Before the accident, Wetschler bought insurance through a start-up plan called Oscar Health through the state exchange Covered California. Insurance is supposed to step in during emergencies when bills can pile up. Isn't that why we pay for it?
But during his recovery, Wetschler learned that many of the bills he incurred would be denied or only partially covered by insurance because Zuckerberg General, San Francisco's leading trauma center, was out of his insurance network. Another rehab center, which he had pre-approval for, also turned out to be out of network.
So when he was unconscious, Wetschler was somehow responsible for making sure the ambulance took him to an in-network facility. And once there, also still unconscious, he was supposed to make sure that the pathologists and anesthesiologists and the entire team that helped him recover were also in network.
It makes no sense.
Wetschler says he said he called his insurer repeatedly to explain that his care was emergent and that his in-patient rehabilitation for his spine surgery was pre-approved.
In his own words,
Each facility billed me and then was only partially covered for being out-of-network. I would call, remind Oscar of pre-approval or emergent care, Oscar would be given numbers to contact the facilities to independently confirm and assure me things would be cleared up. A month later, the same bills would arrive, but now overdue. It was only after innumerable phone calls, frequent follow ups, and, at times insisting on having an Oscar representative and a hospital representative talk on conference call with me listening that things moved forward — one call lasted almost 30 minutes as the two representatives tried to reconcile their different methods of organizing billing data.
During all of this I endured a tone of polite and sometimes not so polite pejorative dismissal (Oscar was quite polite for the most part, the hospital representatives less so), suggesting that it was my misunderstanding that was the source of the problem. Now a second wave of bills have come through, this time from the physician groups that staffed the ICU, radiology services, and surgical services at the hospital. They bill separately from the hospital and have been, again, seen as out of network. The merry-go-round of calls, reassurance and inaction have resumed. By this time it has been over 8 months since my hospitalization and it still hasn't been resolved! The remainder is $27,000, a fraction of the $450,000+ bill but still a devastating amount to the individual. While I don't see Oscar as some nefarious villain trying to deny coverage overtly, it is a violence through inaction. I do believe Oscar will eventually cover the amount but why has it taken 8 months to the point of these insane bills being sent to debt collectors?
Wetschler has been left with almost $30,000 in debt after this experience, a crippling amount.
And if he doesn't pay it, he risks ruining his credit.
"I'm a doctor with a masters degree in health policy, and this happened to me," he said in an interview with CNBC. "What is it like for everyone else?"
Good question. So I turned to Larry Levitt from the Kaiser Family Foundation, a nonprofit focused on health policy research, to understand how insured people can be left with so much personal liability.
"The idea that you're supposed to figure out what out of network providers might treat you when you're in an emergency is insane," said Levitt. "But it happens."
Balance billing, which involves passing on remaining bills to the patient, is technically prohibited in California during an emergency situation, Levitt says. "After that all bets are off," he said.
There's some grey area about what counts as as "emergency": For instance, if Wetschler were conscious before the spine surgery, the insurer could argue that he should have been transferred to an in-network hospital at that point.
In some states, there are far fewer protections.
If there's some discrepancy over payment between the insurer and the hospital, there's often a negotiation process. The way balance billing works is that the provider sometimes goes to the patient for the additional amount. That often results in the bill getting sent over to a debt collection agency. And bear in mind, the costs of procedures and services are often sky-high, because the lack of transparency in health care means that there are no market forces setting price. So a single x-ray could cost thousands of dollars.
"The market doesn't function in these situations," said Levitt. "The patient is just captive."
So what can patients do?
Well, Levitt suggests that some consumers have success pushing back on the health care providers, which are often willing to settle for less. But it's hard to get them to back down entirely.
Ultimately, he said, "it's a mess."