. “I’m not sure if that means I will end up owing nothing, owing a pro-rated amount, or if I’ll be reimbursed for what I’ve already paid through my payment plans.”
Confusion with a Social Security number
At Roxborough Memorial, she was covered by Tricare via her father. So while her responsibility for the charges turned out to be minimal, she learned that the hospital had confused her Social Security number with her father’s, and claims started coming in denied.
“It took me a few months to get that sorted out,” she said. “Each time I got a claim, I had to trace it back to the hospital and explain to them that the Social Security numbers were confused.”
More than a year after her ordeal began, she said, “I am still receiving bills I haven’t seen before. A few weeks ago, I received one for $200. I had to call the hospital to ask for an itemized bill, because I wasn’t sure what they were billing me for.”
How do hospitals treat financial aid?
Hospitals treat financial aid differently, and many people don’t know that this possibility exists.
At Robert Packer, Carolyn Handrick , marketing and communications director in the department of strategic planning and marketing, wrote in an email: “Our charity care policy can be found here https://www.guthrie.org/content/financial-assistance. We have signage throughout our facilities on our program and offer counselors to walk patients through every part of the process.
“We do not know how many of our patients are eligible for the financial aid as we would need detailed financial information from all patients to determine eligibility. Our patients that are un or under insured work with a financial counselor to determine eligibility for assistance and we will also work with them and create a payment plan.”
At Barnes-Kasson, Sara Adornato, executive director of the hospital, wrote in an email:
“We work with our patients in a variety of ways to assist them with managing their health care accounts. We have a robust financial assistance policy that our social service and billing department are able to discuss and assist patients with. We also provide application assistance for insurance products, including medical assistance and other government programs.
“Our financial assistance policy is available by request in registration, social service, and billing. The assistance policy is also distributed throughout the hospital in areas like the main lobby, emergency department, and physician clinics.
“Our financial assistance application is located online at www.barnes-kasson.org. We base assistance guidelines on individual income level and federal poverty guidelines.”
I asked both of them to tell us cash or self-pay prices for several of the tests that were done on P.W. We know from our research that often a cash or self-pay price is significantly lower than the charged price, and significantly lower than even a reduced rate granted through a financial aid program.
Neither hospital would tell us their cash rates, though I asked repeatedly. As we have learned, if you ask in advance for a cash or self-pay rate, you might get a break. If not, and if you get a bill, you’re in the position P.W. was: figure it out after the fact.
What you can do to protect yourself
What lessons did she learn?
- First, have insurance. P.W. said she didn’t think she needed insurance, because she had never been sick, and “I was young and healthy.” Now, months later, she looks back on that choice with regret.
- “Definitely, talk to the hospitals’ financial aid offices,” she said. “The hospitals had them, and they were extremely helpful and extremely nice.” For the Pennsylvania state aid, it was quite different. “If somebody is taking that route, I don’t know what advice to give, other than that you’re going to need to be an extremely patient person.”
- Keep open communications with the provider. “A lot of my bills were nearing collections, and I was waiting for aid to come through, so it was important to keep in touch with them and say “I am working on this. Can you please wait a few days until I get through this?”
- Set up a payment plan. “As long as you can pay something, your bills will stay current, and you won’t go to collection.”
- She learned that medical bills do not accrue interest. Because she is still paying off student loans, which do accrue interest, she found that to be “a huge relief.”
Finally, she said, the entire experience made her think in a different way about the health care system.
“I went to college and graduated with honors, and I was struggling with this,” she said. “I often thought about people who are dealing with this who are not as fortunate as me, and I can’t imagine the struggle they go through.”
(Update: P.W. wrote later: “Surprisingly enough, I actually ended up back in the ER a couple of weeks ago and we’ve finally solved my stomach pain mystery — it had been ovarian cysts. Took me two visits to the ER and a bunch of exams for them to pinpoint it this time around. So, I’ll be getting another slew of bills at some point in time. Thankfully I still have my Aetna coverage, so I expect to pay under $1000 for everything. I was given a prescription for birth control to stop ovulation and hopefully prevent the cysts from occurring again. At least we finally figured it out (only took a year and several ER visits…). C’est la vie.”