A Montana resident was hospitalized with kidney failure and received a dialysis bill for $ 540 842 - ForumDaily
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A Montana resident was admitted to hospital with renal insufficiency and received a dialysis bill for $ 540 842

The 50-year-old coach from Montana had been feeling increasingly unwell over the past few months. He tried changing his diet or exercise routine, but nothing helped. One day the man became so ill that he barely made it to the hospital: his kidneys failed. After two weeks of treatment, Soverin Valentine received a bill for hemodialysis - an “artificial kidney”. The amount was $540.

Фото: Depositphotos

Valentine went to a hospital in a small town of Plains, Montana, where his wife Jessica worked, writes NBC News. According to him, the intoxication was so strong that he could not stop vomiting.

At the hospital, it turned out that Valentine had renal insufficiency, and he immediately needed dialysis.

“I was shocked, but so weak that I couldn’t even worry,” he said.

The man was admitted to a nearby hospital, which was equipped to stabilize his condition and undergo his first dialysis session. There, a social worker arranged for him to undergo outpatient dialysis three times a week. She told the family that Sovereign had two clinic options, both about 70 miles (just over 110 kilometers) from home. The couple chose Fresenius Dialysis Clinic in Missoula.

A few days after the start of treatment, the insurance manager called Valentine, warning that Fresenius was outside the insurance network, so the family could be required to pay all the amounts that the insurer would not cover. As Jessica noted in her notebook, the manager said that “there are no in-network dialysis clinics in Montana” (the insurance company disputes this entry, arguing that the manager was only talking about Missoula).

At the end of the treatment came the bills. The total bill was 540 841,90 USD for 14 weeks of dialysis treatment at the Fresenius clinic, which is not part of the network. The insurer paid 16 241,72 dollars. The clinic billed Valentine for the unpaid balance of 524 600,17 dollars. The service provider was Fresenius Medical Care, one of two companies (along with DaVita) that control about 70% of the US dialysis market.

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Fresenius and DaVita together form what health economists call a "duopoly." They can charge astronomical prices for life-saving treatment, especially when out of the patient's network. The 1973 law allows all end-stage renal disease patients like Sovereign to join Medicare even if they are under 65—but only after a 90-day waiting period. During this time, patients are extremely vulnerable medically and financially.

The amount that the company has exposed to Valentine exceeds the normal cost of a kidney transplant. And it’s twice the debt of his wife Jessica for studying at a medical college. Fresenius took from 13 for Valentine 867,74 dollars for a dialysis session, or about 59 times more than 235 dollars for dialysis for Medicare.

Jessica called the incident a “worst case scenario” and admitted that she cried when she saw the bill. Her husband was outraged.

Dialysis centers justify the high fees they receive from commercial patients by arguing that they make virtually nothing from the rates they pay for Medicare patients. Even so, almost $14 for dialysis is too much.

Dialysis companies are quite profitable. For example, in the 2018 year, Fresenius earned 2 a billion dollars, and most of its revenues went to North America. The difference in remuneration encourages dialysis centers to treat as many private-insured patients as possible and charge as much money as possible while patients are not receiving Medicare. For the same reason, huge sums are taken from patients outside the network.

One possible way to save money on dialysis is to use an at-home option that involves injecting fluids into the abdominal cavity. So-called peritoneal dialysis is common in Europe, but is quite rare in the United States. In July of this year, President Donald Trump announced opportunities to expand the use of these options.

Brad Paffer, a spokesman for Fresenius Medical Care North America, said the company is working with Valentine "to immediately resolve the situation."

“Unfortunately, this individual is a victim of a health care system in which insurers increasingly shift the financial burden to patients,” Puffer said in a written statement Wednesday. “We are committed to doing the right thing so that our patients are not at the center of these controversies.”

On the subject: What to do if you got a medical surprise bill

Фото: Depositphotos

How to act in such a situation?

Decision: As a doctor, Jessica Valentine is well versed in the insurance system. She knew that it was important to find a dialysis provider online. According to her, she and the insurer conducted a search in the online directory of the insurer and could not find it. Perhaps the problem was finding a “supplier” rather than an “object” in the directory. In the end, Jessica wrote to an insurance officer in Montana to find out if the lack of dialysis company violated the requirement that insurers maintain an “adequate network” of providers of such a service.

With the help of the state insurance commissioner, she learned that there is actually a dialysis clinic in the network, operated by a non-profit organization that was not found in the online search and insurer's directory. She immediately arranged for Valentine to start further dialysis there. But bills from Fresenius meanwhile went.

After the company was contacted by reporters, Fresenius' financial advisor told Jessica that Valentine qualified for a 50% discount based on family income - but that was still a whopping $262.

On the subject: What to do if you have problems with paying medical bills

Allegiance, the insurance company that insures Jessica and her husband, said they should have found a clinic online sooner. “Customers can always misunderstand information about how their health plan works, especially in stressful situations,” an Allegiance spokesperson said.

Jessica is looking for a way to challenge the bill with a lawyer. If all else fails, Valentine will consider bankruptcy. As a family doctor working in a rural hospital, Jessica now understands why some of her patients avoid testing and treatment because of the fear of paying a lot of money.

Conclusion: Dialysis is a necessary, life-saving treatment. There is no question of choice here, regardless of the patient’s financial situation. Insurers are required to have adequate networks for all covered health care services in their plans, although the concept of “adequacy” remains vague.

If you feel like there is no choice online, keep looking. Keep in mind that your directory may list dialysis clinics as “facility” rather than “provider.” If you still don't have them, contact your state insurance commissioner for help. Reporting your experience is the only way the Commissioner will know if clinics listed in the directory are not accepting patients or are located far away.

If you have insurance through your employer, you can contact your social department. If there are no options on the network, you must obtain permission to leave the network at intranet rates and with surcharges on the network.

If you receive a bill for out-of-network service, do not write a check. Ask for an itemized invoice and review the expenses. You can also ask the insurance company to negotiate with the provider on your behalf. Find out if your state's laws include the concept of “surprise bills,” in which case you may be protected from high costs.

And when nothing helps, try to negotiate directly with the service provider. They may have a policy of financial assistance and a willingness to significantly reduce costs in order to avoid transferring your case to a debt collector who would pay them very little.

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