The child spent 36 days in a network intensive care unit. Why did the hospital next door send the bill?

Sarah SmithJanuary 30, 2023

Brenna Kearney was seven months pregnant in December 2019 when she developed what she thought were severe flu symptoms.

Her husband, Casey Trumble, drove her from her home in Chicago to the OB/GYN office at Northwestern Medicine Prentice Women’s Hospital in downtown. Due to the sudden rise in blood pressure and the presence of protein in her urine, she was diagnosed with preeclampsia, a potentially fatal but treatable complication of pregnancy. The doctors admitted her to the hospital, saying that she could stay there for up to six weeks and give birth artificially.

Kearney then developed a severe headache and her platelet count plummeted, indicating that she was suffering from a rare and dangerous type of preeclampsia and required an immediate delivery by caesarean section.

Kearney’s daughter, Joey, born at 31 weeks, was put on a ventilator and transferred to the neonatal intensive care unit. Small but healthy, she slowly began to breathe on her own and eat normally. She was discharged at the end of January 2020 after 36 days in the intensive care unit.

Then the bill came.

A patient: Josephine “Joey” Trumble, now 3, was covered by her mother’s health insurance plan through her employer, an advertising agency. For 2019 it was the Aetna plan, and for 2020 it was the Blue Cross and Blue Shield of Illinois plan. Both policies were fully insured plans governed by the laws of the state of Illinois.

Medical service: Neonatologist services were provided in January 2020. Joey needed tube feeding and mechanical ventilation to provide oxygen.

Service Provider: Ann and Robert H. Lurie Children’s Hospital in Chicago, whose staff physicians treated Joey at the Prentice Women’s Hospital of Northwestern Medicine. In terms of ownership, Lurie is independent of Northwestern Medicine, but is physically connected to the Prentice Women’s Clinic by a gated walkway. Lurie has a partnership agreement with Northwestern Medicine to provide neonatology and pediatric services to Prentice Women patients.

Total score: Aetna paid almost all of Joey’s and her mother’s hospital and medical expenses in December, and Blue Cross took over almost all of Joey’s hospital expenses in January. Lurie’s January treatment costs were $14,624.55, of which the family was asked to pay $12,531.58 after payments from Blue Cross.

What gives: It took Kearny months of calls to Blue Cross and two hospitals to figure out why Lurie billed more than $14,000 for doctor’s services: , an out-of-network hospital.

Illinois law prohibits insurance companies from charging patients for neonatal care at out-of-network hospitals.

Kearney said no one told her or her husband that Lurie’s doctors were treating their daughter. She said the family never signed an agreement to consent to treatment from out-of-network doctors.

Although this did not happen here, many patients unknowingly sign extensive financial agreements – saying they will pay for almost anything that their insurance does not cover – on the stacks of documents they receive upon admission to the hospital. In many cases, they are simply asked to sign on the screen without seeing the document.

Blue Cross agreed to pay Lurie an on-net fee for doctors’ services, reducing the bill to about $12,500, which Lurie expected the family to pay.

In November 2020, Kearney began receiving letters from the collection agency ICS Collection Service.

“Conversation with Blue Cross was not possible and Lurie said it was not their problem and just wanted to offer us a payment plan,” Kearney said.

Joey’s 36-day stay in the intensive care unit came before the federal government passed the No Surprises Act, which banned unexpected offline billing. However, there was a state law prohibiting it.

Since 2011, Illinois law has prohibited insurance companies from charging extra rates for neonatologists, anesthesiologists, and certain other physicians when patients are treated at network hospitals.

Kearney said she repeatedly mentioned the law to Lurie and Blue Cross representatives, who denied knowing about the provision.

“Clearly, under the 2011 law, Brenna can only be billed for in-network cost-sharing,” said Kathy Mikos, a registered nurse and patient advocate at the Navocate Group in Woodridge, Illinois, who is not involved in the Kearney case.

In December 2020, an insurance broker working for Kearney’s employer convinced Blue Cross to pay the full cost of Lurie’s out-of-network doctors, leaving the family owed $289.63 for co-insurance, which they promptly paid.

Having spent almost the first year of her daughter’s life wrestling with medical bills since her birth, Kearney thought the ordeal was over.

Then, last month, she got a call from a collection agency that again demanded full off-network charges for Lurie’s doctor services for her daughter three years ago, a bill she believed Blue Cross had paid.

It took Kearney five hours on the phone to piece together what had happened. Blue Cross did pay the out-of-network expenses in December 2020, but withdrew the money two days later, ultimately paying Lurie’s doctors only the in-network rate.

Lurie’s spokesman said Kearney and her husband still owe thousands of dollars. The Blue Cross representative suggested that she put together a payment plan.

“I was desperate and didn’t know how to deal with it anymore,” Kearney said.

Lurie, Blue Cross, and Northwestern Medicine did not respond to multiple KHN requests for comment. Lurie cited patient confidentiality despite having received clearance from Kearney for the federal Health Insurance Portability and Accountability Act, or HIPAA, which allowed the hospital to discuss Joey’s case with KHN.

Permission: After KHN contacted Lurie and Blue Cross, Lurie’s representative called Kearney and offered to eventually accept on-net charges.

Kearney said Tracey A. Spicer, unified services manager at Lurie, told her that Lurie has a “longstanding policy” of accepting Lurie’s on-net fees for physician services provided at Prentice Women’s. Spicer subsequently called it “an old courtesy” and then explained that accepting on-network tariffs was subject to “case-by-case consideration,” Kearney said.

Spicer said the family owed about $3,000 for their co-insurance share and offered to put together a payment plan.

A day later – after more KHN requests for comment – Spicer called Kearney and said she would drop all charges against doctors for caring for her daughter. Spicer did not return a call from KHN asking for comment.

“I am sure that I am not the only person who is still facing such difficulties,” Kearney said.

Kearney filed complaints with the Illinois Department of Insurance and the Illinois Attorney General’s Office. The Attorney General’s Office told KHN that it has never enforced a 2011 law prohibiting billing for certain off-network services.

State Senator Ann Gillespie, who presented the facts in the Kearney case, which sponsored a 2022 state law expanding consumer protection for online bills, told KHN she plans to contact Lurie, Blue Cross and Northwestern Medicine to learn about their billing. agreements and whether they comply with state law.

“We’ll see if that was the pattern and if they need to look back and see if the refunds are justified,” Gillespie said.

The Attorney General’s office told KHN it was investigating Kearney’s complaint, including whether Lurie violated the state’s Consumer Fraud and Misleading Business Practices Act by telling her he was being “polite” by charging her only on-chain rates. although that is what the 2011 law is about. law is required. The insurance department also said they were investigating the complaint.

Conclusion: Even resourceful consumers with the law on their side, like Kearney, can find themselves in a losing, time-consuming battle with the medical billing bureaucracy and facing debt collection actions.

Gillespie, the state senator, said Lurie, Northwestern Medicine and Blue Cross should have known about the state law. She said patients who believe they have been unsubstantiated should file a complaint with their state’s insurance department, which could lead to a broader investigation.

The Federal No Surprises Act, which went into effect last year, prohibits health care providers or insurance companies from billing patients for out-of-network doctor services at a network hospital unless the patient formally consents to see a doctor, not included in the network. For safety reasons, patients should ask their treating physicians if they are in or out of the network, even at a hospital in the network.

While federal law offers patients new protections from offline billing, many Americans are still facing pre-law issues, said Lauren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy. Illinois is one of the relatively few states that has previously enacted consumer protection laws.

In addition, some out-of-network physicians continue to bill patients despite new federal protections. So know your rights. Quote the new law. And don’t write a check.

KHN (Kaiser Health News) is a national news service that produces in-depth journalism on health issues. Together with Policy Analysis and Polling, KHN is one of the three main operating programs of the KFF (Kaiser Family Foundation). KFF is a charitable, non-profit organization providing health information to the nation.