Mark Gottlieb’s life changed instantly when another driver crashed into his car, damaging four vertebrae in his upper spine and smashing six teeth.
In the months after the crash in January 2019, Gottlieb had his teeth crowned and tried injections, chiropractic and physical therapy for debilitating neck pain. The treatments were all covered by his auto insurance.
As in 12 other states, New Jersey law requires drivers to purchase Personal Injury Protection (PIP) coverage in order to pay medical expenses. Gottlieb had the maximum: $ 250,000.
Unfortunately, Gottlieb’s pain continued. “Nothing worked. The only other thing was surgery,” he said.
Although he wanted his surgery to be done near his home, the staff at the Bergen Pain Management clinic where he was being cared for insisted that he go to the Hudson Regional Hospital in Secaucus. On April 3, 2020, Gottlieb underwent a complex fusion operation on the herniated discs in his cervical spine. He went home the same day.
His pain improved a little. Then came the bills.
The patient: Mark Gottlieb, 59, a marketing consultant in Little Ferry, New Jersey, covered $ 250,000 in medical expenses through his Geico auto insurance. He also has Aetna health insurance which is secondary.
Medical service: Anterior cervical discectomy and fusion, a type of neck surgery to replace damaged discs with bone grafts or implants to stabilize the spine.
Service provider: Hudson Regional Hospital, a stand-alone, for-profit facility in Secaucus, New Jersey; and Bergen Pain Management in Paramus, New Jersey.
Entire invoice: Together, the hospital and surgeon Gottlieb billed more than $ 700,000. The hospital billed $ 445,995 for the operation, an amount that Geico reduced to $ 103,778. Bergen Pain Management billed the chief surgeon an additional $ 264,444. Based on a review, Geico reduced that value to $ 141,548. It paid $ 52,365 for it before Gottlieb’s health insurance ran out in its auto policy. Then it was up to his health insurance company or Gottlieb to take care of the rest.
What gives: When injuries are caused by car accidents, the primary responsibility of auto insurance is to negotiate and pay the insurance portion of medical bills. That creates a multitude of financial landmines for patients.
Gottlieb beat them all.
With the US’s high treatment fees, accident victims can easily exhaust the political limits of even generous personal injury coverage, leaving some of them vulnerable to large bills.
While auto insurers rarely complain that they overpaid a hospital or doctor, auto insurers “typically pay more for some of the same services” than health insurers, said Robert Passmore, vice president of the American Property Casualty Insurance Association . a trading group.
This is in part because auto insurers generally don’t have a broad network of medical providers willing to negotiate discounts on their billed fees, as do health insurers. Patients end up “outside the network”, subject to the list price charged by the provider.
Gottlieb said he checked with Geico prior to his surgery, but was told he had no information on networks. With around $ 190,000 remaining in his PIP fund at that point, he wasn’t too concerned. He said efforts to get estimates were unsuccessful.
Instead of network tariffs, auto insurers typically use other payment calculations. Some states set specific payments for fee plans. Not every medical billing code is listed, however, and in those cases they sometimes pay the provider’s bills.
In this case, that was a lot: Gottlieb’s hospital and surgery costs, even after Geico cut them, were about eight times what Medicare would have paid.
While Geico generally pays state-set rates (which are dramatically lower than those charged), Gottlieb’s bill included a number of billing codes that weren’t included in the state plan. For most of them, the insurer paid exactly what was charged. For example, Geico allowed the full $ 65,125 price the surgeon charged to remove a damaged disc and paid the hospital $ 39,195 for nine surgical screws.
By September, Gottlieb’s PIP fund expired after invoices from its various vendors were still in after the remaining $ 52,365 was paid to Bergen Pain Management, just before the $ 141,548 Geico recommended reimbursement to the surgeon .
The insurance company pays the bills as they are submitted, which is often not in the order in which they were treated.
“It appears that Bergen Pain Management is still entitled to the remainder of $ 89,183 from your litigation,” Geico wrote in a September letter to Gottlieb, adding that he could either take this balance to his health insurer or pay it himself .
When he presented the surgeon’s bill to Aetna, he found that neither the doctor nor the hospital were in his insurance network. He hadn’t checked before the surgery as he had never dreamed that outpatient surgery would exhaust car policy.
That means Aetna did not have a negotiated tariff with its providers, which could have lowered the fees dramatically.
Instead, Aetna said it would allow the surgeon to pay $ 4,051 off the network, according to an email to Gottlieb on Jan. 28. In a written statement to KHN, Aetna spokesman Ethan Slavin said the amount was based on Gottlieb’s terms of contract, which set doctors’ payments for off-network care at about 10% above Medicare rates.
Since he had not yet met his annual deductible outside the network, Gottlieb had to pay the $ 4,051 himself. He withdrew his request for payment for Aetna. With surgeons outside of the network often looking for patients to pay the balance of those bills, Gottlieb is waiting to see if Bergen Pain Management – for which $ 52,365 was already paid for surgery – will come after him.
Neither the Bergen Clinic nor the surgeon sent it in collections or sued for the amount. Neither of them responded to multiple emails and phone calls from KHN for comment.
In a written statement, Hudson Regional spokesman Ron Simoncini said the hospital had “collected the state-mandated fee,” where applicable, and where there was no such mandate, “the fees were reasonable.” No additional payment is requested.
Citing policyholder privacy, Geico declined to answer KHN’s questions, including how it determines what is paid.
Has the car insurer paid too much?
Geico had set an allowable reimbursement of $ 141,548 as the surgeon’s fee.
“That is an outrageously high surgeon fee for this type of operation,” said Dr. Eeric Truumees, professor at Dell Medical School at the University of Texas-Austin.
“I do a tremendous amount of complex cervical spine surgeries and have never charged so much for even complex surgeries that take 10 hours,” said Truumees, president of the North American Spine Society. He had no direct knowledge of Gottlieb’s case.
In total, Geico recommended and partially paid the hospital and surgeon $ 245,326 for the procedure.
In contrast, according to researchers at Rand Corp., who analyzed Gottlieb’s bills at the request of KHN and NPR, Medicare would have paid about $ 29,500 for the entire procedure, of which about $ 1,800 to the surgeon and the rest went to the hospital.
According to Barry Silver of Healthcare Horizons Consulting Group in Knoxville, Tennessee, the surgeon’s bill was also high compared to what private insurance companies typically pay. Silver compared Gottlieb’s bills to hundreds of similar claims from two transport companies that operate employer-based health insurance nationwide. The total amount Geico paid the hospital was what the employers paid and was actually below the two highest fees reported in its data. However, the maximum allowable fee in Silver’s database for the surgeon’s fee was $ 87,549, far less than Geico’s recommended $ 141,458.
Resolution: Gottlieb remains in the dark as to whether Bergen Pain Management will charge the remaining $ 89,000 for his bill.
Previously, Gottlieb sued the driver who had caused the accident – and won a substantial court settlement over “pain and suffering”. He wants to keep it for future medical needs.
He has filed numerous complaints about his bills with government regulators, lawmakers, and his insurers. Aetna sent his surgeon’s bill to the in-house Special Investigations Unit after his complaint.
“Based on our investigation, however, we have found that there is no further need for action,” said spokesman Slavin.
Take away: Most people are unaware that car insurance kicks in first after an accident and that it works very differently from health insurance. So you need to be careful how the policies are coordinated.
This is especially true if the accident requires major treatment.
If your car insurance has limited personal injury coverage, your medical bills may be included in your health insurance. When you sign up for non-urgent treatment – especially if it is extensive, such as B. an operation – it is important to make sure that the providers are on your health insurer’s network.
Some auto insurers have networks. Ask if this is the case for you.
Try to get emergency care estimates in writing and compare them to what you have left in your automatic insurance coverage.
“If it’s more than you have left, you may be able to negotiate with the hospital or doctor to lower the fees,” said Silver of Healthcare Horizons.
Bill of the Month is a crowdsourced study by KHN and NPR that breaks down and explains medical bills. Do you have an interesting medical bill that you would like to share with us? Tell us about it!
This article is reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a non-partisan health research organization not affiliated with Kaiser Permanente.