When Susan Gillen’s son Matthew was rushed to the intensive care unit after an accident at a trampoline park, she didn’t know she needed to act as a bouncer at his hospital room door.
The people she needed to keep out weren’t strangers or scammers, though. They were medical personnel not contracted with her insurance company.
When her son arrived at Mercy San Juan Hospital in Carmichael, California, the people who checked him in accepted Gillen’s Blue Shield insurance plan. But unbeknownst to her, that didn’t mean everyone who treated her son was automatically covered.
“You don’t think about this,” Gillen told Healthline. “All you’re worried about is if your kid is going to live.”
Matthew would be fine. But after his injury in July 2014, Gillen found out there were plenty more headaches to come.
“Honestly, the whole thing is a mess and I see it as fraudulent,” she said.
The Doctor Is in but Is Also ‘Out’
First, Gillen says the hospital demanded she pay $6,250 before they would treat her son.
“I told them to send me a bill,” she said.
Then, in January, she received a bill for $721 from Acute Care Surgery, an Ohio company.
“I had no idea what it was for,” Gillen said. “I assumed it was for my son’s injury.”
After calling the company and prodding them for information, Gillen learned the bill was for the doctor who had treated Matthew in the emergency room.
While Mercy San Juan was part of her insurance network, the attending doctor that day was not contracted with them, so the bill wasn’t covered by her insurance or billed as emergency care.
“How could this be? I didn’t pick my doctor. The hospital should only have doctors that accept the same insurance as they do,” Gillen said. “It’s absolutely not my fault. Most people would have given up and paid it. I could just pay my bill, but I’m mad.”
Gillen fought it, along with a separate $1,400 bill that went to collections that she said she never received in the first place.
“The whole thing is a game, as far as I see it,” she said. “The consumer is bullied into paying these amounts, whether they’re correct or not, in fear of collections.”
Mercy San Juan officials said in an email to Healthline, “Our top priority is the care and safety of our patients. We respect the privacy of our patients and legally cannot discuss the specifics of their care. We believe this is an issue between the patient and the insurer.”
Consumer Advocate Groups Join the Fight
Gillen’s case is not unique.
Since the implementation of the Affordable Care Act (ACA), cases like hers are on the rise. The systemic problems with surprise hospital bills have gained the attention of groups like Consumers Union that want loopholes closed to prevent doctors, specialists, labs, and hospitals from pitting patients against their insurance companies when they’ve played by the rules.
In California, Consumer Watchdog and others have sued Blue Shield in particular for misleading its customers about the breadth of coverage their new ACA plans offered.
Today, California’s Department of Managed Health Care announced a settlement with Blue Shield on the matter. Not all of the consumer advocates are pleased, however. In a press release, Consumer Watchdog said the settlement “does not ensure that Blue Shield customers are fully reimbursed for the costs they incurred as a result of the company’s misrepresentations regarding its network of doctors and hospitals.”
The state reached a similar settlement with Anthem Blue Cross.
Liz Helms, president and CEO of the California Chronic Care Coalition (CCCC), has herself been socked with an unexpected bill for healthcare she had presumed was covered. She has become a patient rights advocate because she doesn’t want anyone to have to go through the same thing.
The CCCC launched MyPatientRights.org in July, a site dedicated to helping people navigate this often exhausting and expensive process.
“It’s very confusing to a lot of people. What you don’t know is when you think you’ve paid your bills and then, out of left field, you’re hit with another one for hundreds of dollars that you shouldn’t have been billed for in the first place,” Helms told Healthline. “It’s a bigger problem than we realize. We don’t know how many people this is happening to.”
A Third of Patients Report Receiving Surprise Bills
According to a Consumer Reports survey, one-third of Americans report receiving a surprise medical bill within the past two years when their health insurance paid less than they expected.
Consumers Union, the consumer advocacy arm of Consumer Reports, is pushing to change these practices at the state level.
DeAnn Friedholm, director of health reform for Consumers Union, said avoiding these surprise bills can be tough enough when you can anticipate a doctor visit, but emergency situations make it even more difficult.
“For years we have heard horror stories from consumers hit with surprise medical bills following routine and emergency procedures,” she said in a press release. “Even if you go to a hospital in your network, the unfortunate truth is that there is no guarantee that all your treatment — whether it’s the radiologist, anesthesiologist, or lab work — will be treated as in-network, leaving patients owing thousands of dollars they never anticipated.”
Gillen’s story doesn’t have a happy ending. After about 12 hours on the phone and months of haggling with the hospital and her insurance company, the system finally got to her.
“I gave in and paid, but at least I put up a fight,” she said.
After today’s settlement, she might be able to seek reimbursement from Blue Shield. A lawsuit pending in a San Francisco Court will determine whether customers like Gillen are entitled to a refund for all of their out-of-pocket costs, or just a fraction.