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Last summer, Eloise Reynolds paid the bill for her husband's final stay in the hospital.
In February 2022, doctors said that Kent, her husband of 33 years, was too weak for the routine chemotherapy that had kept his colon cancer at bay since 2018. He was admitted to Barnes-Jewish Hospital in St. Louis, not far from their home in Olivette, Missouri.
Doctors discovered a partial blockage of his bowel, Reynolds said, but she remained hopeful that his treatment would soon resume.
"I remember calling our kids and saying, 'OK, this is all really good news. We just need to get him kind of bolstered back up and feeling well,'" she said.
But years of chemotherapy had taken a toll on his body, and he told his wife that he couldn't go on any longer.
Kent was discharged and began hospice care at home. He died the next month at age 62.
When Reynolds received the bill for the hospital stay, she paid the $823.15 it said her husband owed. She scribbled "paid" on the bill, memorializing the date, June 30, 2022 — the financial endpoint, she thought, of Kent's years of treatment.
Then the bill came (again).
The patient: Kent Reynolds, deceased, had been covered by Blue Cross and Blue Shield of Illinois through his Illinois-based employer.
Medical service: A 14-day hospital stay related to complications from colon cancer, including a partially blocked bowel.
Service provider: BJC HealthCare, a tax-exempt health system that operates 14 hospitals, mostly in the St. Louis area, including Barnes-Jewish Hospital.
Total bill: The hospital charged $110,666.46 for the stay before any payments or adjustments. The insurer negotiated that price down to $60,348.77, and Reynolds paid the $823.15 the hospital said the patient owed. Then, a year after her husband's death, she received a new version of the bill from the hospital, charging her an additional $1,093.16.
What gives: Reynolds encountered a perplexing reality in medical billing: Providers can — and do — come after patients to collect more money for services months or years after a bill has been paid.
The new bill said Kent Reynolds had been enrolled in a payment plan and that the first "monthly installment" on the nearly $1,100 balance was soon due.
She said she called both the hospital and Blue Cross and Blue Shield of Illinois in search of answers but didn't get an explanation that made sense to her.
According to Reynolds, a BJC HealthCare representative told Reynolds that the insurer had paid more than it owed, meaning the health system had to reimburse the insurer and charge the patient more.
Reynolds said she grabbed a yardstick to use as a straight edge and went line by line, comparing both bills side by side, to see what had changed, a task that evoked painful memories of her husband's last days. The amount for each individual charge — medications, lab tests, supplies, and more — was the same on both bills. The total had not changed.
Only three aspects of the bill had changed: the adjustments; the amount paid by the insurance company; and what the patient owed.
Adjustments, or discounts, are amounts that may be subtracted from a medical bill, typically under the provider's pre-negotiated contract with an insurer. Insurers and providers agree to lower, in-network rates for services provided to patients covered by the insurer.
Reynolds also received an EOB, or "explanation of benefits," letter showing the insurer reviewed the bill again in February, a year after the hospital stay. The document said the hospital's charges for her husband's private room — amounting to nearly $77,000 — were more than his health plan's negotiated room rates, which did not cover the full cost.
The EOB noted that the patient could still owe the hospital $50,216.31 for the room charges — a startling amount — although Reynolds ultimately received no bill indicating she owed that much.
Reynolds said she spent hours trying to understand the items on the hospital and insurance paperwork, since they used medical abbreviations and were grouped differently on the documents.
"It shouldn't be this hard for a widow to figure out what the medical bills were," said Erin Duffy, a research scientist at the University of Southern California's Schaeffer Center for Health Policy and Economics.
Blue Cross and Blue Shield of Illinois declined to comment despite receiving a signed release from Reynolds waiving federal privacy protections.
The resolution: Unclear about what had changed and how much she owed, Reynolds held off on paying the second bill. After KFF Health News contacted BJC HealthCare, Laura High, a media relations manager for the system, said the charges were the result of a "clerical error." Reynolds no longer has a balance, High said in an email in May.
"I was shocked by it," Reynolds said. "I'm convinced most of the people I know would have paid this."
High did not answer questions about the cause of the billing error or how often such errors occur.
However, Duffy provided a different explanation for the charges. "This doesn't seem like an error," she said. "It seems consistent with their insurance plan design."
She said it appeared the additional $1,100 charge — assessed a year later — represented Kent's coinsurance share of the private room charges, which she found as a recurring line item on each page of the bill under the heading "Oncology/PVT."
While his coinsurance responsibility could have amounted to 10% of what the insurer paid in room charges — potentially a huge amount — he had met his out-of-pocket payment maximum for the year, so the charges did not reach the full 10% of the room costs, she said.
The takeaway: In the United States, medical bills and insurance statements create a burdensome puzzle for patients to sort through to determine what is actually owed. The first rule of thumb is: "Don't pay the bill before you've gotten the EOB," which is the insurer's accounting of what you owe and what the insurer will pay, said Kaye Pestaina, co-director of KFF's Program on Patient and Consumer Protections.
In addition, ask for an itemized breakdown of charges and compare it against the EOB.
Medical billing experts said standardizing terms and other details on medical bills and EOBs would help patients enormously in this undertaking.
A few states have taken steps toward giving patients more information about health care charges, including by simplifying medical bills. In 2019, New York state lawmakers proposed requiring hospitals to provide patients with bills in plain language, including an itemized list of services labeled as paid by the insurer or owed by the patient. The proposal, which did not advance, required hospitals to send patients a single bill within seven days of leaving the hospital.
Reynolds' experience highlights the lack of laws and standards around how long providers have to bill — and review bills — for medical services. Insurers may dictate in their contracts how long providers have to submit claims; the Medicare program has a 12-month limit to file claims, for instance. However, Dave Dillon, a spokesperson for the Missouri Hospital Association, said no laws restrict how long providers have to send a bill to patients.
Creditors may seek payment from a deceased person's estate to collect whatever they can, said Berneta Haynes, a senior attorney at the National Consumer Law Center. In Missouri, a living spouse can be held responsible for a deceased spouse's medical bills in certain instances, said Terry Lawson, a managing attorney for Legal Services of Eastern Missouri.
Experts said they did not pinpoint anything Reynolds could have done differently, noting that it is the system that needs to change.
"When can she move on from these hospital bills?" Duffy asked.
Stephanie O'Neill Patison reported the audio story. Emmarie Huetteman of KFF Health News edited the digital story, and Taunya English of KFF Health News edited the audio story. NPR's Will Stone edited the audio and digital story.
KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
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Transcript :
MICHEL MARTIN, HOST:
Now it's time for our August Bill of the Month. Dr. Elisabeth Rosenthal is senior contributing editor with our partner, KFF Health News. Welcome back, Dr. Rosenthal.
ELISABETH ROSENTHAL: Good to be here again.
MARTIN: Whose bill are we talking about today?
ROSENTHAL: This month, we're meeting Eloise Reynolds. She's from Missouri and lives in the Saint Louis area. Her husband died in early 2022, and her struggle over the bill for his final hospital stay shows up as a common but maybe little known reality of the medical billing system in the U.S.
MARTIN: And why is that?
ROSENTHAL: Well, the amount a patient owes for health care sometimes changes over time. So a health care provider might come back demanding more money months or even years after you've paid what you think is the final bill.
MARTIN: All right. Let's hear more about that from reporter Stephanie O'Neill Patison. She spoke with Eloise Reynolds.
STEPHANIE O'NEILL PATISON, BYLINE: Eloise Reynolds smiles as she remembers back to the late '80s when Kent Reynolds asked her to marry him. It was only their third date.
ELOISE REYNOLDS: I said yes, but I mean, if one of my children said that to me, I'd be like, I think, you know, let's not rush in.
PATISON: And yet, Eloise now considers that seemingly rash decision as one of the best she's ever made. She's now 62 with two adult kids.
REYNOLDS: If I liked him when he asked me to marry him, I cannot start to tell you how much I liked him 33 years later. And even though he did break my heart by dying, I would do it all over again.
PATISON: Kent first learned he had colon cancer in 2018, and for a while chemotherapy kept the cancer in check. But a few years later, doctors put his treatment on hold. The chemo had worn down Kent's body. It taxed his liver, and doctors had to remove his gallbladder. Then it was time to focus on the cancer again.
REYNOLDS: The whole team was in his room. They were all saying it's a go. They could get him strong enough to get him back on chemo. I was very excited. And then two days later he said, you know, it's over. I'm really not OK. I'm not well, and it's got to stop.
PATISON: Kent, who was then 62 years old, was discharged into hospice at home, where he died on March 12, 2022. The hospital sent a bill for Kent's care. The out-of-pocket cost was just over $800, which Eloise paid in full, finally closing the book on his years of treatment. Or so she thought. But then, about a year after her husband's death, the hospital sent Eloise a new bill that said the Reynolds owed nearly $1,100 more for Kent's hospital stay. Eloise couldn't figure out why because none of the charges for Kent's medications, lab tests, supplies and other care had changed.
REYNOLDS: It's the exact same bill. And I was so confused. And so I called, and the woman said, you know, I really don't understand this either. I'll call you back. She never called back. I sort of put it on the back burner.
PATISON: The hospital sent the bill again.
REYNOLDS: Same thing - I got out the yardstick to make sure I wasn't losing my mind. I called again. I was on hold for quite a long time, and a woman came on and said, I see what happened.
PATISON: Eloise says a hospital representative told her that the insurance company overpaid the hospital, so the hospital reimbursed the insurance company for the overpayment. Then they turned around and went after the family for some of that money, which is why she got that bill a year later. It didn't make sense to Eloise that they could demand more money. And on top of it all, she was still dealing with intense grief over the loss of Kent.
REYNOLDS: It takes a couple of years, but you do stop focusing on the death. But while you're still focused on the death, reliving that last hospital stay is something you really don't want to ever do.
PATISON: Eloise held off on paying the second bill. The health insurance company declined to comment. When KFF Health News reached out to the health system for comment, a representative said the bill was due to a clerical error and that Eloise owes nothing more. Eloise was able to avoid paying extra, but she suspects lots of other people would have just paid the bill. For NPR News, I'm Stephanie O'Neill Patison.
MARTIN: And we're back with Dr. Elisabeth Rosenthal. Dr. Rosenthal, what do we think happened between the hospital and the health system in this story? You have a theory about that?
ROSENTHAL: Well, one thing we know is that hospitals and insurance companies typically have pre-negotiated contracts, and the insurance company is only going to pay the lower negotiated rate. That might explain what happened with that overpayment where the hospital had to send money back to the insurance company. You know, our health care system is so complicated. Clerical mistakes happen all the time. But should a patient or, in this case, a grieving spouse be responsible?
MARTIN: OK. It seems pretty mind-boggling, but let's say that this can happen. So if that can happen, what should patients do?
ROSENTHAL: So the first rule of thumb is don't pay the bill before you've gotten the explanation of benefits. What's called the EOB is the insurance company's accounting of what you owe and what the insurer will pay. If something doesn't look right, the next step is to ask the health care provider for an itemized list of your charges. Then compare that against the EOB - fair amount of work, though.
MARTIN: Yeah. And in this story, we just heard Eloise Reynolds say that she literally had to get a ruler out to make heads or tails of the medical bill. By that, I mean, she probably just took the ruler and just went line by line trying to figure out, you know, what was on those lines. Does it have to be so hard?
ROSENTHAL: Yes, she did the work, but it's hard, which is why many billing experts say it's time for a system-wide change to give patients more information about their health care charges. And that would include medical bills that are simpler and easier for mere mortals to read.
MARTIN: Is there any hope or alternatives for patients like Eloise Reynolds? I mean it's - look, it's hard to fathom another system where you can pay for something and then months or years later have somebody come back and say, actually, no, you owe me more. So is there anything on the table here?
ROSENTHAL: Unfortunately, right now, there's simply not much oversight or industry standard for how long providers have to send a bill for medical services. But I think it'll come because there's really now broad recognition that it's needed. In the meantime, that means patients can be caught off guard months or years later when a bill shows up in the mail. But when that bill does show up, there are options to fight back. You might point out that Medicare won't pay claims submitted after a year. Or, of course, there's always the option of sending your story to Bill of the Month.
MARTIN: Dr. Elisabeth Rosenthal, thank you so much.
ROSENTHAL: Thanks for having me.
MARTIN: And if you have a confusing or outrageous medical bill that you want us to review, do what Dr. Rosenthal said - please go to NPR's Shots blog and tell us all about it.
(SOUNDBITE OF MUSIC) Transcript provided by NPR, Copyright NPR.