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Essential Worker Shoulders $1,840 Pandemic Debt Due To COVID Cost Loophole

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Carmen Quintero works an early shift as a supervisor at a 3M distribution warehouse that ships N95 masks to a nation under siege from the coronavirus. On March 23, she had developed a severe cough, and her voice, usually quick and enthusiastic, was barely a whisper.

A human resources staff member told Quintero she needed to go home.

“They told me I couldn’t come back until I was tested,” said Quintero, who was also told that she would need to document that she didn’t have the virus.

Her primary care doctor directed her to the nearest emergency room for testing because the practice had no coronavirus tests.

The Corona Regional Medical Center is just around the corner from her house in Corona, California, and there a nurse tested her breathing and gave her a chest X-ray. But the hospital didn’t have any tests either, and the nurse told her to go to Riverside County’s public health department. There, a public health worker gave her an 800 number to call to schedule a test. The earliest the county could test her was April 7, more than two weeks later.

At the hospital, Quintero got a doctor’s note saying she should stay home from work for a week, and she was told to behave as if she had COVID-19, isolating herself from vulnerable household members. That was difficult — Quintero lives with her grandmother and her girlfriend’s parents — but she managed. No one else in her home got sick, and by the time April 7 came, she felt better and decided not to get the coronavirus test.

Then the bill came.

The Patient: Carmen Quintero, 35, a supervisor at a 3M distribution warehouse who lives in Corona, California. She has an Anthem Blue Cross health insurance plan through her job with a $3,500 annual deductible.

Total Bill: Corona Regional Medical Center billed Quintero $1,010, and Corona Regional Emergency Medical Associates billed an additional $830 for physician services. She also paid $50 at Walgreens to fill a prescription for an inhaler.

Service Provider: Corona Regional Medical Center, a for-profit hospital owned by Universal Health Services, a company based in King of Prussia, Pennsylvania, which is one of the largest health care management companies in the nation. The hospital contracts with Corona Regional Emergency Medical Associates, part of Emergent Medical Associates.

Medical Service: Quintero was evaluated in the emergency room for symptoms consistent with COVID-19: a wracking cough and difficulty breathing. She had a chest X-ray and a breathing treatment and was prescribed an inhaler.


What Gives: On that day in late March when her body shook from coughing, Quintero’s immediate worry was infecting her family, especially her girlfriend’s parents, both over 65, and her 84-year-old grandmother.

“If something was to happen to them, I don’t know if I would have been able to live with it,” said Quintero.

Quintero wanted to isolate in a hotel, but she could hardly afford to for the week that she stayed home. She had only three paid sick days and was forced to take vacation time until her symptoms subsided and she was allowed back at work. At the time, few places provided publicly funded hotel rooms for sick people to isolate, and Quintero was not offered any help.

For her medical care, Quintero knew she had a high-deductible plan yet felt she had no choice but to follow her doctor’s advice and go to the nearest emergency room to get tested. She assumed she would get the test and not have to pay. Congress had passed the CARES Act just the week before, with its headlines saying coronavirus testing would be free.

That legislation turned out to be riddled with loopholes, especially for people like Quintero who needed and wanted a coronavirus test but couldn’t get one early in the pandemic.

“I just didn’t think it was fair because I went in there to get tested,” she said.

Carmen Quintero (right) still tries to keep a safe distance from her grandmother, Teresa Carapia, and two other family members over 65. Quintero says she worried about them as she tried to self-isolate with COVID-like symptoms.(Heidi de Marco/KHN)

Some insurance companies are voluntarily reducing copayments for COVID-related emergency room visits. Quintero said her insurer, Anthem Blue Cross, would not reduce her bill. Anthem would not discuss the case until Quintero signed its own privacy waiver; it would not accept a signed standard waiver KHN uses. The hospital would not discuss the bill with a reporter unless Quintero could also be on the phone, something that has yet to be arranged around Quintero’s workday, which begins at 4 a.m. and ends at 3:30 p.m.

Three states have gone further than Congress to waive cost sharing for testing and diagnosis of pneumonia and influenza, given these illnesses are often mistaken for COVID-19. California is not one of them, and because Quintero’s employer is self-insured — the company pays for health services directly from its own funds — it is exempt from state directives anyway. The U.S. Department of Labor regulates all self-funded insurance plans. In 2019, nearly 2 in 3 covered workers were in these types of plans.

Resolution: As lockdown restrictions ease and coronavirus cases rise around the country, public health officials say quickly isolating sick people before the virus spreads through families is essential.

But isolation efforts have gotten little attention in the U.S. Nearly all local health departments, including Riverside County, where Quintero lives, now have these programs, according to the National Association of County and City Health Officials. Many were designed to shelter people experiencing homelessness but can be used to isolate others.

Raymond Niaura, interim chairman of the Department of Epidemiology at New York University, said these programs are used inconsistently and have been poorly promoted to the public.

“No one has done this before and a lot of what’s happening is that people are making it up as they go along,” said Niaura. “We’ve just never been in a circumstance like this.”

Quintero still worries about bringing the virus home to her family and fears being in the same room with her grandmother. Quintero returns from work every day now, puts her clothes in a separate hamper and diligently washes her hands before she interacts with anyone.

The bills have been another constant worry. Quintero called the hospital and her insurance company and complained that she should not have to pay since she was seeking a test on her doctor’s orders. Neither budged, and the bills labeled “payment reminders” soon became “final notices.” She reluctantly agreed to pay $100 a month toward her balance — $50 to the hospital and $50 to the doctors.

“None of them wanted to work with me,” Quintero said. “I just have to give the first payment on each bill so they wouldn’t send me to collections.”

The Takeaway: If you suspect you have COVID-19 and need to isolate to protect vulnerable members of your household, call your local public health department. Most counties have isolation and quarantine programs, but these resources are not well known. You may be placed in a hotel, recreational vehicle or other type of housing while you wait out the infection period. You do not need to have a positive COVID test to qualify for these programs and can use these programs while you await your test result. But this is an area in which public health officials repeatedly offer clear guidance — 14 days of isolation — which most people find impossible to follow.

At this point in the pandemic, tests are more widely available and federal law is very clearly on your side: You should not be charged any cost sharing for a coronavirus test.

Be wary, though, if your doctor directs you to the emergency room for a COVID test, because any additional care you get there could come at a high price. Ask if there are any other testing sites available.

If you do find yourself with a big bill related to suspected COVID, push beyond a telephone call with your insurance company and file a formal appeal. If you feel comfortable, ask your employer’s human resources staff to argue on your behalf. Then, call the help line for your state insurance commissioner and file a separate appeal. Press insurers — and big companies that offer self-insured plans — to follow the spirit of the law, even if the letter of the law seems to let them off the hook.

Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!



from Health Industry – Kaiser Health News

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Hospital Executive Charged In $1.4B Rural Hospital Billing Scheme

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A Miami entrepreneur who led a rural hospital empire was charged in an indictment unsealed Monday in what federal prosecutors called a $1.4 billion fraudulent lab-billing scheme.

In the indictment, prosecutors said Jorge A. Perez, 60, and nine others exploited federal regulations that allow some rural hospitals to charge substantially higher rates for laboratory testing than other providers. The indictment, filed in U.S. District Court in Jacksonville, Florida, alleges Perez and the other defendants sought out struggling rural hospitals and then contracted with outside labs, in far-off cities and states, to process blood and urine tests for people who never set foot in the hospitals. Insurers were billed using the higher rates allowed for the rural hospitals.

Perez and the other defendants took in $400 million since 2015, according to the indictment. Many of the hospitals run or managed by Perez’s Empower companies have since failed as they ran out of money when insurers refused to pay for the suspect billing. Half of the nation’s rural hospital bankruptcies in 2019 were affiliated with his empire.

“This was allegedly a massive, multi-state scheme to use small, rural hospitals as a hub for millions of dollars in fraudulent billings of private insurers,” said Assistant Attorney General Brian Benczkowski of the Justice Department’s Criminal Division in a statement.

Attempts to reach Perez for comment Monday evening were unsuccessful. But last year when Perez spoke to KHN, he said he was losing sleep over the possibility he could go to jail after propping up struggling rural hospitals.

“I wanted to see if I could save these rural hospitals in America,” Perez said. “I’m that kind of person.”

Pam Green, a former night charge nurse at the now-shuttered Horton Community Hospital in Horton, Kansas (population under 1,700), said she hopes Perez and his colleagues receive long prison sentences.

“He just devastated so many people, not just in Kansas, but in Oklahoma and all the other places where he had hospitals,” said Green, 58, of nearby Muscotah, Kansas. “I went months and months without pay, without health insurance. He robbed the community.”

Green recalled that money was so tight under Perez’s management of her former hospital that the electricity was shut off at least twice and staffers had to bring in their own supplies. She said she is owed about $12,000 in back pay, as well as money for uncovered dental expenses and a workplace injury that would have been covered had employees’ insurance or workers’ compensation premiums been paid.

A KHN investigation published in August 2019 detailed the rise and fall of Perez’s rural hospitals. At the height of his operation, Perez and his Miami-based management company, EmpowerHMS, helped oversee a rural empire encompassing 18 hospitals across eight states. Perez owned or co-owned 11 of those hospitals and was CEO of the companies that provided their management and billing services.

Perez styled himself a savior of rural hospitals, swooping into small towns with promises to save their struggling facilities using his “secret sauce” of financial ventures. Multiple employees told KHN they had no idea what happened to the money their hospitals earned after Perez and his associates took control, since the facilities seemed perpetually starved for cash.

Over the past two years, amid mounting legal challenges and concerns about the lab-billing operation, insurers cut off funding and his empire crumbled. Overall, 12 of the hospitals have entered bankruptcy and eight have closed. The staggering collapse left hundreds of employees without jobs and small towns across the Midwest and South without lifesaving medical care.

The four rural hospitals named in the indictment are Campbellton-Graceville Hospital in Graceville, Florida; Regional General Hospital of Williston, Florida; Chestatee Regional Hospital in Dahlonega, Georgia; and Putnam County Memorial Hospital in Unionville, Missouri.

The indictment marks the third major case federal prosecutors have filed alleging billing fraud at Perez-affiliated hospitals. In October, David Byrns pleaded guilty to a federal charge of conspiracy to commit health care fraud involving a Missouri hospital he managed with Perez. A Missouri Auditor General report previously found that the 15-bed hospital, Putnam County Memorial in Unionville, had received about $90 million in questionable insurance payments in less than a year.

In July 2019, Kyle Marcotte, owner of a Jacksonville Beach, Florida, addiction treatment center pleaded guilty for his part in a $57 million lab-billing scheme involving two Perez-affiliated hospitals, Campbellton-Graceville and Regional General Hospital. Marcotte admitted cooperating with unnamed hospital managers to provide urine samples from his patients for lab testing that was billed through the rural hospitals and, in exchange, getting a cut of the proceeds.

Perez, on his own and through Empower-affiliated companies, in 2016 and 2017 purchased South Florida properties that totaled more than $3.7 million, including three condos on Key Largo, according to property records. He told KHN last year that the Florida properties were bought with earnings from unrelated software companies but declined to give details. He and his brother Ricardo Perez, if convicted, must forfeit over $46 million, according to the indictment, as well as two Key Largo condos and other properties.

Another defendant, Aaron Durall, if convicted, could lose $184.4 million and a six-bedroom, 6,500-square-foot home in the affluent Parkland district north of Fort Lauderdale, Florida.

Perez-affiliated hospitals also face ongoing lawsuits in Missouri and other states filed by dozens of insurers asking for hundreds of millions in restitution for allegedly fraudulent billings. In those court documents, Perez repeatedly has denied wrongdoing. He told KHN last year that his lab-billing setup was “done according to Medicare and state guidelines.”

For former employees of EmpowerHMS and members of the affected communities, the indictment represents vindication. As the company foundered, hundreds of employees worked without pay in vain efforts to keep their hospitals afloat. They would discover later that, along with the missing paychecks, their insurance premiums had not been paid and their medical policies had been discontinued. In the June 2019 interview, Perez acknowledged that, as finances withered, he stopped paying employee payroll taxes.

“It’s nice to think he might be held accountable,” said Melva Price Lilley, a former X-ray technician at Washington County Hospital in Plymouth, North Carolina, which has reopened with new owners under a new name. “At least there’s a chance that he might have to suffer some consequences. That gives me some hope.”

Lilley, 56, said she and other employees could not retrieve their retirement savings from the bankrupt hospital until about three weeks ago. She has been trying to pay off about $68,000 in medical bills from a back surgery she needed for a workplace injury that wasn’t covered by workers’ compensation insurance premiums that went unpaid for hospital employees. She remains unable to work full time.

I-70 Community Hospital, an Empower facility in Sweet Springs, Missouri, has remained closed since February 2019. Tara Brewer, head of the Sweet Springs Chamber of Commerce and the local health department, said she was almost shocked to hear that Perez had gotten indicted after months of wondering if anything would happen.

While she hopes these charges bring closure to her community, she said, the charges do little to fix the closed hospital doors for a county that has had one of the highest per capita rates of coronavirus cases in Missouri.

“What he did to us will linger on for a long time,” Brewer said.



from Health Industry – Kaiser Health News

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Workers Filed More Than 4,100 Complaints About Protective Gear. Some Still Died.

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COVID-19 cases were climbing at Michigan’s McLaren Flint hospital. So Roger Liddell, 64, who procured supplies for the hospital, asked for an N95 respirator for his own protection, since his work brought him into the same room as COVID-positive patients.

But the hospital denied his request, said Kelly Indish, president of the American Federation of State, County and Municipal Employees Local 875.

On March 30, Liddell posted on Facebook that he had worked the previous week in both the critical care unit and the ICU and had contracted the virus. “Pray for me God is still in control,” he wrote. He died April 10.

Roger Liddell(Courtesy of Bill Sohmer)

The hospital’s problems with personal protective equipment (PPE) were well documented. In mid-March, the state office of the Occupational Safety and Health Administration (OSHA) received five complaints, which described employees receiving “zero PPE.” The cases were closed April 21, after the hospital presented paperwork saying problems had been resolved. There was no onsite inspection, and the hospital’s written response was deemed sufficient to close the complaints, a local OSHA spokesperson confirmed.

The grief and fear gripping workers and their families reflect a far larger pattern. Since March, more than 4,100 COVID-related complaints regarding health care facilities have poured into the nation’s network of federal and state OSHA offices, which are tasked with protecting workers from harm on the job.

A KHN investigation found that at least 35 health care workers died after OSHA received safety complaints about their workplaces. Yet by June 21, the agency had quietly closed almost all of those complaints, and none of them led to a citation or a fine.

The complaint logs, which have been made public, show thousands of desperate pleas from workers seeking better protective gear for their hospitals, medical offices and nursing homes.

The quick closure of complaints underscores the Trump administration’s hands-off approach to oversight, said former OSHA official Deborah Berkowitz. Instead of cracking down, the agency simply sent letters reminding employers to follow Centers for Disease Control and Prevention guidelines, said Berkowitz, now a director at the National Employment Law Project.

“This is a travesty,” she said.

A third of the health care-related COVID-19 complaints, about 1,300, remain open and about 275 fatality investigations are ongoing.

During a June 9 legislative hearing, Labor Secretary Eugene Scalia said OSHA had issued one coronavirus-related citation for violating federal standards. A Georgia nursing home was fined $3,900 for failing to report worker hospitalizations on time, OSHA’s records show.

“We have a number of cases we are investigating,” Scalia said at the Senate Finance Committee hearing. “If we find violations, we will certainly not hesitate to bring a case.”

Texts between Barbara Birchenough and her daughter, (in blue) Kristin Carbone.(Courtesy of Kristin Carbone)

A March 16 complaint regarding Clara Maass Medical Center in Belleville, New Jersey, illustrates the life-or-death stakes for workers on the front lines. The complaint says workers were “not allowed to wear” masks in the hallway outside COVID-19 patients’ rooms even though studies have since shown the highly contagious virus can spread throughout a health care facility. It also said workers “were not allowed adequate access” to PPE.

Nine days later, veteran Clara Maass registered nurse Barbara Birchenough texted her daughter: “The ICU nurses were making gowns out of garbage bags. … Dad is going to pick up large garbage bags for me just in case.”

Kristin Carbone, the eldest of four, said her mother was not working in a COVID area but was upset that patients with suspicious symptoms were under her care.

In a text later that day, Birchenough admitted: “I have a cough and a headache … we were exposed to six patients who we are now testing for COVID 19. They all of a sudden got coughs and fevers.”

“Please pray for all health care workers,” the text went on. “We are running out of supplies.”

By April 15, Birchenough, 65, had died of the virus. “They were not protecting their employees in my opinion,” Carbone said. “It’s beyond sad, but then I go to a different place where I’m infuriated.”

OSHA records show six investigations into a fatality or cluster of worker hospitalizations at the hospital. A Labor Department spokesperson said the initial complaints about Clara Maass remain open and did not explain why they continue to appear on a “closed” case list.

Nestor Bautista, 62, who worked closely with Birchenough, died of COVID-19 the same day as she did, according to Nestor’s sister, Cecilia Bautista. She said her brother, a nursing aide at Clara Maass for 24 years, was a quiet and devoted employee: “He was just work, work, work,” she said.

Barbara Birchenough(Courtesy of Kristin Carbone)

Nestor Bautista(Courtesy of Cecilia Bautista)

Responding to allegations in the OSHA complaint, Clara Maass Medical Center spokesperson Stacie Newton said the virus has “presented unprecedented challenges.”

“Although the source of the exposure has not been determined, several staff members” contracted the virus and “a few” have died, Newton said in an email. “Our staff has been in regular contact with OSHA, providing notifications and cooperating fully with all inquiries.”

Other complaints have been filed with OSHA offices across the U.S.

Twenty-one closed complaints alleged that workers faced threats of retaliation for actions such as speaking up about the lack of PPE. At a Delaware hospital, workers said they were not allowed to wear N95 masks, which protected them better than surgical masks, “for fear of termination or retaliation.” At an Atlanta hospital, workers said they were not provided proper PPE and were also threatened to be fired if they “raise[d] concerns about PPE when working with patients with Covid-19.”

Of the 4,100-plus complaints that flooded OSHA offices, over two-thirds are now marked as “closed” in an OSHA database. Among them was a complaint that staffers handling dead bodies in a small room off the lobby of a Manhattan nursing home weren’t given appropriate protective gear.

More than 100 of those cases were resolved within 10 days. One of those complaints said home health nurses in the Bronx were sent to treat COVID-19 patients without full protective gear. At a Massachusetts nursing home that housed COVID patients, staff members were asked to wash and reuse masks and disposable gloves, another complaint said. A complaint about an Ohio nursing home said workers were not required to wear protective equipment when caring for COVID patients. That complaint was closed three days after OSHA received it.

It remains unclear how OSHA resolved hundreds of the complaints. A Department of Labor spokesperson said in an email that some are closed based on an exchange of information between the employer and OSHA, and advised reporters to file Freedom of Information Act requests for details on others.

“The Department is committed to protecting America’s workers during the pandemic,” the Labor Department said in a statement. “OSHA has standards in place to protect employees, and employers who fail to take appropriate steps to protect their employees may be violating them.”

The agency advised its inspectors on May 19 to place reports of fatalities and imminent danger as a top priority, with a special focus on health care settings. Since late March, OSHA has opened more than 250 investigations into fatalities at health care facilities, government records show. Most of those cases are ongoing.

According to the mid-March complaints against McLaren Flint, workers did not receive needed N95 masks and “are not allowed to bring them from home.” They also said patients with COVID-19 were kept throughout the hospital.

Patrick Cain and his wife, Kate(Courtesy of Kelly Indish)

Filing complaints, though, did little for Liddell, or for his colleague, Patrick Cain, 52. After the complaints were filed, Cain, a registered nurse, was treating people still awaiting the results of COVID-19 diagnostic tests — potentially positive patients ― without an N95 respirator. He was also working outside a room where potential COVID-19 patients were undergoing treatments that research supported by the University of Nebraska has since shown can spread the virus widely in the air.

At the time, there was a debate over whether supply chain breakdowns of PPE and weakened CDC guidelines on protective gear were putting workers at risk.

Cain felt vulnerable working outside of rooms where COVID patients were undergoing infection-spreading treatments, he wrote in a text to Indish on March 26.

Texts between union president Kelly Indish and Patrick Cain (right)(Courtesy of Kelly Indish)

“McLaren screwed us,” he wrote.

He fell ill in mid-March and died April 4.

McLaren has since revised its face-covering policy to provide N95s or controlled air-purifying respirators (CAPRs) to workers on the COVID floor, union members said.

A spokesperson for the McLaren Health Care system said the OSHA complaints are “unsubstantiated” and that its protocols have consistently followed government guidelines. “We have always provided appropriate PPE and staff training that adheres to the evolving federal, state, and local PPE guidelines,” Brian Brown said in an email.

Separate from the closed complaints, OSHA investigations into Liddell and Cain’s deaths are ongoing, according to a spokesperson for the state’s Department of Labor and Economic Opportunity.

Nurses at Kaiser Permanente Fresno Medical Center also said the complaints they aired before a nurse’s death have not been resolved. (KHN is not affiliated with Kaiser Permanente.)

On March 18, nurses filed an initial complaint. They told OSHA they were given surgical masks, instead of N95s. Less than a week later, other complaints said staffers were forced to reuse those surgical masks and evaluate patients for COVID without wearing an N95 respirator.

Several nurses who cared for one patient who wasn’t initially suspected of having COVID-19 in mid-March wore no protective gear, according to Amy Arlund, a Kaiser Fresno nurse and board member of the National Nurses Organizing Committee board of directors. Sandra Oldfield, a 53-year-old RN, was among them.

Arlund said Oldfield had filed an internal complaint with management about inadequate PPE around that time. Arlund said the patient’s illness was difficult to pin down, so dozens of workers were exposed to him and 10 came down with COVID-19, including Oldfield.

Sandra Oldfield(Courtesy of Lori Rodriguez)

Lori Rodriguez, Oldfield’s sister, said Sandra was upset that the patient she cared for who ended up testing positive for COVID-19 hadn’t been screened earlier.

“I don’t want to see anyone else lose their life like my sister did,” she said. “It’s just not right.”

Wade Nogy, senior vice president and area manager of Kaiser Permanente Fresno, confirmed that Oldfield had exposure to a patient before COVID-19 was suspected. He said Kaiser Permanente “has years of experience managing highly infectious diseases, and we are safely treating patients who have been infected with this virus.”

Kaiser Permanente spokesperson Marc Brown said KP “responded to these complaints with information, documents and interviews that demonstrated we are in compliance with OSHA regulations to protect our employees.” He said the health system provides nurses and other staff “with the appropriate protective equipment.”

California OSHA officials said the initial complaints were accurate and the hospital was not in compliance with a state law requiring workers treating COVID patients to have respirators. However, the officials said the requirement had been waived due to global shortages.

Kaiser Fresno is now in compliance, Cal/OSHA said in a statement, but the agency has ongoing investigations at the facility.

Arlund said tension around protective gear remains high at the hospital. On each shift, she said, nurses must justify their need for a respirator, face shield or hair cap. She expressed surprise that the OSHA complaints were considered “closed.”

“I’m very concerned to hear they are closing cases when I know they haven’t reached out to front-line nurses,” Arlund said. “We do not consider any of them closed.”



from Health Industry – Kaiser Health News

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Ghost Bill: UVA Siphons Couple’s Tax Refund To Pay 20-Year-Old Medical Debt

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The notice from the Virginia tax department puzzled a Charlottesville couple last October. It said their state income tax refund had been reduced because of an outstanding medical debt to the University of Virginia Medical Center. Instead of $220, they got $110.

Mystified, they contacted UVA for details about the unpaid bill. The answer astonished them. The medical center had asked the tax department to withhold the money for medical care their son received in 2001 and 2002.

Jane Collins and Anthony Blow received a notice last year from the Virginia tax department, which reduced their state income tax refund to offset outstanding medical debt.(Courtesy of Jane Collins)

“The amount is not the issue; it’s this whole idea that you can go after something that is so old,” said Jane Collins. “Maybe technically you are entitled to that money, but do you mean to tell me you can go into the deep recesses of your computer and now you’re going to take this?”

Initially, Collins couldn’t remember what the bill was for, and she no longer had paper records from nearly two decades ago.

According to financial documents the hospital sent Collins and her husband, Anthony Blow, late last year, the bills relate to three hospitalizations for their son, who was born prematurely and frequently hospitalized as a child.

Collins believes the 2001 hospital visits are probably related to a shunt her son had when he was 3 to relieve fluid buildup in his brain. She’s uncertain what the 2002 charges are for. The computer printouts she received from UVA list service codes and billed charges but don’t describe why he was hospitalized.

“I’m utterly confused by all of this,” said Collins, whose family is covered by the same employer plan they had then. “Eighteen years later, I don’t remember disputing anything about the bills.”

A spokesperson for the health system said patient privacy laws prohibit them from commenting on specific cases.

Virginia is one of at least a dozen states that can dock residents’ income tax refunds to pay delinquent medical debts, according to Richard Gundling, a senior vice president for the Healthcare Financial Management Association, an organization for finance professionals. In Virginia, state-affiliated hospitals like the University of Virginia Medical System and Virginia Commonwealth University Health System generally first attempt to collect money owed to them directly or by enlisting a collection agency.

If those efforts fail, they send the claims to the state tax department’s Set-Off Debt Collection Program. The tax department uses Social Security numbers to electronically match claims submitted by the hospitals with individual income tax refunds. When the system finds a match, it withholds all or part of the refund and sends it to the hospital.

In fiscal 2018, Virginia collected $68 million in individual debts through the program, a figure that includes medical bills and other types of debt owed to state and local government agencies and state courts, among others.

It’s a controversial way to collect medical debt, especially for care delivered decades ago.

“This gives a whole new meaning to surprise medical bills,” said Mark Rukavina, business development manager at Community Catalyst, a consumer advocacy organization. “Digging up a bill that’s 20 years old and informing someone that they owe it by attaching their tax refund is not good policy.”

State laws prohibit private collection agencies from suing consumers after a specified period of time, often three to six years. The laws don’t extinguish the debt, but they protect consumers from being taken to court many years later, when documents may be lost and memories fuzzy.

But there’s no similar time limit for going after Virginia consumers’ tax refunds through the setoff program.

“[This] hospital is an agency of the commonwealth and the statute of limitations doesn’t apply to the commonwealth,” said Caroline Klosko, an attorney at the Legal Aid Justice Center in Charlottesville. Klosko said she worked with a client who faced a similar refund capture by UVA for a medical debt that was six years old.

In addition to the age of the debt, concerns over whether the amount billed is accurate are often legitimate.

What if people are charged too much in the first place? Federal law requires nonprofit hospitals to have patient financial assistance policies and to publicize them widely. For-profit hospitals generally seem to have similar programs, said Rukavina. But income standards and other requirements to qualify for discounted or free care vary widely and may not be easy for patients to find.

A new state law will prohibit UVA and VCU from taking consumers’ tax refunds to satisfy medical debts unless the health systems have determined that patients aren’t eligible for their financial assistance programs or Medicaid, the state-federal health insurance program for low-income people.

UVA screens people routinely for financial assistance and Medicaid eligibility, according to spokesperson Eric Swensen. Every year, the health system helps roughly 3,500 people qualify for Medicaid or Family Access to Medical Insurance Security, a program for children whose families earn too much for regular Medicaid, he said.

If someone has an overdue bill with UVA, the health system turns to the refund setoff program as a last resort after all other options, including establishing interest-free payment plans, have been exhausted, Swensen said. In 2019, UVA received $4 million from tax refunds for delinquent medical debt, according to Swensen. Virginia Commonwealth University Medical Center collected approximately $7.7 million through the debt setoff program in 2019, according to spokesperson Laura Rossacher.

Collins said that she and her husband knew nothing about their debt until they got their smaller-than-expected “tax relief refund” last fall, along with a notice directing them to contact UVA if they had questions. (Under a 2019 state law, Virginia taxpayers were eligible to receive a one-time tax relief refund of up to $110 for individuals and $220 for married couples who file their taxes jointly.)

She said the couple had received state tax refunds in the years since this care was provided.

Swensen said that, in general, once a patient’s outstanding balance is sent to the state’s setoff program, “we are required to resubmit that balance to the state database each year until the patient pays their outstanding balance or the outstanding balance is satisfied through the debt setoff program.”

“If a patient had previous tax refunds that were not assessed, we are unsure why this happened,” he said.

A patient financial services representative at UVA told Collins the health system had sent billing statements, as well as final notices informing the couple that their accounts were being referred to collections. UVA also said it had notified them that the accounts would be reported to the state Department of Taxation.

Collins said that they never received those notices but that after their tax refund was withheld, they did receive several notices.

In October and November, Collins and Blow received letters from both UVA and the tax department informing them of four setoff claims totaling $220, in the amounts of $67.39, $42.61, $78.63 and $31.37. Two of the dollar amounts matched up with the itemized bills from UVA, but two did not. If they wanted to contest the claims, the notices said, they could request a hearing with UVA. Collins did so.

Subsequently, the UVA patient services rep said that as a “one-time courtesy” the health system would release the hold on the $110 from their refund, Collins recounted.

In late May, Collins and Blow received a “patient refund card” worth $31.37 from UVA for their son’s care. But the odyssey continues. The following week, the state tax department informed them it had once again withheld money from their tax refund — $5.79 this time — to satisfy an unpaid UVA debt.

Collins said she planned to call UVA to ask about the refund offset, but she assumes it’s also related to her son’s care nearly 20 years ago.

How much longer will this go on, Collins wonders. Do Collins and Blow still owe money to UVA? If they do owe money, how much do they owe? And why did it take so long for UVA to come looking for it?

Collins said she has asked UVA those questions but hasn’t gotten clear answers. Her frustration is through the roof.

“You know what I think government agencies and state hospitals are good at?” Collins asked. “Obfuscation.”



from Health Industry – Kaiser Health News

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US Nurses At For-Profit Hospital Chain To Strike Over Cuts And PPE Shortages

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Nurses and support staff at HCA Healthcare, the largest for-profit hospital chain in the U.S., plan to strike Friday in protest over cuts and concessions the corporation is pushing on front-line health care workers as the coronavirus continues to spread nationwide.

The Guardian and KHN have so far identified reports of 679 front-line health care workers who have died of COVID-19 in the U.S. amid continuing reports of long hours and shortages of personal protective equipment (PPE).

Erin McIntosh, a nurse in the code blue/rapid response department at the HCA-owned Riverside Community Hospital in Riverside, California, for six years, is one of around 1,000 nurses represented by SEIU Local 121RN planning to strike in protest of hospital understaffing during the pandemic, which they say violates California’s nurse-to-patient ratio laws.

“HCA has continuously not upheld their end of the mediation agreement of our nurses staying in ratio,” said McIntosh. The agreement was made in March 2019. “We’re striking June 26 through July 6 because they didn’t want to uphold our mediation agreement.”

Hospital staffs have regularly reused masks and gowns throughout the pandemic, McIntosh explained, creating another layer of stress for health care workers.

“When the pandemic hit, I thought HCA, our hospital, would be revving up the resources, that we would have more resources, more staff, but unfortunately it was the opposite. They started making cuts, and we’re working with skeleton crews,” McIntosh added. “We’re being cut to the bare minimum.”

Job listings for nurses at HCA-owned hospitals in the Los Angeles area were posted in anticipation of the strike actions. HCA reportedly created a unit focused on strike-related labor shortages, offering nurses who appear for shifts during strikes higher pay than they currently receive and free continental breakfast. The company is also seeking to hire labor relations directors in Denver, Dallas, Kansas City and Nashville, Tennessee, and has continued retaining union avoidance consultants in Asheville, North Carolina, amid a union organizing drive at Mission Hospital.

“After thoughtful consideration; the hospital and 121RN failed to come to an agreement and we declined to extend the current agreement,” a spokesperson for HCA told the Guardian in an email. “At this time we believe we are independently making significant progress around the topic of staffing at Riverside Community Hospital and believe that we can support our employees on our own without the influence of an outdated agreement.”

Around the U.S., nurses and hospital workers at HCA have reported understaffing and a lack of resources through the coronavirus pandemic. HCA is currently pushing employees to accept several concessions to pay and benefits — including wage freezes, elimination of 401(k) retirement contributions — and signaling the possibility of layoffs, with non-union employees already forced to accept freezes to annual wage and salary raises.

HCA received about $1 billion in federal coronavirus relief that does not have to be repaid, and over $4 billion in accelerated Medicare payments. The corporation made over $7 billion in profits over the past two years, and HCA CEO Sam Hazen received $27 million in total compensation in 2019, his first year in the position. Hazen and other executives reportedly took pay cuts in 2020, citing the pandemic, but based on his 2019 salary the cut equates to less than 1% of his total compensation.

“Patient safety is not there due to the lack of staffing,” said Xochitl Gonzalez, a certified nursing assistant at Los Robles Medical Center in Thousand Oaks, California. CNAs don’t have mandated staffing ratios, and Gonzalez noted she is currently expected to cover up to 30 patients throughout the day. “They’ve received billions of dollars in federal stimulus relief and they’re still cutting staffing. Managers are doing our work and they’re sending people home, cutting our hours.”

At HCA-owned University Hospital Medical Center in Oakland Park, Florida, nurses with SEIUHealthcare are currently bargaining for a new union contract. The current one is set to expire at the end of July.

Nurses at 19 HCA-owned hospitals around the U.S. are represented by National Nurses United, who also face pressure from HCA to make concessions to current union contracts and have held protests during the pandemic over the lack of hospital preparation and resources to handle coronavirus cases, and the threat of layoffs.

“The federal relief funding should not be a bargaining chip for management,” said Kimberly Smith, a registered nurse at Corpus Christi Medical Center in Texas. “We’re not in negotiations, we have a set contract. For me, it’s set in disbelief and distrust in HCA for trying to change something they already agreed to.”

In Florida, Barbara Murray, a registered nurse at St. Petersburg General Hospital recently protested outside her hospital over the threats of possible layoffs and compensation cuts, even as the current union contract runs until May 2021.

“It’s very frustrating. A lot of days we don’t have enough staff, enough techs,” said Murray. “I’ve been a nurse for 40 years and I’ve seen a lot of changes over time, but the changes aren’t in nurses, we just want our patients to be safe, get well and go home, and we expect our hospital to provide us with what we need to take care of them to get them home safely to their families.”

A spokesperson for HCA told The Guardian there have not been any furloughs or layoffs directly related to the pandemic yet. “We asked our unions to forgo their raises, as well, to maintain continuation pay for their members, and they refused. As a result, while the pay continuation program will continue for most of our colleagues, it will end June 6 for most colleagues represented by a union. While we hope to continue to avoid layoffs, the unions’ decisions have made that more difficult for our facilities that are unionized,” said the spokesperson.

They cited $138 million spent so far on pay continuation programs during the coronavirus pandemic for 120,000 employees, said corporate executive leadership have taken pay cuts between 10% and 30% and said — despite PPE shortages across the nation — HCA Healthcare has provided all hospitals with adequate PPE.



from Health Industry – Kaiser Health News

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Readers And Tweeters Ponder Racism, Public Health Threats And COVID’s Cost

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Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

Rising Above Racism

I want to compliment writer Anna Almendrala on her article “Masked or Not, Asians Are Still Attacked” in the Los Angeles Times (“Hate Unmasked In America, May 29). I was deeply moved by her eloquent prose and her compassionate voice. During this difficult time, after being cruelly attacked by a neighbor, she was still able to respond to an egregious insult with an impressive amount of empathy. I hope that readers learn from her example. I have.

— Jayne Muñoz, Santa Ana, California

— Barbara Glickstein, New York City

Threats Against Public Health Workers

Thank you for publishing the story describing the dire threats that public health professionals have received (“Public Health Officials Face Wave Of Threats, Pressure Amid Coronavirus Response,” June 12). I left an academic career in public health, as the former director of prevention and control for the Cancer Center of Hawaii, because of institutional racism. But that pales in comparison to what these professionals are being subjected to.

— Dr. Brian Martin, Portland, Oregon

I would have liked the authors of this article to also have mentioned what percentage of the officials who quit or were fired were female. I have noticed since the beginning that most state and local health officials are female. (Noticed it is the same in Canada.) And did they investigate/consider whether that fact has also played a part in the hostility and threats?

— Ann-Marie Tate, Phoenix

Editor’s note: Please be on the lookout for follow-up stories, produced in partnership with The Associated Press, which will include more data. 

— Dr. Faiz Kidwai, Syracuse, New York

Lessons In Holistic Healing

The long history of mistreatment and distrust between Native Americans and the federal government is no secret (“Returning to Roots, Indian Health Service Seeks Traditional Healers,” May 14), but I find that myself and many of my peers in medical school have limited knowledge when it comes to the health care of Native Americans. This article provides an enriching example of the importance of cultural diversity and holistic medicine.

In the era of medicine where chronic diseases such as cardiovascular disease are the most common cause of death, there are no treatments that “cure” conditions as there are with many infectious diseases. As such, treatment relies on addressing risk factors, lifestyle changes, and the social environment. While the advancement of modern medicine is nothing short of remarkable, there is something to be learned from the traditional healers of the Native American reservations. They seek not only to treat physical conditions, but also to address the “mental, emotional, and spiritual needs” of the community, as so elegantly stated in the article. This comprehensive approach to medicine is perhaps more suitable to the chronic diseases we see today, where cardiovascular disease is intertwined with risk factors such as poor diet, low income, distrust of medicine, etc.

The recruitment of traditional healers by the Indian Health Service, a federally funded organization, gives me hope that not only is the government starting to accept the importance of cultural diversity, but that it is beginning to acknowledge a more holistic approach to medicine.

— Brandon Jocher, St. Louis

— Brett Chapman, Tulsa, Oklahoma

Their Lives Did Count

I watched Dr. Elisabeth Rosenthal on CNN and related to her story “First-Person Perspective: My Mother Died Of The Coronavirus. It’s Time She Was Counted,” May 27). I lost two parents. Ten hours apart. In two different New York City hospitals. One came from a skilled nursing facility. One came from an independent living facility. 92 and 93 years old. Neither of them “counted.” It’s a terrible feeling. Their lives surely counted, but not their deaths.

— Robin Tolkoff Levy, Owings Mills, Maryland

On Dentists Cleaning Up

I saw your article on increased dental fees (“Open (Your Wallet) Wide: Dentists Charge Extra For Infection Control,” June 3). It is very true. I am a private practice dentist and am facing increased “disposable goods” costs, as well as additional trash collection fees, and have hired an additional staff member whose sole task is cross-contamination prevention. I am forced to pass these charges along to the patients.

To the patients interviewed in your article who were “shocked” by the added fees, you can look for a dentist who will not have to increase his or her fees — but you likely won’t find one. I have had a few patients refuse to pay the charge and they are dismissed from my practice. When they realize that our charges are reasonable and call to try and get an appointment (and 80% do), we won’t make them an appointment. “But there isn’t another dentist in 200 miles who takes my insurance,” they complain. Shouldn’t have complained.

Several local dentists have retired completely because they couldn’t (or chose not to)  keep up with the changes. We are booked into November. On the plus side, my existing patients are thrilled to be able to be seen and arrive early, don’t balk at having to wait in the parking lot and are extremely pleased with our efforts to avoid cross-contamination. My rate of “missed appointments” is way down.

Dentistry now outpaces logging and fishing as the most hazardous job on the planet. We went from being the brunt of jokes to valued members of the health care community.

In 1962, there were 100,000 dentists, 100,000 physicians and 70,000 attorneys. Today there are about 190,000 dentists, 950,000 physicians and 1.1 million lawyers. Earning a dental degree requires more than a quarter of a million dollars. There is a reason modern dental care is so expensive — because it is worth it.

— Dr. William Hartel, Bristol, Tennessee

— Jennifer Hyk, Sioux Falls, South Dakota

Not only am I disturbed by the inflammatory title, but also by the tone of this article. I am waiting for one journalist to actually do some research and find out exactly the level of expense related to all the new (and ever-changing) rules and regulations related to patient safety because of COVID-19. These additional measures are costly and ongoing. Add to that the fact that many suppliers are acting like black-market profiteers by escalating their costs. It’s almost like Martin Shkreli bought out all the supply chains that provide PPE.

The dental offices you covered in your article all handled this exactly how the CDC, OSHA, ADA and almost every state dental organization has recommended. This is not a routine “cost of doing business.” For offices contracted with the dental “insurance” companies, the offices are contractually forbidden to charge above the usual, customary and reasonable (UCR) cost dictated by the companies. In short, if the dentist tries to bundle the fee into the cost of a procedure, he/she will not be reimbursed by the insurance companies. Bottom line: The dentist is expected to eat the cost.

In contrast to what the general public may think, the great majority of dentists are not millionaires. They are hardworking men and women who sacrificed eight additional years of their early adulthood to learn their specialty. Many graduate from dental school with loans in excess of $250,000, which is close to what the average American spends to buy a home. Once in practice, they are pushed around by the dental “insurance” Goliaths that have not increased their average annual “benefit” maximum since the 1960s. Oh, and let’s not discount this increasingly litigious society that directly affects annual malpractice premiums.

These dentists endure all of this. They carry the responsibility of usually being a solo business owner, leader of a team and responsible for them and their families, having to deal with constantly changing local, state and national regulations, ever-increasing license and business costs, and possibly being exposed to a deadly disease on a daily basis. (By the way, I’m not lumping COVID in with “deadly disease” — I’m talking about deadly diseases like hepatitis, tuberculosis, HIV, etc.).

I don’t know of any dentist who has gotten one red cent in “unemployment benefits” during the past three months. Yes, they may have received PPP money, but guess what? That goes straight to expenses or must be paid back. This is quite different from the unemployment benefits that millions of American employees have received since the middle of March.

Lastly, for those patients who are complaining about the $10 PPE fee, I wonder how many of them drop at least that much within two days of going to their local Starbucks? I’m willing to bet it’s a pretty high percentage of them. It’s almost as if those people value their full-fat, whipped-cream, half-caf, double shot, venti mochaccino more than they do their oral and general health.

— Dr. Gerilyn Alfe, Chicago

‘Lost on the Frontline’: Beyond The Statistics

Not sure why this is a story (“Lost on the Frontline: Exclusive: Nearly 600 — And Counting — US Health Workers Have Died Of COVID-19,” June 6). The ratio of COVID deaths in health care workers to the number of health care workers (about 600 of 16 million) is the same as the national rate (about 11,000 of 328 million) and is virtually the same as the world rate (about 400,000 of 7.8 billion). Presenting the death toll in that light would show that health care workers are contracting COVID at the same rate as everyone else. We’re not special (in the eyes of disease). Who’d a thunk?

— John Coburn, Atascadero, California

— Julie Fairman, Philadelphia

This is a wonderful service. Thank you for doing it. They are the heroes in this world and should be memorialized. I’m a retired surgeon and have nothing but awe for every single one of these people and their efforts on our behalf.

One request: Dr. Atul Gawande and others have indicated that “properly protected” health care workers have a very low risk of infection with SARS CoV-2. It would be beneficial to all of us if you could perhaps publish weekly a tally of those who have passed and how many of those were wearing adequate PPE. I’m particularly interested in how well surgical masks protect people (as opposed to N95, which we know work but don’t have enough of), so having that tidbit of information would be great. Thanks again so much for your work and dedication.

— Dr. Robert Ley, Aptos, California

I read the article and sent it to family and friends. Everyone was very pleased and also saddened. Once people see all the faces and the different occupations, it seems to be a collective gasp. Thank you again for reaching out to me so that I could be a part of this expression of love, knowledge, informative journalism and dedication.

— Barbara Abernathy, Chicago, mother of Michelle Abernathy, a residential services supervisor who died of COVID-19 on April 13

— Laura Elena Belmonte, Albuquerque, New Mexico

I just wanted to drop you a note of thanks for your ongoing documentation of medical workers killed by COVID-19 in the line of duty. Our charity is dedicated to providing recognition and support for both medical services personnel who become casualties, and their families who suffer loss, as a result of the providers’ care for patients in the fight against COVID-19 and infectious disease. So we’re very appreciative of your efforts and hope that we can do more to support these incredible people.

— Kevin Higgins, president of The Fallen Providers Project Inc., Lebanon, Ohio

— Nancy Quinn, Concho, Arizona

In your “Lost on the Frontline” series, respiratory therapists are not mentioned as health care providers. They intubate and place patients who have difficulty breathing on life support. They make up an important front-line team that manages the ventilators and helps with transport while patients are on life support. Respiratory therapists work with COVID-19 patients and many have been exposed — in the ICU. The doctors, nurses — and respiratory therapists — are the main people in the COVID-19 rooms!

— Barb Homberger, Virginia Beach, Virginia

Steer Clear Of ‘Painkillers’

While I appreciate the info and public education on the need to be prepared (“Asking Never Hurts: Society Is Reopening. Prepare To Hunker Down At Home Again,” June 9), I think using the term “painkillers” in this article was not the best choice of words. If your point is to educate people to have medications that help relieve body aches from the virus, using a different term such as OTC pain relievers (Tylenol, etc.) is more appropriate.

Many people think the term painkiller means opioids/narcotics. We are in the middle of an opioid crisis, so using that term should be avoided if we are encouraging people to make sure they are prepared for the coronavirus.

— Amy Krajec, Oceanside, California

A Missed Opportunity To Educate

You are missing an important opportunity with this story (“A Teen’s Death From COVID,” June 15). You glossed over the importance of diabetic ketoacidosis (DKA) and focused mainly on the positive COVID test. This boy died from something that, if caught early enough, Type 1 diabetes, is entirely manageable. There are many groups and families trying to work and raise awareness about DKA and the warning signs of Type 1 diabetes. This story could have helped these efforts. If more had been known, that child may not have died. His symptoms were normal for advanced DKA and coma associated with that. Organizations like Beyond Type 1, Project Blue November and Kisses for Kycie have been trying to raise awareness of the symptoms of DKA and need help from the media. Too many children die needlessly in this country and around the world each year from undiagnosed Type 1 diabetes. Not to undermine the reporting and seriousness of COVID-19, but we are fighting an uphill battle to raise awareness and save lives.

— Carrie Berry, Austin, Texas

— Rob Szczerba, Pittsburgh

I was overwhelmed by the story about Andre Guest’s battle with COVID-19 and his passing. I can’t get it out of my head. Cry every time I think about that sweet, beautiful child devastated by this thing. Is there a way to let the parents know my thoughts are with them?

— Kevin Orton, Newcastle, Washington

While this is a tragic story, the reporting is not thorough and the stated facts are concerning, indicating possible negligence of care.

Despite this teen’s age, obesity is a known and well-reported underlying condition associated with higher mortality in those who are infected with the coronavirus. And, for still unknown reasons, so is being Black. Although the article does not mention in the text either contributing factor, the accompanying photos show them clearly.

The article states: “Although Andre had no underlying medical conditions, the first thing doctors discovered was that he had developed Type 1 diabetes. …” It is also well known that obesity and diabetes are comorbidities. While a recent COVID-19 finding is a possible potential for the development of acute diabetes, this teen’s obesity should have alerted health care professionals to the potential for diabetes and prior monitoring, especially considering it “was the first thing doctors discovered” in this case.

It is also known that autoimmune disease is associated with autism, although the precise etiology remains unknown. Diabetes is an autoimmune disease associated with increased mortality in COVID-19 patients.

The actual facts of this boy’s health and that the mother is a nurse and that this article originates from a major hospital system seems to imply ignorance and potential negligence of care. The bizarre inclusion of quotes about bedtime peanut butter and jelly sandwiches and video games implies further evidence of questionable lifestyle choices contributing to childhood obesity.

While this case does highlight the fact that young people can die from COVID-19, that this particular boy’s death would be publicized as an example that “perfectly healthy” young people are dying of COVID-19 is inaccurate. The real takeaway of this tragic story should be a focus on the fact that young people can and do have multiple underlying health concerns and that parents need to be informed and proactive in the health care of their children.

— Barbara Tefft, Newfield, New York

It Happened To Me

When I read your article about unusual symptoms in the elderly, it sounded like my experience (“Seniors With COVID-19 Show Unusual Symptoms, Doctors Say,” April 24). I am 77 and on the evening of March 2 something clicked off in my brain. When speaking, all that came out of my mouth was gibberish. I went to bed but don’t remember doing that. My alarm went off at 6 a.m. — I had an appointment at 9 a.m. for chemotherapy and my daughter was coming to pick me up for that appointment. When I got up at 6, I could not figure out what I was supposed to do. I could not figure out how to get dressed, so I went back to bed. The doorbell rang at 8 a.m. I got up but was in some kind of fog.

We live in a two-story house. I went to the top of the stairs and kept walking. I fell facedown and bounced down the stairs. My daughter called 911. I do not remember the paramedics coming or the 18 hours I spent in the ER. My daughter said I never spoke a word during that time. When spoken to, she said, I would get a confused look on my face but never spoke. I did not have a stroke. An MRI showed no clots or bleeds. I woke up the next morning and was able to speak and answer questions.

I was in the hospital for 10 days due to my injuries related to the fall. I am doing fine now. The doctors were never able to come up with a reason for what happened. He said we’ll just call it a TIA (transient ischemic attack) because we don’t know what else to call it. But my symptoms were not those caused by a TIA. I am wondering if what happened could have been caused by COVID 19. The symptoms were so bizarre. It frustrates me not to know the cause. I only hope that reliable antibody tests might eventually provide an answer.

— Kathy Oldershaw, Visalia, California

— Amy Abrams, San Diego

Cutting Through The Confusion

The article “Antibody Tests Were Hailed As Way To End Lockdowns. Instead, They Cause Confusion” (May 28) is misleading and reflects incomplete reporting.

  1. Both the FDA and the CDC have suggested doing two independent antibody tests to confirm a positive finding in low prevalence areas. The FDA has had those data pertaining to test accuracy posted for a long time.
  2. This story ignores the many other places in the USA and abroad that have done seroprevalence studies.
  3. There is an indication for using antibody testing: the large number of people who had classic COVID-19 symptoms and clinical course but who were told to stay home and were never tested. It’s too late to do antigen studies on them. They need antibody testing to confirm the diagnosis.
  4. People with symptoms shed antigen for perhaps 10-14 days or even longer. But testing for antigen later in the disease can yield negative findings and antibody testing can be useful.
  5. The “gold standard” antigen test can be falsely negative 30-40% of the time.
  6. Then there is the problem of the large numbers of asymptomatic persons with the disease. Antigen testing can be misleading, too. Antibody testing plays a role.
  7. Given the complex nature of the disease, the timing of testing both for antigen and antibodies is critical. That’s why the instructions for use (IFUs) for antibody tests break down test results in terms of days since symptom onset.
  8. Just because the disease is complex does not mean that testing should not be done. What is needed is a better understanding and less media bashing of manufacturers and labs.
  9. Why don’t you interview some of the professors who have done seroprevalence testing and who have the required academic credentials you approve of?
  10. This report sounds like the ones that were written weeks ago. Nothing new here.
  11. Those of us who participate in the weekly live FDA town hall webinars have heard these issues discussed for weeks and seen them reported also.

— Dr. Brant Mittler, San Antonio, Texas

— Carmel Shachar, Cambridge, Massachusetts

Emergency Care’s Most Urgent Problem

The extortionate costs of ambulance services in California is worse than that ER bill (“Bill Of The Month: COVID-Like Cough Sent Him To ER — Where He Got A $3,278 Bill,” May 25). My daughter experienced a medical emergency while traveling in California. The first hospital where she received care arranged to transfer her to another hospital. The ambulance service selected by hospital A was outside her network. She has been hit with an $8,000 bill, which includes a $4,600 base rate and $2,645.50 for mileage (37 miles from hospital A to hospital B).

The selection of ambulance service was completely outside her control. Of course, a reasonable rate is appropriate, but this amount is extortionate and bears no relationship to the cost or value of the transport.

This should not be allowed to occur to anyone, but especially not to someone who is not in a position to select their own provider. Apparently, the hospital staff arranging the transfer confirmed that hospital B was within the insurance network, but did not confirm the status of the ambulance service.

I am outraged by the impact of this incident on my family and suspect others have also been treated this way. This is price gouging at its worst! This practice should also be exposed by KHN.

— Bobbie Gregg, Dallas

— Daniel Sosnoski, Jacksonville, Florida

I was a nurse contractor in San Jose, California, when I started getting short of breath and experiencing chest pain. I went to the Valley Health emergency room, the one closest to me, and I received an $8,000 ER bill. I can’t afford to pay this bill and our insurance didn’t pay. I’m trying to negotiate the bill, but I was never tested for COVID-19 while there, which I found out I had after I returned home to Houston. Ridiculous charge for a non-traumatic ER visit.

— Kelly Lenz, Houston

— Devon Seeley, Salt Lake City

Perhaps the most important takeaway is not that his bill was coded incorrectly, but that we need low-cost urgent care facilities that are open 24/7, so that we are not billed thousands of dollars for simple tests or a couple of stitches. How many people go into debt or go untreated because basic services are simply not available?

— Isabel Cabanne, Glencoe, Illinois

Getting The COVID Code Right

I am a certified professional medical coder, and love your podcast, as I am also a grad student majoring in epidemiology. I listened to the episode in which Phil Galewitz suggested patients should tell their health care providers to code “possible COVID-19” in order to avoid the bill for services (“KHN’s ‘What The Health?’: Still Seeking A Federal Coronavirus Strategy,” May 28).

This is incorrect; national coding guidelines prohibit coders to code “suspected, possible or rule-out diagnoses.” Health care providers as well are not able to document such conditions until confirmed by a test, study or another diagnostic means, described as “gold standard” for that specific condition. This rule is described in “ICD-10-CM Professional for Physicians” manual, 2020.

What UnitedHealthcare stated was correct: It is unable to recognize a claim for COVID-19 when an ICD-10 diagnosis for it (U07.1) was not reported. The proper procedure would have been to get the patient tested, defer the claim processing until the results came back, and then report the U07.1 as the reason for the encounter. When a patient is not tested, the proper coding initiative would be to report symptoms only, which of course would not suffice for the copay reduction initiative. However, a patient would have the option to request that Denver Health appeal the claim with proof of documentation, which would require them to submit a provider’s note from the visit and prompt UHC to manually review the claim and have it reprocessed.

Overall, this is a common reason certain claims are not covered by payers, but there are multiple stipulations in terms of coding guidelines that limit what can be coded for any particular encounter.

— Ksenia Brewster, Poquoson, Virginia



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