Mark Gottlieb’s life changed in an instant when another driver crashed into his car, damaging four vertebrae in his upper spine and shattering six teeth.
In the months following that accident in January 2019, Gottlieb had his teeth crowned and, for debilitating neck pain, tried injections, chiropractic care and physiotherapy. The treatments were all covered by his auto insurance.
New Jersey law, like in 12 other states, requires drivers to purchase personal injury protection, or PIP coverage, to pay for medical bills. Gottlieb had the maximum: $ 250,000.
Unfortunately, Gottlieb’s pain persisted. “Nothing was working. The only other thing was surgery, ”he said.
Although he wanted his operation to be done near his home, Gottlieb said, staff at the Pain Management Clinic in Bergen, where he was receiving treatment, insisted he go to the hospital. Hudson Regional Hospital in Secaucus. On April 3, 2020, Gottlieb underwent a complex type of fusion surgery on herniated discs in his cervical spine. He returned home the same day.
Her pain improved a bit. Then the invoices arrived.
The patient: Mark Gottlieb, 59, a marketing consultant in Little Ferry, New Jersey, covered $ 250,000 in medical expenses through his Geico auto insurance. He also has an Aetna health insurance policy, which is secondary.
Medical service: Anterior cervical discectomy and fusion, a type of cervical surgery to replace damaged discs with bone grafts or implants to stabilize the spine.
Service provider: Hudson Regional Hospital, an independent for-profit facility in Secaucus, New Jersey, and Bergen Pain Management in Paramus, New Jersey.
Total invoice: Together, the hospital and the surgeon billed Gottlieb over $ 700,000. The hospital billed $ 445,995 for the surgery, an amount reduced to $ 133,778 by Geico, who ultimately paid $ 103,354. Bergen Pain Management billed an additional $ 264,444 for the primary surgeon. Based on a review, Geico reduced this amount to $ 141,548. He paid $ 52,365 for it before Gottlieb’s medical coverage in his auto policy ran out. Then it was up to his health insurer or Gottlieb to take care of the rest.
Which give: When injuries are the result of auto accidents, auto insurance is primarily responsible for negotiating and paying the insurance portion of medical bills. This creates a host of financial land mines for patients.
Gottlieb hit them all.
With the high fees common in the United States for treatment, accident victims can easily exhaust the policy limits of even generous personal injury coverage, leaving some vulnerable to huge bills.
While it’s rare to hear auto insurers complain about overpaying a hospital or doctor, auto insurers “typically pay more for some of the same services” than health insurers, said Robert Passmore, vice-president. president of the American Property Casualty Insurance Association, a trade group.
This is in part because auto insurers typically do not have large networks of medical providers who have agreed to negotiate discounts on their billed fees, just like health insurers. Patients are therefore found “outside the network”, subject to the list price invoiced by the supplier.
Gottlieb said he checked with Geico before his surgery, but was told he had no media information for him. With around $ 190,000 remaining in his PIP fund at the time, he wasn’t too worried. He said efforts to obtain cost estimates had not been successful.
Instead of network tariffs, auto insurers typically use other payment calculations. Some states set specific payments on fee schedules. But not all medical billing codes are listed, and in these cases, they sometimes pay the supplier’s bills.
In this case, it was a lot: Gottlieb’s hospital and surgeon fees, even after being cut by Geico, were about eight times what Medicare would have paid.
While Geico typically pays state-set rates (which are significantly lower than what was billed), Gottlieb’s bill included a bunch of billing codes that weren’t on the state’s schedule. For the most part, the insurer paid exactly what was billed. For example, Geico authorized the full price of $ 65,125 charged by the surgeon for the removal of a damaged disc and paid the hospital $ 39,195 for nine surgical screws.
In September – with invoices from its various vendors still outstanding – Gottlieb’s PIP fund ran out after the remaining $ 52,365 was paid to Bergen Pain Management, less than the $ 141,548 that Geico had recommended as reimbursement. for the surgeon.
Insurance pays bills as they are submitted, which is often not in the order in which processing was done.
“It appears Bergen Pain Management is still entitled to the $ 89,183 billing balance for your procedure,” Geico wrote in a September letter to Gottlieb, who added that he could submit this balance to his health insurer or pay it himself.
When he submitted the surgeon’s bill to Aetna, he discovered that neither the doctor nor the hospital was part of his insurance network. He hadn’t checked before the operation because he had never imagined that outpatient surgery would exhaust auto policy.
This means that Aetna did not have a negotiated rate with its suppliers, which could have drastically lowered fees.
Instead, Aetna said she would authorize an off-grid payment of $ 4,051 for the surgeon, according to an email January 28 to Gottlieb. In a written statement to KHN, Aetna spokesman Ethan Slavin said this amount was based on the terms of Gottlieb’s policy, which set doctors’ payments at around 10% above the rates of Medicare for off-grid care.
Because he had not yet reached his annual off-grid franchise, Gottlieb himself would have to pay the $ 4,051. He withdrew his request for payment to Aetna. Because off-grid surgeons frequently lash out at patients for paying off the balance of these bills, Gottlieb is waiting to see if Bergen Pain Management – who has already been paid $ 52,365 for the surgery – will sue him for more.
Neither the Bergen clinic nor the surgeon sent it to collections or sued for the amount. Neither responded to multiple emails and phone calls made by KHN for comment.
In a written statement, Hudson-area spokesperson Ron Simoncini said the hospital “charges state-mandated fees” where applicable, and that in the absence of such warrant, “the costs were reasonable.” It does not ask for additional payment.
Citing the confidentiality of policyholders, Geico declined to answer questions from KHN, including how he determines what he will pay.
Has the auto insurer overpaid?
Geico had set an eligible reimbursement of $ 141,548 as the surgeon’s fees.
“These are shockingly high surgeon’s fees for this type of surgery,” said Dr. Eeric Truumees, a professor at Dell Medical School at the University of Texas-Austin.
“I do a huge number of complex cervical spine surgeries and have never had such a high cost, even for complex surgery that takes 10 hours,” said Truumees, president of the North American Spine Society. He had no direct knowledge of Gottlieb’s case.
In total, Geico recommended and partially paid almost $ 245,000 to the hospital and surgeon for the procedure.
In contrast, Medicare reportedly paid around $ 29,500 for the entire procedure, of which around $ 1,800 would go to the surgeon and the rest to the hospital, according to researchers at Rand Corp. who analyzed Gottlieb’s invoices at the request of KHN and NPR.
The surgeon’s bill was also high compared to what private insurance usually pays, according to Barry Silver of the Healthcare Horizons Consulting Group in Knoxville, Tennessee. Silver compared Gottlieb’s bills with hundreds of similar claims from two carriers that administer employer-based health insurance nationwide. The total amount Geico paid to the hospital was what employers paid and was actually lower than the two highest charges seen in its data. But the highest charge allowed in Silver’s database for the surgeon’s fees was $ 87,549, well below the $ 141,458 recommended by Geico.
Resolution: Gottlieb still does not know if Bergen Pain Management will seek the remaining $ 89,000 for his bill.
Previously, Gottlieb had sued the driver who caused the crash – and had obtained a substantial “pain and suffering” court settlement. He wants to preserve it for future medical needs.
He has filed numerous complaints about his bills with state regulators, lawmakers and his insurers. Aetna sent her surgeon’s bill to her internal special investigations unit following her complaint.
But, “based on our investigation, we determined that there was no longer a need to act,” spokesman Slavin said.
Takeaway meals: Most people don’t know that auto insurance comes first after an accident and works very differently from health insurance – so you need to be careful with policy coordination.
This is especially true if the accident requires major treatment.
If you have a low amount of personal injury coverage in your auto policy, your medical bills may well be included in your health insurance policy. So when you sign up for non-urgent treatment – especially intensive one, such as surgery – it’s important to make sure the providers are part of your health insurance network.
Some auto insurers have networks. Ask if yours does.
Try to get written cost estimates for non-emergency care and compare them with what you left on your auto policy.
“If it’s more than you have left, it may be possible to negotiate with the hospital or doctor to reduce their costs,” said Silver of Healthcare Horizons.
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