Affording medical care continues to be among the top health concerns facing Americans today. In the seventh year of KFF Health News’ “Bill of the Month” series, readers shared their most perplexing, vexing, and downright expensive medical bills and asked us to help figure out what happened. Our reporters analyzed $800,000 in charges, including more than $370,000 owed by 12 patients and their families.

This year, we met several patients who fought back.

Caitlyn Mai of Oklahoma City was preapproved for a hearing implant, yet for months she was still hounded by notices saying she owed $139,000.

To resolve the problem, Mai estimated she spent at least 12 hours on the phone doing tasks that typically fall to someone working in a hospital billing department. “I said, ‘I’ve done your job for you — now can you please take it from here?’”

Jamie Holmes of Lynden, Washington, refused to buckle when a surgery center tried to make her pay for two operations after she underwent only one — even after a collection agency sued her.

She showed up at two court hearings and explained her side. “I just got stonewalled so badly. They treated me like an idiot,” she told “Bill of the Month.” “If they’re going to be petty to me, I’m willing to be petty right back.”

As always, we reached out to medical billing experts for their takeaways and learned that these patients had the right idea.

“You know what? It pays to be stubborn in situations like this,” said Berneta Haynes, a senior attorney for the National Consumer Law Center who reviewed Holmes’ bill for KFF Health News.

From our curious, tireless “Bill of the Month” team, happy holidays — and, when in doubt, don’t pay the bill.

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).

The goal was to understand how the U.S. health care system generates outsize bills and to empower patients with strategies to avoid them. We asked readers and listeners to submit their bills — and they kept coming. “Bill of the Month” has received nearly 10,000 submissions, each a picture of a health system’s dysfunction and the financial burden it places on the patients.

Since 2018, we have analyzed bills totaling almost $6.3 million — including nearly $2.8 million that patients were expected to pay out-of-pocket.

Cited at statehouses and the U.S. Capitol, the series has led to changes in health policy. Two patients featured by “Bill of the Month” were invited to the White House in 2019 to discuss their surprise bills: Elizabeth Moreno’s $18,000 urine test and Drew Calver’s $109,000 heart attack. In 2020, Congress passed the federal No Surprises Act, shielding patients from most out-of-network bills in emergencies, among other protections.

Last year, the Biden administration announced plans to lower health costs that included targeting a loophole that allowed health providers to evade the surprise-billing law — a problem first identified by “Bill of the Month.”

Many patients submitted high prescription drug bills. In treatment for prostate cancer, Paul Hinds was billed nearly $74,000 for two shots of an old drug called Lupron, which can cost just a couple of hundred dollars overseas.

Now, the federal government has identified Lupron as one of the medicines that has seen its price rise faster than inflation — meaning its manufacturer owes rebates to Medicare under President Joe Biden’s 2022 Inflation Reduction Act.

The law also authorized the Biden administration to begin negotiating the price of specified drugs for Medicare patients, who now benefit from a cap on the price of insulin.

“Bill of the Month” has helped many patients and readers get their medical bills reduced or forgiven. Roughly 1 in 3 bills were resolved for patients by the time their features were published.

Bisi Bennett was charged $550,124 after her son was in a neonatal intensive care unit for nearly two months — despite having insurance. In a recent interview, nearly three years after her bill was investigated by “Bill of the Month,” she said she initially thought resolving the bill would be simple.

“Nine months later, 10 months later, I was still fighting with them,” she said. “I really did feel like it kind of robbed me a little bit of the joy of the first months of motherhood.”

Once a reporter started making calls, Bennett said, “they somehow miraculously figured out how to bill the right parties and get it sorted out.”

But relief from individual bills is one thing; patients say bigger solutions are needed for what ails our health system. “This isn’t just about my bill,” Calver said in 2018, when his nearly $109,000 bill was reduced to $332 after being investigated by “Bill of the Month.” “I don’t feel any consumer should have to go through this.”

The Takeaways

The “Bill of the Month” mantra is: If the bill is unexpected or seems off, don’t write the check. Each installment offered directions to navigate health care’s rough financial waters.

Some bills memorably illustrated the absurdity of a system that turns ordinary mishaps into extraordinary revenues. After 3-year-old Lucy Branson got a Polly Pocket doll shoe stuck up her nose, her family was charged about $2,659 for an ER doctor to fish it out with forceps — essentially a long pair of tweezers.

Here are some of the most important lessons — and some patients who offered their experiences to teach them:

• Before scheduling services, ask if a provider is in-network — then read waiting-room forms closely. Feeling sick and unable to rule out covid-19, Elyse Greenblatt booked a telemedicine appointment. But her in-network doctor’s office paired her with an out-of-network doctor — and said she’d signed a consent form. Her insurer declined to pay a penny of the $660 bill.
• Ask for an itemized bill, and question charges that don’t make sense. Eloise Reynolds paid her husband’s final hospital bill after he died from colon cancer. A year later, she received a second bill for his stay. Reynolds requested an itemized bill — and using a yardstick as a straight edge, went line by line to sort out why the hospital said she owed nearly $1,100 more. The balance was eventually deemed a “clerical error” and eliminated.
• Beware ambulances. The landmark No Surprises Act protected patients from many surprise bills in emergencies, but it does not apply to ground ambulances, which are unlikely to contract with insurance and thus might bill willy-nilly. When Peggy Dula was in a car accident, she was picked up by a fire department ambulance that was out-of-network. Though she wasn’t terribly hurt, her ride generated a $3,606 charge, and — after her insurance paid an amount it deemed “reasonable and customary” — she owed around $2,711.
• Location Matters, Part 1: Any intervention or test done in a hospital is likely to cost more than elsewhere. After her first prenatal checkup, Reesha Ahmed had her blood drawn for routine tests by a hospital lab. The bill: $9,520. Ahmed, who had a miscarriage, owed $2,390.
• Location Matters, Part 2: Doctors’ offices can be reclassified as hospital facilities if they’re purchased by a hospital system — and then add on hospital facility fees. Kyunghee Lee, a retired seamstress, went to her doctor for regular injections to treat arthritis for a copay of about $30. Then the office moved one floor up — and her bill changed: Newly designated as taking place in “a hospital-based setting,” one visit was billed at $1,394, including a facility fee listed as “operating room services.” Lee owed about $355.
• Location Matters, Part 3: Some free-standing emergency rooms may look like urgent care centers but come with ER charges. Tieqiao Zhang believed he was visiting urgent care when he sought treatment for a kidney stone at a facility called an “urgent care emergency center.” He went there twice and, both times, was given IV hydration and painkillers, then sent home. The visits yielded a bill of $19,543, including a $500 copay for each visit to what was actually a free-standing ER.
• Sometimes it can pay to pay cash. Dani Yuengling needed a breast biopsy after a concerning mammogram. The hospital’s online price calculator listed a price of about $1,400 for those without insurance. So she was shocked to see her own bill, paid using insurance, was almost $18,000, of which she owed more than $5,000 under the terms of her high-deductible plan.

The Resolution

Some bills signal that there’s more to be done to tame a health care industry in which seemingly everything can be billable. Mansi Bhatt took her toddler, Martand, to the emergency room for a burn on his hand, but after a long wait, they left before being seen by a doctor. Just checking in yielded an $859 bill, which the family had to pay since they hadn’t met their deductible.

Even new protections, such as those for air-ambulance bills, have problems. Amari Vaca was 3 months old and recovering from open-heart surgery when he contracted the life-threatening virus RSV, or respiratory syncytial virus. When doctors said he needed specialized care, he was transferred by air ambulance to a different hospital. The family’s insurer denied the claim, determining the flight wasn’t medically necessary, and the hospital declined to file an appeal. Vaca’s mother, Sara England, notified KFF Health News in October that their final appeal was denied. They owe $97,000.

And old bills die hard. When “Bill of the Month” reconnected with Phil Gaimon this fall, he said he had called his providers recently to check his outstanding balance — and learned it was, at last, zero.

Gaimon was competing to qualify for the Olympics when he was in a bicycle crash and wound up with bills topping $200,000. “I think I was home from the hospital in 10 days, riding my bike again in a month,” he said in an interview. “And then the bills … three years.”

While our “Bill of the Month” partnership with NPR is sunsetting, the “Bill of the Month” series will continue as KFF Health News investigates your medical bills. Keep them coming! And watch for future stories in The Washington Post’s Well+Being.

Elisabeth Rosenthal is a senior contributing editor for KFF Health News and the creator of “Bill of the Month.”

Emily Siner reported the audio story.

Henry Larweh and Molly Castle Work of KFF Health News contributed reporting for this article.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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The Chicago health care consultant contacted his physician at Northwestern Medicine, who referred him for a diagnostic colonoscopy, at least partly because Contos, 45, has a family history of colon issues.

“I work out a lot,” he said. “But my partner said this isn’t normal. My primary care physician said, ‘Given your family history, let’s get you in.’”

Northwestern Memorial Hospital asked him to prepay $1,000 out-of-pocket, and he underwent the procedure in June.

Then the bill came.

The Medical Procedure

Colonoscopies are performed in the United States more than 15 million times a year. Rates of colorectal cancer are on the rise, particularly among younger people.

The procedure, which is also a recommended screening for people 45 or older, involves examining the large intestine using a tube with a video camera that can also collect tissue samples.

It typically takes less than one hour, with another hour spent taking the patient’s history, administering anesthesia, and monitoring their recovery, said Glenn Littenberg, a physician who recently chaired the reimbursement committee of the American Society of Gastrointestinal Endoscopy.

According to Contos’ medical record, the gastroenterologist who performed his colonoscopy described it as “not difficult.” He biopsied and removed small growths called polyps from two spots and identified large internal hemorrhoids, which are swollen veins.

The biopsy samples were sent to pathology for testing and found to be precancerous. But the gastroenterologist reported finding no evidence of cancer, and after reviewing the pathology report, he concluded hemorrhoids were the likely cause of the bleeding.

The Final Bill

The hospital charged a total of $19,206 for the procedure, including physician fees. The insurer negotiated the price to $5,816 and paid $1,979, leaving a patient share of $4,047. (It wasn’t clear why the payments added up to slightly more than the negotiated price.) After Contos had paid $1,000 up front, plus $1,381 right after the procedure, the hospital said he still owed $1,666.

The Billing Problem: Colonoscopies That Find Polyps Cost More

Contos was shocked and angry when he received his itemized bill. “I said, ‘I don’t understand this.’ Then I started to research the cost.”

He asked the hospital what it charges for a diagnostic colonoscopy and was told he’d been sent a cost estimate through his online patient portal prior to the procedure.

The estimate, which took his deductible of $3,200 into account, listed a total price of $7,203, with an out-of-pocket bill of $2,381. He asked Northwestern why the charges were nearly three times the estimate and why his out-of-pocket share was nearly twice as high.

One big reason was revealed in an explanation of benefits (EOB) statement from Contos’ insurance company, Aetna: Northwestern had charged for two colonoscopies, at $5,466 each. And there were two fees for the gastroenterologist — $1,535 and $1,291.

The first procedure was listed as “colonoscopy and biopsy,” while the second was listed as “colonoscopy w/lesion removal.” Aetna’s negotiated member rate reduced the first $5,466 hospital charge to $3,425, while the charge for the second procedure was lowered to $1,787 — $1,638 less.

Neither the bill nor the EOB explained why there was a second procedure listed, at a reduced price.

After examining Contos’ bill, Littenberg said it’s standard for providers to bill for two colonoscopies if they remove two or more polyps in different ways, because of the extra work. As in this case, hospitals typically use a modifier code that reduces the amount charged for the second billed colonoscopy so they charge only for the extra work, he added.

“How do you explain that in sensible terms that anyone could understand?” Littenberg said.

Even with that reduction, Littenberg said, he thought Contos’ total out-of-pocket cost of $4,047 was “a lot, though not rare for large academic centers.”

Contos’ insurance documents show Aetna’s negotiated rate for his colonoscopy at Northwestern was more than twice the insurer’s median negotiated rate for the same procedure at other Chicago-area hospitals, according to Forrest Xiao, director of quantitative research at Turquoise Health, a company that gathers health care price data.

In exchanges with Northwestern and Aetna representatives, Contos asked why he was charged for two colonoscopies. A Northwestern representative said that because of the modifier code, he wasn’t actually being billed for two procedures, which Contos found bewildering.

“I told Northwestern, ‘I’m not paying that, and I don’t care if you send me to collections,’” he said. He filed appeals with the hospital and Aetna but was ultimately told the billing was correct.

The Resolution

In an email, Contos told the billing department that its charge was “ridiculously high.” A representative responded that Northwestern’s pricing is in line with other academic medical centers in Chicago and “non-negotiable” — and that his account would be turned over to a collections agency.

CVS Health spokesperson Phillip Blando said in a written statement to KFF Health News that the claims for Contos were “paid accurately” by Aetna, declining further comment. (CVS Health owns Aetna.)

Northwestern did not respond to multiple requests for comment.

Contos said he wrote to his physician that he was regretfully dropping him and leaving Northwestern entirely because of the health system’s high pricing.

He said he’s still experiencing periodic symptoms, which he relieves with over-the-counter Preparation H. A one-ounce tube of the ointment costs $10.99 at CVS.

The Takeaway

To get a colonoscopy at a lower price, Littenberg said, patients should consider going to a freestanding endoscopy center or ambulatory surgery center not associated with a hospital. A 2023 study found that ambulatory surgery centers billed insurers an average of about $1,030 for a colonoscopy with biopsy or with removal of a polyp, compared with $1,760 at a hospital.

Bill of the Month

• A Toddler Got a Nasal Swab Test but Left Before Seeing a Doctor. The Bill Was $445. Nov 27, 2024
• Toddler’s Backyard Snakebite Bills Totaled More Than a Quarter Million Dollars Oct 30, 2024
• In Chronic Pain, This Teenager ‘Could Barely Do Anything.’ Insurer Wouldn’t Cover Surgery. Sep 25, 2024

To get a sense of how much a diagnostic colonoscopy could cost, patients can consult a hospital’s price website and an insurer’s cost-estimator website, both required by federal price transparency rules.

Patients also can look up a good-faith estimate of the cash price, which can be lower than the price for patients using insurance to pay for a procedure. In addition, they can check prices through websites such as Turquoise Health and Fair Health, which draw from federal price transparency data or claims data from insurers.

Still, the actual cost could be higher than the estimate if the colonoscopy finds one or more polyps that need to be removed and biopsied, which occurs in at least 40% of all colonoscopies, Littenberg said. Patients should ask whether the price includes those potentially extra services. After all, the point of a diagnostic colonoscopy is to find and, if necessary, treat lesions that could cause problems — regardless of the number found.

It all should be easier for patients, Xiao said: “You shouldn’t have to be a medical billing expert to know what you’re going to pay.”

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

Her mother, Maggi Wettstein, remembered fearing it could be a yeast or urinary tract infection, something they had been dealing with during potty training. The urgent care centers around them were closed for the night, so around 10:30 p.m. she decided to take Ryan to the emergency room at Carle Health.

The Medical Procedure

The ER wasn’t very busy when they arrived at 10:48 p.m., Wettstein recalled. Medical records indicate they checked in and she explained Ryan’s symptoms, including an intermittent fever. The toddler was triaged and given a nasal swab test to check for covid-19 and influenza A and B.

Wettstein said they sat down and waited to be called. And they waited.

As Wettstein watched Ryan in the waiting room’s play area, she noticed her daughter had stopped crying.

In fact, she seemed fine.

So Wettstein decided to drive them home. Ryan had preschool the next day, and she figured there was no point keeping her awake for who knew how much longer and getting stuck with a big ER bill.

There was no one at the check-in desk to inform that they were leaving, Wettstein said, so they just headed home to go to bed.

Ryan went to her preschool the next day, and Wettstein said they forgot all about the ER trip for eight months.

Then the bill came.

The Final Bill

$445 for the combined covid and flu test — from an ER visit in which the patient never made it beyond the waiting room.

The Billing Problem: A Healthy Hospital Markup and Standard Insurance Rules

Even though Ryan and her mother left without seeing a doctor, the family ended up owing $298.15 after an insurance discount.

At first, Wettstein said, she couldn’t recall Ryan being tested at all. It wasn’t until she received the bill and requested her daughter’s medical records that she learned the results. (Ryan tested negative for covid and both types of flu.)

While Wettstein said the bill isn’t going to break the bank, it seemed high to her, considering Walgreens sells an at-home covid and flu combination test for $30 and can do higher-quality PCR testing for $145.

Under the public health emergency declared in 2020 for the covid pandemic, insurance companies were required to pay for covid tests without copayments or cost sharing for patients.

That requirement ended when the emergency declaration expired in May 2023. Now, it is often patients who foot the bill — and ER bills are notoriously high.

“That’s a pretty healthy markup the hospital is making on it,” Loren Adler, associate director of the Brookings Institution Center on Health Policy, told KFF Health News when contacted about Ryan’s case.

The rates the insurance companies negotiate with hospitals for various procedures are often based on multipliers of what Medicare pays, Adler said.

Lab tests are one of the few areas in which insurance companies can often pay less than Medicare, he said — the exception being when the test is performed by the hospital laboratory, which is often what happens during ER visits.

Medicare pays $142.63 for the joint test that Ryan received, but the family is on the hook for more than twice that amount, and the initial hospital charge was over three times as much.

The hospital is “utilizing their market power to make as much money as possible, and the insurance companies are not all that good at pushing back,” Adler said. A markup of a few hundred dollars is a drop in the bucket for big insurers. But for the patients who get unexpected bills, it can be a big burden.

Brittany Simon, a public relations manager for Carle Health, did not respond to specific questions but said in a statement, “We follow policies that support the safety and wellbeing of our patients, which includes the initial triage of symptomatic patients to the Emergency Department.”

While Ryan’s family would not have had to pay for a covid test during the public health emergency, it was the family’s insurer, Cigna, that did not have to pay this time, since the family had not yet met a $3,000 yearly deductible.

A Cigna representative did not respond to requests for comment.

The Resolution

Wettstein said she knew she could just pay the bill and be done with it, “but the fact that I never saw a provider, and the fact that it was just for a covid test, is mind-blowing to me.”

She contacted the hospital’s billing department to make sure the bill was correct. She explained what happened and said the hospital representative was also surprised by the size of the bill and sent it up for further review.

“‘Don’t pay this until you hear from me,’” Wettstein remembered being told.

Soon, though, she received a letter from the hospital explaining that the charge was correct and supported by documentation.

Wettstein thought she was avoiding any charges by taking Ryan home without being seen. Instead, she got a bill “that they have verified that I have to pay.”

“Like I said, it’s mind-blowing to me.”

The Takeaway

ERs are among the most expensive options for care in the nation’s health system, and the meter can start running as soon as you check in — even if you check out before receiving care.

If your issue isn’t life-threatening, consider an urgent care facility, which is often cheaper (and look for posted notices to confirm whether it’s actually an urgent care clinic). The urgent care centers near Ryan’s home were closed that evening, but some facilities stay open late or around the clock.

In some ways, Wettstein was lucky. KFF Health News’ “Bill of the Month” has received tips from other patients who left an ER after a long wait without seeing a doctor — and got slapped with a facility fee of over $1,000.

Making the decision about where to go is tough, especially in a stressful situation — such as when the patient is too young to communicate what’s wrong. Trying to figure out what’s going on physically with a 3-year-old can feel impossible.

If you decide to leave an ER without treatment, don’t just walk out. Tell the triage nurse you’re leaving. You might get lucky and avoid some charges.

Wettstein won’t think twice about taking Ryan to the pediatrician or an urgent care center the next time she’s ailing. But, Wettstein said, after getting this bill, “I’m not going to create a habit out of going to the emergency room.”

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

Health care might not have been the biggest issue in the campaign, but the return of Donald Trump to the presidency is likely to have a seismic impact on health policy over the next four years. 

Changes to the Affordable Care Act, Medicaid, and the nation’s public health infrastructure are likely on the agenda. But how far Trump goes will depend largely on who staffs key health policy roles and on whether Democrats take a majority in the U.S. House, where several races remain uncalled. 

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Stat, and Alice Miranda Ollstein of Politico.

Panelists

Among the takeaways from this week’s episode:

• As of Friday morning, it remained unclear which party will control the House next year. A Democratic-controlled House would offer a check against Republican policy changes and some control of key government oversight committees. A Republican House would give the party full control of Congress and the presidency. Either way, the party in control will have a slim majority.
• Majorities of voters in eight states voted to protect abortion rights — though the ballot measures passed in only seven states. (More than half of voters in Florida voted for the abortion rights measure, but the state requires at least 60% support for ballot measures to pass.)
• Robert F. Kennedy Jr. — now a key voice in the Trump transition team — is telegraphing big plans for health policy. Who ends up in Trump’s Cabinet will make a difference, as the president-elect is seemingly outsourcing much of his health policy planning in favor of focusing on issues such as the economy, immigration, and trade.
• And conservative appointees throughout the judicial system are likely to remain friendly to Trump administration causes, which could open the door to more challenges to federal policies. Several important legal challenges are already winding through the courts.

Also this week, Rovner interviews KFF Health News’ Jackie Fortiér, who reported and wrote the latest KFF Health News-Washington Post “Bill of the Month” feature, about a 2-year old who had an expensive run-in with a rattlesnake. Do you have a medical bill that is exorbitant, baffling, infuriating, or all of the above? Tell us about it!

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too: 

Julie Rovner: KFF Health News’ “Dentists Are Pulling ‘Healthy’ and Treatable Teeth to Profit From Implants, Experts Warn,” by Brett Kelman and Anna Werner of CBS News. 

Alice Miranda Ollstein: Politico’s “The Election’s Stakes for Global Health,” by Carmen Paun. 

Rachel Cohrs Zhang: KFF Health News’ “As Nuns Disappear, Many Catholic Hospitals Look More Like Megacorporations,” by Samantha Liss. 

Also mentioned in this week’s podcast:

• The New York Times’ “R.F.K. Jr. Lays Out Possible Public Health Changes Under Trump,” by Remy Tumin.
• KFF Health News’ “Toddler’s Backyard Snakebite Bills Totaled More Than a Quarter Million Dollars,” by Jackie Fortiér.

[Correction: During this episode, the discussion about a toddler’s medical bills after a rattlesnake bite misstated the total amount billed. The total amount was $297,461 — not $279,461.]

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Friday, November 8th, at 10 a.m. As always, and particularly this week, news happens fast, and things might have changed by the time you hear this. So, here we go. 

Today, we are joined via videoconference by Rachel Cohrs Zhang of Stat News. 

Rachel Cohrs Zhang: Hi, everybody. 

Rovner: And Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hi, Julie. 

Rovner: Later in this episode, we’ll have my interview with KFF Health News’ Jackie Fortiér, who reported and wrote the latest “Bill of the Month” about a very lucky 2-year-old who suffered a very expensive rattlesnake bite. But first, this week’s news. So, I want to start with some broad themes on what Donald Trump 2.0, a Republican-majority Senate, and maybe a Republican-majority House, too, will mean for health care. 

Next week, we’ll talk more about the lame-duck Congress and the Affordable Care Act open enrollment, which started already. But this week I want to take a bit longer view. First, what difference will it make if the House flips to Democratic control, even by only a vote or two, compared to the trifecta of Republicans in charge of the House, the Senate, and the presidency? 

Ollstein: I mean, a Democratic House would really be the only check on what Republicans would be able to do, and so it would limit the scope of their ambition on health care and everything else. I think that it will have a big effect on things like appropriations, where we’ve seen efforts to, for instance, put a bunch of policy riders in appropriations bills to do all kinds of things, quote-unquote “culture war” actions on abortion and trans rights and other things, but also other health policy priorities across the board, and so I think appropriations is a big area that would be influenced. And, also, I think, I’m sure we’re going to talk a lot about the Obamacare subsidy fight coming up next year, and I think that’s another area where control of the House will have a major influence. 

Rovner: Oversight, too, right? I mean, even if they only have a one- or two-seat majority, Democrats would then control the committees, which is a big deal. 

Cohrs Zhang: Right. The oversight and also just like the structure of oversight committees. I know there’s a select committee on China, that it was unclear if that was going to continue if the House remained in Democratic control, and, obviously, subpoena power. 

Rovner: You mean if the House switched to Democratic control? 

Cohrs Zhang: Yeah, if the House switched to Democratic control, that the future of that was unclear, and then, obviously, subpoena power, those fun things. So I think certainly the control of the committees in general, but also the structure of how things work and what the hearings would be focused on. 

Rovner: We’ve seen the Republican majority — the little, the teeny-tiny Republican majority they’ve had this Congress. Not very effective, because they haven’t been able to get everybody on the same page. Two questions. If they keep their majority, it’s likely to continue to be teeny-tiny, and if the Democrats get it, theirs is likely to be teeny-tiny. Whoever controls the House is likely to control it by, at most, three or four votes. Would Democrats with a very small majority be any more successful in getting anything done than Republicans with their very small majority? 

Cohrs Zhang: It wouldn’t be as much about getting things done as stopping things from getting done, almost. I think, clearly, we see, I think, with a Republican trifecta, the opportunity, again, like Democrats used in 2022, for a reconciliation bill that includes taxes and, like Alice was talking about, the ACA. So I think that would just take that off of the table, but if Republicans do hold the House, then I think that just opens up a really broad range of policy on a lot of different issues, including reform of public health agencies and just some other targets that Republicans have been waiting for amid this era of Democratic control of Congress. 

Rovner: Or at least partial Democratic control of Congress. Also, what is this election a mandate for? As we’ll get into later, voters were often completely contradictory. In eight of 10 states with abortion ballot measures, majorities voted to enshrine abortion rights. Yet, in many of those same states, majorities also voted not just for Trump, but for validly anti-abortion Republicans for Senate and other offices. In five swing states, majorities voted for Trump, but also, apparently, for Democratic senators. This doesn’t feel like a populace clamoring for a repeal of the ACA and a federal abortion ban. This feels like a populace that isn’t quite sure what it wants. 

Ollstein: So, a few things. One, we know from polling, including from KFF’s polling, that the top issues people were voting on were not abortion. They were not health care issues. Those ranked lower down on the priority list. And so I think when you look at the large support for Trump and for several other downballot Republicans, I don’t think you can say that it’s a mandate on health care. I think it’s a mandate on other issues. 

Also, in terms of the split with the ballot measure results, people should not be surprised. We’ve seen this ever since the beginning of this wave in Dobbs. The very first state to vote, in Kansas, they reelected a very anti-abortion attorney general on the same ballot where they voted in favor of abortion rights. In Kentucky, which was one of the ones that came after that, people reelected [Sen.] Rand Paul, who’s very anti-abortion. At the same time, they voted in favor of abortion rights on the ballot measure. This has been a pretty consistent trend, and so it seemed to take a lot of people by surprise this year, but I’m not really sure why. 

Rovner: Because they don’t listen to “What the Health?,” because we’ve been talking about it ever since. 

Ollstein: I guess so. And there’s been some very interesting introspection in the abortion rights community and grappling with the question of whether ballot measures created — one source of mine called it a “permission structure” for people to feel OK voting for Republicans because they felt: Oh, well, I took care of the threat to abortion by voting on the ballot initiative. Now I can focus on other things when I go to pick a president or pick a senator. 

Rovner: Rachel, what about other health issues? I mean, does anybody come out of this feeling like they’re emboldened and empowered to do something specific? 

Cohrs Zhang: Well, I think we’ve certainly seen Robert F. Kennedy Jr. really excited, and I think his pitch for the “Make America Healthy Again” agenda was a key part of the Trump campaign’s closing message leading into Election Day. It was a relatively recent development if you look at the whole arc of the campaign, but I think that the Trump campaign finally just seized on this message that did appeal more to his voters who were skeptical of Operation Warp Speed and just the development of the covid-19 vaccine, distrustful of public health institutions. And we’re seeing it all come to a head by empowering him. 

Potentially, again, we’ll see who gets what positions in the transition. He was promised things before that didn’t materialize in 2016. So, again, it’s early stages, but I think that RFK Jr., who has been a surrogate on TV, on podcasts, just really rallying his supporters for the Trump cause, I think he would feel empowered. He certainly has seemed like it. He’s been making promises about things that the Trump administration would do in the early days. And so I think this transition period will be really instrumental in determining how much that influence will actually transfer to policymaking power. 

Rovner: Which is a perfect segue to my next big question, which is: How much does this all depend on who gets what jobs? Trump, obviously, can’t run all the agencies himself, and even his loyalists can get in trouble when they think they’re interpreting what he wants. How many times on the campaign trail did Trump directly contradict something Vice President-elect JD Vance said? For example, two of the names I’ve heard bandied about for HHS [Department of Health and Human Services] secretary are Bobby Jindal, a former HHS official under President George W. Bush and former Louisiana governor and kind of an old-school conservative at this point, and Florida Surgeon General Joseph Ladapo, whose name will be familiar to podcast listeners as a basically vaccine denier with an M.D. So, I mean, I assume a lot of this is going to be … Health has never been Trump’s sort of — 

Cohrs Zhang: Top priority? 

Rovner: Yeah. 

Cohrs Zhang: Yeah. 

Rovner: Yes, his highest personal priority, so, I mean, what difference does it make who ends up with these jobs? 

Cohrs Zhang: Oh, it makes all the difference, because I think this isn’t a top priority for Trump. He’s made it very clear that his top priorities are immigration and trade and economic issues. And so, in the advocacy space and also in the health industry space, there’s just a lot of focus on who is going to be in these key Cabinet roles, as well as further down in the bureaucracy, because that’s where the rubber is really going to meet the road, and they feel like they’re going to have a lot of room to do whatever they want, because this isn’t going to be a top focus of the Trump administration. And so you’re seeing a lot of anti-abortion groups really arguing that personnel is policy, and they want to see people who are aligned with them ideologically in these key roles pushing these policies. 

Rovner: I mean, it’s going to be interesting, and we’ll get to this in a few minutes, on when it comes to abortion, where Trump has said all these things about leaving abortion to the states, but it’s hard to imagine that, not anti-abortion activists in any of these jobs, don’t you think? 

Cohrs Zhang: I mean, it’s unclear, because the RFK Jr. wing, even though he’s sort of been all over the place on abortion and, at times, has advocated for national restrictions on abortion, but then backed away from it and sort of has been flip-flopping. But, like Trump, it does not seem to be his top priority. And so, in his world, skepticism of vaccines and Big Pharma is more of a priority, and so I think you’re not going to see a lot of abortion rights advocates in these roles, but you could see people who are sort of — 

Rovner: For whom it’s not their top priority, either. 

Cohrs Zhang: Exactly, exactly, who are much more focused on other areas. 

Rovner: So we also need to talk about how some of Trump’s bigger efforts could end up having an outsize impact on health policy. Deporting millions of immigrants could take a bite out of the health care workforce, for example. And purging the government of civil servants who are perceived to be disloyal could lead to a really big brain drain, particularly in health agencies where there’s a lot of expertise, like the NIH [National Institutes of Health] and the FDA [Food and Drug Administration] and the CDC [Centers for Disease Control and Prevention]. Rachel, that’s something you guys are looking at, right? 

Cohrs Zhang: Certainly. I think we’re looking at just how the agencies could look different. And, I mean, even, I think, the most traditional conservative, lowercase-C former Trump officials, we’ve seen Scott Gottlieb call for CDC reform, and I think that just the general sense is that the public health agencies are doing too much, they shouldn’t necessarily be weighing in on gun violence or even smoking cessation sometimes. And I think they’re just arguing for kind of a back-to-the-basics approach. And I think RFK Jr. certainly has threatened jobs at the FDA, especially in the food division. Civil servants do have legal protections, but there are plans to change those, and so I think we are going to see protracted legal fights over some of these executive orders. And, when they come, and I think it’s not going to be like a Day 1 thing, but it’s certainly going to be a very important theme that we’re going to be tracking, as to how the shape of these agencies change in this larger anti-bureaucratic movement. 

Rovner: And, once again, you have walked right into the next question, which is how courts are going to be pivotal here, because we already know from his first term that Trump likes to blow through regulatory and legal guardrails and is likely to do it even more now that he’s term-limited and, basically, has been given carte blanche by the Supreme Court. On the other hand, the Supreme Court overturning Chevron deference last year suggests it will be easier to use the courts to block government actions. The Democrats were all hand-wringing about how, Oh, my goodness, the government is not going to have a lot of power, because courts are going to now have to say, “Congress, you need to spell out everything you’re going to do.” So this could be one of the few sort of bright spots for the anti-Trump forces, right? 

Cohrs Zhang: Well, potentially, but we’ve also seen courts that are dominated by very conservative appointees treat different clients’ arguments differently. So, yes, in theory, curtailing administrative power cuts both ways and would curtail the administrative power of conservatives, but you’ve seen courts not always be consistent in how they apply these principles. And so I think it’s very possible that a Trump administration could get more deference from federal courts than the Biden administration has on some of these rulemaking efforts. 

Rovner: With or without Chevron. 

Cohrs Zhang: We’ve definitely seen that in the past. And folks I’ve talked to insist that, overall, this is a win for them because they do believe in less regulation, and so their ability to create new regulations being limited is not the blow to them that it is to progressives. 

Rovner: Yes. Well, courts will certainly be active in the next four years, as they would have been no matter who won. All right. Well, let’s dig down just a little bit deeper. Alice, I think I’m counting right, there were 11 abortion ballot questions in — 

Ollstein: Ten. 

Rovner: — 10 states on Tuesday. 

Ollstein: Oh, yes, yes. 

Rovner: Yeah, but there was — 

Ollstein: Eleven in 10 states, yes. 

Rovner: Right, 11 in 10 states, because there were two in Nebraska. What happened to them? And how soon might some of them take effect? 

Ollstein: Yeah, so here’s the breakdown. So, on seven of them, states either voted to restore abortion access, protect existing abortion access, or expand abortion access. So seven of the 10 went in favor of the abortion rights movement. Three did not, including, you mentioned, Nebraska, where there were two competing initiatives on the ballot, which many predicted would be confusing to voters. And, in that state, the more restrictive option prevailed. 

In Florida — I saw a lot of misleading reporting on Florida. I saw stories that said, Voters reject the abortion rights amendment in Florida. Let’s be clear. Fifty-seven percent of voters voted in favor of that, so I don’t think you can say voters reject. But the state has long, for decades, required a 60% supermajority to pass ballot initiatives, so it did fall short, even though an overwhelming majority voted in favor. And in South Dakota, one of the most conservative states to ever take up this issue, a majority of voters did, in fact, reject the proposed abortion rights measure that would have restored some access in the state. So, it was a mixed bag. 

Rovner: It’s funny. People talk about South Dakota as being so conservative. I covered the South Dakota abortion referendum in 2006 and 2008. There were two, and they both lost. Those were efforts to restrict abortion, probably, at that point, illegally. Would have gone to this, I mean, they were trying to set up a Supreme Court challenge. But it was surprising, both in 2006 and 2008, that that lost. So, obviously, South Dakota has turned even more red since the mid-aughts. I mean, most of these that passed, though, are just, as you said, reassuring states where it was already legal. I mean, there were only, what, two where it actually overturned a ban. 

Ollstein: Yes, Arizona, where it overturned a 15-week ban, and Missouri, where it overturned a near-total ban. And I saw that the abortion rights groups in Missouri have already moved aggressively to file a lawsuit challenging the state’s ban, pointing to the newly passed measure, and not just challenging the state’s overall ban on abortion, but challenging a lot of narrower policies in terms of regulations on abortion. So I think they’re moving to argue in court that these restrictions can’t stand under the new ban, so we’ll see what happens there. 

Rovner: So nothing happens immediately? 

Ollstein: Yeah. I think that’s important for folks to realize. These ballot measures passed, but then you either have to go to court to get the actual state laws changed or the state legislature can act to say: OK, the voters, this is the will of the people. We need to repeal the things that are currently on the books. 

Rovner: Meanwhile, I feel like it bears repeating that, even though Trump has said repeatedly during the campaign that he wants to leave abortion to the states and that he wouldn’t sign a nationwide ban, which probably couldn’t pass Congress in its current form even if Republicans have both Houses, he could actually do things that would make abortion effectively unavailable in much of the country. Remind us what a couple of those things are. 

Ollstein: Oh, I mean, there’s a lot that can happen both through the administrative side and through courts. There are several pending cases in court that could really curtail access nationwide. At the administrative level, you have FDA regulation of abortion pills. Abortion pills are used in more than two-thirds of all abortions in the U.S., and so there are expected to be efforts both to reimpose the pre-pandemic restrictions on how people can access the pills or challenge their decades-old approval and really cut off access entirely. There are also efforts to use the Comstock Act to restrict mail delivery of both abortion pills and any medication or instruments that could potentially be used for abortion. And so folks should understand that these things would impact people everywhere, including in states that just voted in favor of these ballot initiatives. 

Rovner: Exactly. All right. Well, I want to turn to coverage, and I’m including this as a giant category that includes Medicare, Medicaid, and the Affordable Care Act. Trump, of course, said repeatedly on the campaign trail that he wouldn’t cut Medicare, but that’s not really Republican health policy doctrine. I mean, Rachel, we don’t expect Medicare to just sort of float on untouched for the next four years. Right? 

Cohrs Zhang: Well, I mean, I don’t know that we’re going to see I think what people think of when they think of Medicare cuts, like raising the eligibility age, some of those really unpopular policies. I mean, under a Republican administration, we certainly could see more people moving into Medicare Advantage plans. I think that dynamic, which the group’s already been growing, of people who are enrolled in Medicare Advantage plans instead of a traditional Medicare plan. So we could see the growth of those private plans, which, again, lawmakers have raised some concerns about, just quality and access for people who are in those plans. 

We also could see some tweaks to the drug pricing policies that Democrats passed in 2022. From what my sources are saying, that even if there is a Republican trifecta, it’s unlikely that we’ll see a wholesale repeal of Medicare drug price negotiation, just because it would be really expensive. They’d have to find some other way to pay for that, which is not necessarily something that they would want to do. But there are some tweaks that the pharma industry has been asking for around the edges. And so I think there is a significant chance that we could see some changes to that program. So I think there are just — I don’t know that we’ll see quote-unquote “cuts” to the Medicare program, but there can certainly be changes and people getting funneled into different plans. And I think it will be a really interesting dynamic to watch, especially in the MA space. 

Rovner: Yeah. And, of course, not only has Trump failed to include Medicaid in the programs that he has promised to protect, but Medicaid was a major target in his first term. So, Alice, I guess we’re expecting action on the Medicaid front, right? 

Ollstein: That’s right. I mean, it’s just a question of, if you take massive programs of Medicare and Social Security off the table, as they’re purporting to do, I mean, really, what’s left? 

Rovner: Oh, that program that covers 80 million Americans? 

Ollstein: Exactly. Exactly. And so, again, there’s just a lot of things they could do. Depending if they win control of the House, there’s a lot they could do through Congress, but there’s also a lot they could do through waivers and rulemaking. And I think we really should be watching what happens on the expansion population, because that is where conservatives really oppose the level of spending currently. 

Rovner: Meaning, the additional subsidies for states to expanded Medicaid under the ACA? 

Ollstein: Exactly. 

Rovner: That expansion population. 

Ollstein: Exactly. There are a lot of conservatives who believe that that happened at the expense of the so-called traditional Medicaid population of pregnant women, low-income parents, et cetera, et cetera, et cetera, people with disabilities. And so a lot of conservatives are critical of the subsidized expansion of coverage to able-bodied childless adults, and so I would be really watching to see what happens there. 

Rovner: We also know, as you mentioned, Alice, that the expanded subsidies for the Affordable Care Act, not the Medicaid subsidies, expanded subsidies for people expire at the end of next year. Is it safe to say that those are toast under a Republican Congress and President Trump? 

Cohrs Zhang: I would say that it’s a little more complicated than that, just because a lot of these subsidies actually are benefiting states that have not expanded Medicaid, so they’re mostly Republicans who are politically benefiting from these subsidies and would politically feel the blowback if they were to expire and premiums would spike for their constituents. But I think they’re — I could see even a middle ground where they’re certainly not going to be renewed at their current levels, but there could be some scaling back who might be eligible for them. You could have some sort of guardrails around fraud, which I know is something that some Republicans in Trump’s orbit have raised. We certainly could see a scenario in which they just choose to not renew them entirely. But I think there is a possible middle ground here if the Republicans from these states like Florida really do stand up and realize the potential political blowback for them. 

Ollstein: Yeah. I also think there could be some horse trading. I mean, especially if Democrats manage to flip the House. There are a lot of other things Republicans really want. Extending tax cuts is one of them, and so I think there could be some horse trading to allow, like Rachel said, some of the subsidies to continue in exchange for something else. 

Rovner: Well, there’s so much more to cover. I think we’re going to stop there for this week. We will have more in the coming weeks. There will be no shortage of news. Now we will play my “Bill of the Month” interview with KFF Health News’ Jackie Fortiér, and then we’ll come back and do our extra credit. 

I am so pleased to welcome to the podcast my KFF Health News colleague Jackie Fortiér, who reported and wrote the latest KFF Health News “Bill of the Month.” 

Jackie, thanks for joining us. 

Jackie Fortiér: Thanks for having me. 

Rovner: So tell us about this month’s patient, who he is, what kind of medical care he needed. 

Fortiér: Yeah. Brigland Pfeffer had just turned 2 years old last April when he was bit by a small rattlesnake in his family’s backyard. They live in San Diego, and, like a lot of houses, their backyard is right next to rattlesnake habitat. Brigland Pfeffer was bit on his right hand between his thumb and his pointer finger while his parents were just a few feet away. His older brother saw that it was a rattlesnake, and his mom immediately called 911. EMTs took him to the nearest emergency room that had antivenom. But while he was in the ambulance he went into shock, and at the emergency room they couldn’t find a vein to start the antivenom. His blood pressure was dropping, so the ER doctor ended up drilling into his leg bone to get that starting dose of antivenom going. They stabilized Brigland and then transported him via another ambulance to Rady Children’s Hospital in San Diego, where he was in the pediatric intensive care unit for two days. He got more antivenom there, and then, after a couple days, he was sent home. 

Rovner: And, just to cut to the chase, he’s OK now, right? 

Fortiér: Yes. He is a rambunctious 2½-year-old. His hand has healed. You can’t even see where he was bit. But his mom tells me that he does have nerve damage in that hand and his right thumb isn’t as dexterous as his other fingers. And she said that he used to be right-handed but, since he was bit by the rattlesnake, he’s now left-handed. 

Rovner: Yeah. Well, he hasn’t been to kindergarten yet, so it should be OK, right? 

Fortiér: Yeah. Yeah. Exactly. 

Rovner: Now, sometimes, the bills we write about are fairly small and it’s the principle of the thing that’s the story. This is not one of those cases. This was a really, really big bill. How much was it? 

Fortiér: Yeah. The total bill for his care was [$297,461]. That includes two hospitals, two ambulance rides, and a couple of days in pediatric intensive care. Now, Brigland needed 30 vials of antivenom to save his life. So, out of that total bill, antivenom alone accounted for about 70%, or just about $213,000. 

Rovner: How did it break down? I assume that the family was not asked to pay six figures for their child’s medical care. 

Fortiér: The family’s health insurer covering Brigland negotiated down the antivenom charges by tens of thousands of dollars. And the cost was mostly covered by insurance. Brigland’s family did pay $7,200 of their plan’s out-of-pocket maximum. But insurance didn’t pay all the claims. His mother, Lindsay, got a letter saying that they owed a little over $11,000 for one of the ambulance rides that the insurance didn’t cover. And, as you know, the landmark No Surprises Act protects patients from many out-of-network bills and emergencies, but the law controversially exempted bills for ground ambulances, so his family may have to pay more than $18,000 for his care. 

Rovner: Yikes. But the big story here is how expensive that antivenom was. Why does it cost so much? You obviously don’t have time to comparison-shop when your 2-year-old’s just been bitten by a rattlesnake. 

Fortiér: And you can’t. I mean, there’s no way to know which emergency rooms have antivenom and which don’t. Antivenom is extremely expensive, for a couple of reasons. The first explanation is hospitals can and do mark up products as much as they want to balance overhead costs and to make money. At the first hospital where Brigland received the antivenom, they charged more than $9,574 per vial. The second hospital, they charged almost $3,700 less for exactly the same medication. 

The second reason antivenom is so expensive is the lack of competition. There’s only two companies cleared to sell snake antivenom in the U.S. For decades, CroFab was the only company. Then Anavip, which is what Brigland got, entered the market in about 2018. But its makers had to settle a patent infringement lawsuit with CroFab’s maker, so the makers of Anavip have to pay royalties until 2028. Anavip initially debuted at a retail price of about $1,200 per vial, but then the price later rose to cover the manufacturer’s millions of dollars in legal costs. So there’s a few complicated reasons why antivenom is so expensive. 

Rovner: Awesome. Just a great — a little microcosm of why health care is so expensive. Somebody is making money off of it, usually not the patient. What’s the takeaway here other than to try to make sure your 2-year-old doesn’t try to make friends with a venomous snake? 

Fortiér: Yes, being snake-aware is a good idea. I mean, this is really why you have health insurance, so make sure your coverage doesn’t lapse. One thing that really surprised me when I was reporting this story was the amount of antivenom that Brigland needed. He got 30 vials of antivenom. That sounds like a lot. But I talked to Michelle Ruha, who’s a toxicologist and an emergency room doctor in Arizona, and she told me that’s not unusual. She’s given 30 vials and more to numerous patients just this year. So there’s many more people who could be facing these enormous bills. Bottom line, if you or your family member gets bit by a rattlesnake, get to a hospital as quickly as you can. There is a saying: “Time is tissue.” A lot of people who get bit have amputations. Don’t put a tourniquet on it or ice. Just get to a hospital. And then, when the bills come, don’t pay the first bill, and try to negotiate them down. 

Rovner: And good luck. 

Fortiér: Yeah, and good luck. I mean, hopefully you have health insurance. And, if you don’t, you could be facing tens of thousands of dollars. 

Rovner: And, hopefully, the hospital you go to has the antivenom. 

Fortiér: Yes. Exactly. Usually, if they don’t have the antivenom, they will get antivenom sent from another facility or you get another ambulance ride to another hospital. When I talked to Dr. Ruha, she recommended going to a larger hospital if you can, because they’re more likely to have antivenom than a freestanding ER or urgent care. 

Rovner: All right. More than I ever want to know about rattlesnake bites. Jackie Fortiér, thank you so much. 

Fortiér: Thank you. 

Rovner: OK. We’re back. And now it’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. 

Rachel, why don’t you go first this week? 

Cohrs Zhang: Sure. My piece is in KFF Health News, by Samantha Liss. And the headline is, “As Nuns Disappear, Many Catholic Hospitals Look More Like Megacorporations.” And I think this is part of a larger series on Catholic health care in America by KFF Health News, which is an area of personal interest for me. And I think, as I’ve been reporting on systems in the past, I think there is just this stark transition from leadership by actual clergy, by nuns. And now I think you see more professional businesspeople, a lot of times not even medical professionals. They’re MBAs and accountants that are leading these organizations. 

And I think it’s important to note that trend and ask: What does Catholic health care really mean today? And I think, certainly, there are nuns who work at that, in the institutions, that do amazing work. And I think, when I’ve had the privilege to meet them, I mean, it’s just, they’re still certainly active in this space. But, in terms of decision-making at the top executive levels, both inside the hospitals but also in the structures that oversee them within the church, I think there’s just been this movement away from actually having nuns controlling health care. And I think there are really valid questions to ask about what that means for the systems as a whole. So I think— 

Rovner: It changes the mission. 

Cohrs Zhang: It does change the mission, yeah, and so I think this is a great way to quantify that effect. 

Rovner: Really good series. Really good story. Alice. 

Ollstein: Yeah, I chose a piece by my co-worker Carmen Paun about “The Election’s Stakes for Global Health.” I think a lot of these things really went under the radar and were not a major focus, but she really walks through what a Trump win means for things like WHO [World Health Organization] membership and the ongoing pandemic treaty negotiations that are happening there, programs for family planning around the world, programs for global health around the world. And so I just really recommend it, because this was not something that came up on the campaign trail very much and not something you’ve been hearing about in the wake of the election. But, obviously, it has major implications. 

Rovner: Oh yeah. Well, my story this week is from my colleague here at KFF Health News Brett Kelman and Anna Werner of CBS News, and it’s called “Dentists Are Pulling ‘Healthy’ and Treatable Teeth To Profit From Implants, Experts Warn.” And, I confess, I just had a tooth pulled to make way for an implant that I may or may not get now, and I’m left wondering if that was really necessary. And like all good stories involving profitable but questionably necessary care, yes, this one involves private equity investors. You should read it even if you have good teeth. 

OK. That is our show for this election week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks this week to our fill-in producer, editor Zach Dyer, as well as our editor, Emmarie Huetteman. Also, as always, you can email us your comments or questions. We’re at whatthehealth, all one word, @kff.org. Or you can still find me for now at X. I’m @jrovner. 

Rachel, where are you? 

Cohrs Zhang: I’m on X, @rachelcohrs, and also on LinkedIn. 

Rovner: Alice? 

Ollstein: On X, @AliceOllstein, and on Bluesky, @alicemiranda. 

Rovner: We will be back in your feed next week. Until then, be healthy. 

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His mother, Lindsay Pfeffer, was a few feet away when Brigland made a noise and came running from the stone firepit, holding his right hand. She noticed a pinprick of blood between his thumb and forefinger when her older son called out, “Snake!”

“I saw a small rattlesnake coiled up by the firepit,” she said.

Pfeffer called 911, and an ambulance transported Brigland to Palomar Medical Center Escondido.

The Medical Procedure

When they arrived, Brigland’s hand was swollen and purple.

Antivenom, an antibody therapy that disables certain toxins, is usually administered via an intravenous line, directly into the bloodstream. But emergency room staffers struggled to insert the IV.

“They had so many people in that room trying his head, his neck, his feet, his arms — like, everything to find a vein,” Pfeffer said.

Still unable to start the antivenom, a doctor asked for her permission to try drastic measures. “Just get something going,” she recalled pleading.

It worked. Using a procedure that delivers medicine into the bone marrow, the medical team gave Brigland a starting dose of the antivenom Anavip.

He was transferred to the pediatric intensive care unit at Rady Children’s Hospital, where he received more Anavip.

The swelling that had spread to his armpit slowly decreased. A couple of days later, he left the hospital with his grateful parents.

Then the bills came.

The Final Bill

$297,461, which included two ambulance rides, an emergency room visit, and a couple of days in pediatric intensive care. Antivenom alone accounts for $213,278.80 of the total bill.

The Billing Problem: The High Cost of Antivenom

The Centers for Disease Control and Prevention estimates venomous snakes bite 7,000 to 8,000 people in the United States every year. About five people die. That number would be higher, the agency says, if not for medical treatment.

Many snakebites happen far from medical care, and not all emergency rooms keep costly antivenom in stock, which can add big ambulance bills to already expensive care.

It often takes more than a dozen vials, typically costing thousands per vial, to treat a snakebite. The median number per patient is 18 vials, said Michelle Ruha, an emergency room doctor in Arizona and a former president of the American College of Medical Toxicology.

Manufacturing, which hasn’t fundamentally changed since antivenom was developed more than a century ago, does not explain the high price. Venomous creatures are milked, then a small, non-harmful amount of toxin is injected into animals like horses or sheep. Antibodies are extracted from their blood and processed to make antivenom.

Why the high price? One explanation is that hospitals mark up products to balance overhead costs and generate revenue.

Brigland received Anavip at two hospitals that charged different prices.

Palomar, where emergency staffers treated Brigland, charged $9,574.60 per vial, for a total of $95,746 for the starting dose of 10 vials of Anavip.

Rady, the largest children’s hospital on the West Coast, charged $5,876.64 for each vial. For the 20 vials Brigland received there, the total was $117,532.80.

Neither hospital responded to requests for comment.

Those charges are “eye-popping,” said Stacie Dusetzina, who is a professor of health policy at Vanderbilt University Medical Center and reviewed the bills at the request of KFF Health News. “When you see the word ‘charges,’ that’s a made-up number. That isn’t connected at all, usually, to what the actual drug cost.”

For instance, Medicare — the government program for those who are at least 65 or disabled — pays about $2,000 for a vial of Anavip. On average, Dusetzina said, that is the price hospitals pay for it.

Leslie Boyer, a doctor and toxicology researcher, helped found a group that was instrumental in developing Anavip, as well as the other available snake antivenom, CroFab, which dominated the market for decades. In 2015, she published an editorial in the American Journal of Medicine breaking down the “true” cost of antivenom. (Boyer declined to comment for this article.)

Using cost data collected from factory supervisors, animal managers, hospital pharmacists and other sources, Boyer developed a model for a hypothetical antivenom, at a final cost of $14,624 per vial. She found the cost of venom, included in that total, was just 2 cents. Manufacturing accounted for $9 of the $14,624 total.

More than 70% of the price tag — $10,250 — is attributable to hospital markups, her research showed.

Another explanation for antivenom’s high cost is a lack of meaningful competition. Anavip entered the market in 2018 as the only competitor to CroFab. But its makers settled a patent infringement lawsuit with CroFab’s maker, requiring the makers of Anavip to pay royalties until 2028.

Anavip debuted at a retail price of $1,220 per vial. Boyer noted that the price later rose to cover the manufacturers’ millions of dollars in legal costs.

The Resolution

The insurer covering Brigland — Sharp Health Plan, which did not respond to requests for comment — negotiated down the antivenom charges by tens of thousands of dollars.

The cost was mostly covered by insurance. Brigland’s family paid $7,200, their plan’s out-of-pocket maximum.

Insurance did not pay all the claims, including one ambulance bill. Pfeffer said she received a letter this summer indicating they owe an additional $11,300 for Brigland’s care. While the landmark No Surprises Act protects patients from many out-of-network bills in emergencies, the law controversially exempted bills for ground ambulances.

Brigland’s hand healed, though nerve damage and scar tissue have left his right thumb less dexterous. He is now left-handed.

“He’s very, very lucky,” Pfeffer said.

The family has since installed snake fencing around the yard.

The Takeaway

There’s a saying in toxicology: Time is tissue. If bitten by a snake, “get to medical care,” Ruha said.

Not all emergency rooms have antivenom, and there are no online resources identifying which ones do. Ruha recommends going to a large hospital, which is more likely to have antivenom in stock than free-standing emergency rooms.

When the bill comes, be ready to negotiate, Dusetzina said. Providers know their charges are high and may be willing to take less.

You can compare the charges against average prices using cost estimation tools like Fair Health Consumer or Healthcare Bluebook.

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

“First practice, he came back, he said, ‘Dad, I love it,’” recalled his father, Lothar Nafz, of Hoover, Alabama. “He lives for lacrosse.”

But years of youth sports took a toll on Preston’s body. By the time the teenager limped off the field during a lacrosse tournament last year, the pain in his left hip had become so intense that he had trouble with simple activities, such as getting out of a car or turning over in bed. Months of physical therapy and anti-inflammatory drugs didn’t help.

Not only did he have to give up sports, but “I could barely do anything,” said Preston, now 17.

The Medical Procedure

A doctor recommended Preston undergo a procedure called a sports hernia repair to mend damaged tissue in his pelvis, believed to be causing his pain.

The sports medicine clinic treating Preston told Lothar that the procedure had no medical billing code — an identifier that providers use to charge insurers and other payers. It likely would be a struggle to persuade their insurer to cover it, Lothar was told, which is why he needed to pay upfront.

With his son suffering, Lothar said, the surgery “needed to be done.” He paid more than $7,000 to the clinic and the surgery center with a personal credit card and a medical credit card with a zero-interest rate.

Preston underwent surgery in November, and his father filed a claim with their insurer, hoping for a full reimbursement. It didn’t come.

The Final Bill

$7,105, which broke down as $480 for anesthesia, a $625 facility fee, and $6,000 for the surgery.

The Billing Problem: No CPT Code

Before the surgery, Lothar said, he called Blue Cross and Blue Shield of Alabama and was encouraged to learn that his policy typically covers most medical, non-cosmetic procedures.

But during follow-up phone calls, he said, insurance representatives were “deflecting, trying to wiggle out.” He said he called several times, getting a denial just before the surgery.

Lothar said he trusted his son’s doctor, who showed him research indicating the surgery works. The clinic, Andrews Sports Medicine and Orthopaedic Center, has a good reputation in Alabama, he said.

Other medical providers not involved in the case called the surgery a legitimate treatment.

A sports hernia — also known as an “athletic pubalgia” — is a catchall phrase to describe pain that athletes may experience in the lower groin or upper thigh area, said David Geier, an orthopedic surgeon and sports medicine specialist in Mount Pleasant, South Carolina.

“There’s a number of underlying things that can cause it,” Geier said. Because of that, there isn’t “one accepted surgery for that problem. That’s why I suspect there’s not a uniform CPT.”

CPT stands for “Current Procedural Terminology” and refers to the numerical or alphanumeric codes for procedures and services performed in a clinical or outpatient setting. There’s a CPT code for a rapid strep test, for example, and different codes for various X-rays.

The lack of a CPT code can cause reimbursement headaches, since insurers determine how much to pay based on the CPT codes providers use on claims forms.

More than 10,000 CPT codes exist. Several hundred are added each year by a special committee of the American Medical Association, explained Leonta Williams, director of education at AAPC, previously known as the American Academy of Professional Coders.

Codes are more likely to be proposed if the procedure in question is highly utilized, she said.

Not many orthopedic surgeons in the U.S. perform sports hernia repairs, Geier said. He said some insurers consider the surgery experimental.

Preston said his pain improved since his surgery, though recovery was much longer and more painful than he expected.

By the end of April, Lothar said, he’d finished paying off the surgery.

The Resolution: A billing statement from the surgery center shows that the CPT code assigned to Preston’s sports hernia repair was “27299,” which stands for “a pelvis or hip joint procedure that does not have a specific code.”

After submitting more documentation to appeal the insurance denial, Lothar received a check from the insurer for $620.26. Blue Cross and Blue Shield didn’t say how it came up with that number or which costs it was reimbursing.

Lothar said he has continued to receive confusing messages from the insurer about his claim.

Both the insurer and the sports medicine clinic declined to comment.

The Takeaway

Before you undergo a medical procedure, try to check whether your insurer will cover the cost and confirm it has a billing code.

Williams of the AAPC suggests asking your insurer: “Do you reimburse this code? What types of services fall under this code? What is the likelihood of this being reimbursed?”

Persuading an insurer to pay for care that doesn’t have its own billing code is difficult but not impossible, Williams said. Your doctor can bill insurance using an “unlisted code” along with documentation explaining what procedure was performed.

“Anytime you’re dealing with an unlisted code, there’s additional work needed to explain what service was rendered and why it was needed,” she said.

Some patients undergoing procedures without CPT codes may be asked to pay upfront. You can also offer a partial upfront payment, which may motivate your provider to team up to get insurance to pay.

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

Holmes, who lives in northwestern Washington state, had surgery in 2019 to have her fallopian tubes tied, a permanent birth-control procedure that her insurance company agreed ahead of time to cover.

During the operation, while Holmes was under anesthesia, the surgeon noticed early signs of endometriosis, a common condition in which fibrous scar tissue grows around the uterus, Holmes said. She said the surgeon later told her he spent about 15 minutes cauterizing the troublesome tissue as a precaution. She recalls him saying he finished the whole operation within the 60 minutes that had been allotted for the tubal ligation procedure alone.

She said the doctor assured her the extra treatment for endometriosis would cost her little, if anything.

Then the bill came.

The Patient: Jamie Holmes, 38, of Lynden, Washington, who was insured by Premera Blue Cross at the time.

Medical Services: A tubal ligation operation, plus treatment of endometriosis found during the surgery.

Service Provider: Pacific Rim Outpatient Surgery Center of Bellingham, Washington, which has since been purchased, closed, and reopened under a new name.

Total Bill: $9,620. Insurance paid $1,262 to the in-network center. After adjusting for prices allowed under the insurer’s contract, the center billed Holmes $2,605. A collection agency later acquired the debt and sued her for $3,792.19, including interest and fees.

What Gives: The surgery center, which provided the facility and support staff for her operation, sent a bill suggesting that Holmes underwent two separate operations, one to have her tubes tied and one to treat endometriosis. It charged $4,810 for each.

Holmes said there were no such problems with the separate bills from the surgeon and anesthesiologist, which the insurer paid.

Holmes figured someone in the center’s billing department mistakenly thought she’d been on the operating table twice. She said she tried to explain it to the staff, to no avail.

She said it was as if she ordered a meal at a fast-food restaurant, was given extra fries, and then was charged for two whole meals. “I didn’t get the extra burger and drink and a toy,” she joked.

Her insurer, Premera Blue Cross, declined to pay for two operations, she said. The surgery center billed Holmes for much of the difference. She refused to pay.

Holmes said she understands the surgery center could have incurred additional costs for the approximately 15 minutes the surgeon spent cauterizing the spots of endometriosis. About $500 would have seemed like a fair charge to her. “I’m not opposed to paying for that,” she said. “I am opposed to paying for a whole bunch of things I didn’t receive.”

The physician-owned surgery center was later purchased and closed by PeaceHealth, a regional health system. But the debt was turned over to a collection agency, SB&C, which filed suit against Holmes in December 2023, seeking $3,792.19, including interest and fees.

The collection agency asked a judge to grant summary judgment, which could have allowed the company to garnish wages from Holmes’ job as a graphic artist and marketing specialist for real estate agents.

Holmes said she filed a written response, then showed up on Zoom and at the courthouse for two hearings, during which she explained her side, without bringing a lawyer. The judge ruled in February that the collection agency was not entitled to summary judgment, because the facts of the case were in dispute.

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Representatives of the collection agency and the defunct surgery center declined to comment for this article.

Sabrina Corlette, co-director of Georgetown University’s Center on Health Insurance Reforms, said it was absurd for the surgery center to bill for two operations and then refuse to back down when the situation was explained. “It’s like a Kafka novel,” she said.

Corlette said surgery center staffers should be accustomed to such scenarios. “It is quite common, I would think, for a surgeon to look inside somebody and say, ‘Oh, there’s this other thing going on. I’m going to deal with it while I’ve got the patient on the operating table.’”

It wouldn’t have made medical or financial sense for the surgeon to make Holmes undergo a separate operation for the secondary issue, she said.

Corlette said that if the surgery center was still in business, she would advise the patient to file a complaint with state regulators.

The Resolution: So far, the collection agency has not pressed ahead with its lawsuit by seeking a trial after the judge’s ruling. Holmes said that if the agency continues to sue her over the debt, she might hire a lawyer and sue them back, seeking damages and attorney fees.

She could have arranged to pay off the amount in installments. But she’s standing on principle, she said.

“I just got stonewalled so badly. They treated me like an idiot,” she said. “If they’re going to be petty to me, I’m willing to be petty right back.”

The Takeaway: Don’t be afraid to fight a bogus medical bill, even if the dispute goes to court.

Debt collectors often seek summary judgment, which allows them to garnish wages or take other measures to seize money without going to the trouble of proving in a trial that they are entitled to payments. If the consumers being sued don’t show up to tell their side in court hearings, judges often grant summary judgment to the debt collectors.

However, if the facts of a case are in dispute — for example, because the defendant shows up and argues she owes for just one surgery, not two — the judge may deny summary judgment and send the case to trial. That forces the debt collector to choose: spend more time and money pursuing the debt or drop it.

“You know what? It pays to be stubborn in situations like this,” said Berneta Haynes, a senior attorney for the National Consumer Law Center who reviewed Holmes’ bill for KFF Health News.

Many people don’t go to such hearings, sometimes because they didn’t get enough notice, don’t read English, or don’t have time, she said.

“I think a lot of folks just cave” after they’re sued, Haynes said.

Emily Siner reported the audio story.

After six years, we’ll have a final installment with NPR of our Bill of the Month project in the fall. But Bill of the Month will continue at KFF Health News and elsewhere. We still want to hear about your confusing or outrageous medical bills. Visit Bill of the Month to share your story.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).

Growing up, she learned to cope — but it wasn’t easy. With only one functioning ear, she couldn’t tell where sounds were coming from. She couldn’t follow along with groups of people in conversation — at social gatherings or at work — so she learned to lip-read.

For many years, insurers wouldn’t approve cochlear implants for single-sided deafness due to concerns that it would be hard to train the brain to manage signals from a biological ear and one that hears with the aid of an implant. But research on the detrimental effects of single-sided deafness and improvements in technique changed all that.

So Mai, now 27 and living near Oklahoma City, was thrilled last fall to get a prior authorization letter from her insurer saying she was covered for cochlear implant surgery.

She had successful outpatient surgery to implant the device in December and soon after was eagerly attending therapy to get her brain accustomed to its new capabilities.

“It was amazing. When I’d misplaced my phone and it rang, I could tell where the sound was coming from and find it,” she said.

Then the bill came.

The Patient: Caitlyn Mai, who is insured through her husband’s job by HealthSmart, which is owned by UnitedHealth Group.

Medical Services: Cochlear implant surgery, including the operating room, anesthesia, surgical supplies, and drugs.

Service Provider: SSM Health Bone & Joint Hospital at St. Anthony, an orthopedic hospital in Oklahoma City that is part of SSM Health, a Catholic health system in the central U.S.

Total Bill: $139,362.74 — or, with a “prompt pay discount” if she paid about two months after surgery, $125,426.47.

What Gives: Providers and insurers often have disagreements over how a bill is submitted or coded, and as they work through them (or don’t), the patient is left holding the bag, facing sometimes huge bills.

“I almost had a heart attack when I opened the bill,” Mai said of the first monthly missive, which arrived in late December. She said she was so upset she left work to investigate. Before surgery, “I’d even checked that all hospitals and doctors were in-network and that I’d met my deductible,” she said.

While she was never threatened with having her bill sent to collections, she said she worried about that possibility when the same bills arrived in January, February, and March, with ominous warnings that “your balance is now past due.”

Mai said she first called the hospital billing office but that the representative could tell her only that the claim had been denied and didn’t know why. She called her insurer, and a representative there said the hospital didn’t adequately itemize its charges or include billing codes. She then called the hospital back and relayed exactly what her insurer said must be done to rectify the bill — and the name and number of the insurance employee to fax it to.

When her insurer told her a week or two later it hadn’t received a corrected bill, Mai said, she called the hospital again … and again.

“I said, ‘I’ve done your job for you — now can you please take it from here?’” she said.

Mai said a hospital staffer promised to fax over the corrected, itemized bill in two to three weeks. “How does it take that long to send a fax,” she wondered. She said she asked to speak with a supervisor and was told the person wasn’t available but would call her back. No one did.

After receiving another $139,000 bill in late February, Mai said, she checked back in with her insurer, but a representative said it had not yet received the revised bill.

Finally, she said, she told the hospital to “just send it to me and I’ll send it over.” This time, she forwarded the bill to her insurer herself. But in late March she got another bill demanding the full amount — and offering an $11,000-a-month payment plan.

Mai said she had met her out-of-pocket deductible and, with prior authorization in hand, expected the surgery to be fully covered.

SSM Health did not respond to multiple requests for comment about why it billed Mai.

“It’s outrageous that the patients end up umpiring the decisions,” said Elisabeth Ryden Benjamin, vice president of health initiatives at the Community Service Society of New York, an advocacy organization. “And it’s outrageous that providers are allowed to bill patients while they’re haggling with the insurer.”

Indeed, more and more patients are stuck with such bills as insurers and hospitals spend more and more time arguing in the trenches, data shows. A recent report by Crowe, an accounting firm that works with a large number of hospitals, found that more than 30% of claims submitted to commercial insurers early last year weren’t paid for more than 90 days — striking compared with the lower rates of such delays in Medicare, which were 12% for inpatient claims and 11% for outpatient claims.

The Crowe report found a particular justification for denying claims was cited at 12 times the rate by commercial insurers as by Medicare: that they needed more information before they would process the submission. Such a request allows insurers to sidestep laws in most states that require claims be paid in 30 to 40 days, automatically granting health plans the right to delay payment.

In a separate analysis, the American Hospital Association complained that increases in insurance denials and delays “strain hospital resources” and “inhibit medically necessary care.”

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But perhaps no one is harmed as gravely as the patient, who is barraged with bills and believes they must pay up — particularly when the missives are stamped “past due” and contain offers of prompt-payment discounts or no-interest payment plans. “The stress and anxiety was huge,” Mai said.

Caroline Landree, a spokesperson for UnitedHealth Group, said the insurer could pay Mai’s claims only “after receiving a detailed bill from her provider.”

“We encourage our members to contact the number on their insurance cards for more information on the status of payments,” she added.

The Resolution: Mai estimated she spent at least 12 hours on the phone doing tasks that typically fall to someone working in a hospital billing department: making sure the bill was coded as needed and that the insurer had what it wanted to process the payment.

More than 90 days after her surgery, after Mai had received four terrifyingly huge bills, her insurance finally paid the claim. Mai owed nothing more.

She added: “I’ve never got that call back from a supervisor to this day.”

The Takeaway: It’s not uncommon for an insurer to delay paying a claim until it receives an itemized bill; providers sometimes get creative with billing codes to increase revenue, and studies show that more than half of hospital bills contain errors. But studies also suggest insurers are wont to drag their feet, niggling over coding and charges — and, in doing so, delaying reimbursement and holding on to the cash.

Medical billing experts say it may not seem right for patients to receive bills as this process plays out but that it’s probably legal.

“Laws say ‘hold the patient harmless,’” Benjamin said. “What we didn’t say is, ‘Don’t send them a bill.’” She said it is also unfair that patients may be forced to act as the go-between for providers and insurers who should be talking to each other.

What’s a patient to do? First step: Don’t pay the bill (aside from a copay or coinsurance) for care or services preapproved by insurance. Call the health care provider and explain they should take up their bill with the insurer.

Second, ask the provider to send an itemized bill with all billing codes used, then review it for errors. As the patient, you would know that you never had an MRI, for example. Your insurer wouldn’t.

If submissions to “Bill of the Month” are reflective of trends, many patients these days are finding themselves ping-ponging between representatives for providers and insurers to get bills resolved and paid.

“Bravo for Ms. Mai for having the energy to keep at it and get resolution,” Benjamin said.

Dan Weissmann reported the audio story.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

After it subsided later that night, he thought it might be food poisoning. When the pain returned the next morning, Zhang realized the source of his pain might not be as “simple as bad food.”

He didn’t want to wait for an appointment with his regular doctor, but he also wasn’t sure if the pain warranted emergency care, he said.

Zhang, 50, opted to visit Parkland Health’s Urgent Care Emergency Center, a clinic near his home in Dallas where he’d been treated in the past. It’s on the campus of Parkland, the city’s largest public hospital, which has a separate emergency room.

He believed the clinic was an urgent care center, he said.

A CT scan revealed that Zhang had a kidney stone. A physician told him it would pass naturally within a few days, and Zhang was sent home with a prescription for painkillers, he said.

Five days later, Zhang’s stomach pain worsened. Worried and unable to get an immediate appointment with a urologist, Zhang once again visited the Urgent Care Emergency Center and again was advised to wait and see, he said.

Two weeks later, Zhang passed the kidney stone.

Then the bills came.

The Patient: Tieqiao Zhang, 50, who is insured by BlueCross and BlueShield of Texas through his employer.

Medical Services: Two diagnostic visits, including lab tests and CT scans.

Service Provider: Parkland Health & Hospital System. The hospital is part of the Dallas County Hospital District.

Total Bills: The in-network hospital charged $19,543 for the two visits. BlueCross and BlueShield of Texas paid $13,070.96. Zhang owed $1,000 to Parkland — a $500 emergency room copay for each of his two visits.

What Gives: Parkland’s Urgent Care Emergency Center is what’s called a freestanding emergency department.

The number of freestanding emergency rooms in the United States grew tenfold from 2001 to 2016, drawing attention for sending patients eye-popping bills. Most states allow them to operate, either by regulation or lack thereof. Some states, including Texas, have taken steps to regulate the centers, such as requiring posted notices identifying the facility as a freestanding emergency department.

Urgent care centers are a more familiar option for many patients. Research shows that, on average, urgent care visits can be about 10 times cheaper than a low-acuity — or less severe — visit to an ER.

But the difference between an urgent care clinic and a freestanding emergency room can be tough to discern.

Generally, to bill as an emergency department, facilities must meet specific requirements, such as maintaining certain staff, not refusing patients, and remaining open around the clock.

The freestanding emergency department at Parkland is 40 yards away from its main emergency room and operates under the same license, according to Michael Malaise, the spokesperson for Parkland Health. It is closed on nights and Sundays.

(Parkland’s president and chief executive officer, Frederick Cerise, is a member of KFF’s board of trustees. KFF Health News is an editorially independent program of KFF.) The hospital is “very transparent” about the center’s status as an emergency room, Malaise told KFF Health News in a statement.

Malaise provided photographs of posted notices stating, “This facility is a freestanding emergency medical care facility,” and warning that patients would be charged emergency room fees and could also be charged a facility fee. He said the notices were posted in the exam rooms, lobby, and halls at the time of Zhang’s visits.

Zhang’s health plan required a $500 emergency room copay for each of the two visits for his kidney stone.

When Zhang visited the center in 2021 for a different health issue, he was charged only $30, his plan’s copay for urgent care, he said. (A review of his insurance documents showed Parkland also used emergency department billing codes then. BCBS of Texas did not respond to questions about that visit.)

One reason “I went to the urgent care instead of emergency room, although they are just next door, is the copayment,” he said.

The list of services that Parkland’s freestanding emergency room offers resembles that of urgent care centers — including, for some centers, diagnosing a kidney stone, said Ateev Mehrotra, a health care policy professor at Harvard Medical School.

Having choices leaves patients on their own to decipher not only the severity of their ailment, but also what type of facility they are visiting all while dealing with a health concern. Self-triage is “a very difficult thing,” Mehrotra said.

Zhang said he did not recall seeing posted notices identifying the center as a freestanding emergency department during his visits, nor did the front desk staff mention a $500 copay. Plus, he knew Parkland also had an emergency room, and that was not the building he visited, he said.

The name is “misleading,” Zhang said. “It’s like being tricked.”

Parkland opened the center in 2015 to reduce the number of patients in its main emergency room, which is the busiest in the country, Malaise said. He added that the Urgent Care Emergency Center, which is staffed with emergency room providers, is “an extension of our main emergency room and is clearly marked in multiple places as such.”

Malaise first told KFF Health News that the facility isn’t a freestanding ER, noting that it is located in a hospital building on the campus. Days later, he said the center is “held out to the public as a freestanding emergency medical care facility within the definition provided by Texas law.”

The Urgent Care Emergency Center name is intended to prevent first responders and others facing life-threatening emergencies from visiting the center rather than the main emergency room, Malaise said.

“If you have ideas for a better name, certainly you can send that along for us to consider,” he said.

Putting the term “urgent” in the clinic’s name while charging emergency room prices is “disingenuous,” said Benjamin Ukert, an assistant professor of health economics and policy at Texas A&M University.

When Ukert reviewed Zhang’s bills at the request of KFF Health News, he said his first reaction was, “Wow, I am glad that he only got charged $500; it could have been way worse” — for instance, if the facility had been out-of-network.

The Resolution: Zhang said he paid $400 of the $1,000 he owes in total to avoid collections while he continues to dispute the amount.

Zhang said he first reached out to his insurer, thinking his bills were wrong, before he reached out to Parkland several times by phone and email. He said customer service representatives told him that, for billing purposes, Parkland doesn’t differentiate its Urgent Care Emergency Clinic from its emergency department.

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BlueCross and BlueShield of Texas did not respond to KFF Health News when asked for comment.

Zhang said he also reached out to a county commissioner’s office in Dallas, which never responded, and to the Texas Department of Health, which said it doesn’t have jurisdiction over billing matters. He said the staff for his state representative, Morgan Meyer, contacted the hospital on his behalf, but later told him the hospital would not change his bill.

As of mid-May, his balance stood at $600, or $300 for each visit.

The Takeaway: Lawmakers in Texas and around the country have tried to increase price transparency at freestanding emergency rooms, including by requiring them to hand out disclosures about billing practices.

But experts said the burden still falls disproportionately on patients to navigate the growing menu of options for care.

It’s up to the patient to walk into the right building, said Mehrotra, the Harvard professor. It doesn’t help that most providers are opaque about their billing practices, he said.

Mehrotra said that some freestanding emergency departments in Texas use confusing names like “complete care,” which mask the facilities’ capabilities and billing structure.

Ukert said states could do more to untangle the confusion patients face at such centers, like banning the use of the term “urgent care” to describe facilities that bill like emergency departments.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Emily Siner reported the audio story.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).