Editor's note: Shortly after this story by Kaiser Health News and NPR was published and broadcast on Monday, St. David's said it was now willing to accept $782.29 to resolve the $108,951 balance because Drew Calver qualifies for its "financial assistance discount." In a statement, the hospital said this offer was contingent on Calver submitting his application for a discount based on his household finances. Calver disputed that he owes any additional money to St. David's and said this situation should have been resolved long before now.
Drew Calver took out his trash cans and then waved goodbye to his wife, Erin, as she left for the grocery store the morning that upended his picture-perfect life.
Minutes later, the popular high school history teacher and swim coach in Austin, Texas, collapsed in his bedroom from a heart attack. He pounded his fist on the bed frame, violent chest pains pinning him to the floor.
"I thought I was dying," the 44-year-old father recalled. He called out to the only other person in the house, his oldest daughter, Eleanor, now 7. Using the voice-recognition feature on his phone, he texted his wife, who was at the store with their youngest, Emory, now 6. A neighbor rushed him to the nearby emergency room at St. David's Medical Center on April 2, 2017.
The ER doctors confirmed the damage to Calver's heart and admitted him to the hospital's cardiac unit. The next day, doctors implanted stents in his clogged "widow-maker" artery.
The heart attack was a shock for Calver, an avid swimmer who had competed in an Ironman triathlon just five months before.
Despite the surprise, Calver asked from his hospital bed whether his health insurance would cover all of this, a financial worry that accompanies nearly every American hospital stay. He was concerned because St. David's is out-of-network on his school district health plan. The hospital told him not to worry and that they would accept his insurance, Calver said.
The hospital charged $164,941 for his surgery and four days in the hospital. Aetna, which administers health benefits for the Austin Independent School District, paid the hospital $55,840, records show. Despite the difference of more than $100,000, with the hospital's prior assurance, Calver believed he would not bear much, if any, out-of-pocket payment for his life-threatening emergency and the surgery that saved him.
Then the bills came.
Patient: Drew Calver, 44, a high school history teacher and father of two in Austin, Texas.
Total bill: $164,941 for a four-day hospital stay, including $42,944 for four stents and $10,920 for room charges. Calver's insurer paid $55,840. The hospital billed Calver for the unpaid balance of $108,951.31.
Service provider: St. David's HealthCare, a large hospital system in central Texas. It's run by HCA Healthcare, the nation's largest for-profit hospital chain, and two nonprofit foundations.
Medical treatment: Emergency room treatment followed by four days in the hospital, most of it spent in the cardiac unit. During surgery, four stents were implanted to clear a blockage in his left anterior descending artery, the source of so-called widow-maker heart attacks because they are so frequently deadly.
What gives: St. David's Medical Center is billing Calver for the $108,951.31 balance — an amount nearly twice his annual pay as a teacher.
The hospital's billing company sent a notice June 26, urging him to take advantage of this "FINAL opportunity to settle your balance."
"They're going to give me another heart attack stressing over this bill," Calver said. "I can't pay this bill on my teacher salary, and I don't want this to go to a debt collector."
Following his heart attack, Calver fell victim to twin medical billing practices that increasingly bedevil many Americans: surprise bills and balance billing.
Surprise bills occur when a patient goes to a hospital in his insurance network but receives treatment from a doctor who does not participate in the network, resulting in a direct bill to the patient. They can also occur in cases like Calver's, where insurers will pay for needed emergency care at the closest hospital — even if it is out of network — but the hospital and the insurer may not agree on a reasonable price. The hospital then demands that patients pay the difference, in a practice called balance billing.
Several states, including Texas (as well as New York, California and New Jersey) have passed laws to help shield consumers from surprise bills and balance billing, particularly for emergency care.
But there's a huge loophole: Those state-mandated protections don't apply to people, like the Calver family, who get their health coverage from employers that are self-insured, meaning the companies or public employers pay claims out of their own funds. Federal law governs those health plans — and it does not include such protections.
About 60 percent of people with employer health benefits are covered by self-insured plans, but many don't even know it, since employers typically hire an insurer to administer the plan and employees carry a card bearing the name of Blue Cross Blue Shield or another major insurer.
This case "illustrates the dangers that even insured people face," said Carol Lucas, an attorney in Los Angeles with experience in health care payment disputes. "The unfairness is especially acute when there is an emergency and the patient, who might ordinarily be completely compliant, has no say about the facility he winds up in."
In a statement, St. David's HealthCare defended its handling of Calver's bill and sought to blame the school district and Aetna for offering such a narrow network.
"While we did everything right in this particular situation, the structure of the patient's insurance plan as a narrow network product placed a large portion of the financial responsibility directly on the patient because our hospital was not in-network," the hospital said.
Patients experiencing an emergency are particularly at risk of landing at an out-of-network hospital. St. David's said once ER patients are deemed stable, it tries to transfer them to an in-network facility. "However, this is not always possible because the patient's health must come first," the hospital said.
This case also raises questions about the validity of the hospital's charges.
Industry analysts and consumer advocates say St. David's has a reputation for exorbitant billing and for trying to collect big payouts as an out-of-network provider. "This is a well-known, problematic provider. We've seen multiple bills from them and they are always highly inflated," said Dr. Merrit Quarum, chief executive of WellRithms, which scrutinizes medical bills for self-funded employers and other clients nationwide.
WellRithms reviewed Calver's bill in detail at the request of Kaiser Health News and determined that a reasonable reimbursement would have been $26,985. That's less than half what Aetna paid.
Healthcare Bluebook, which offers cost estimates for medical tests and treatments, arrived at a similar conclusion. It said a fair price for a hospitalization in Austin involving four heart stents would be about $36,800. St. David's Medical Center charged four times that amount.
Quarum and other analysts who reviewed the bill said several charges stood out, especially on the four stents, which were billed at $42,944. Coronary stents are typically metal mesh tubes implanted in arteries to improve blood flow. Most are coated with drugs to assist in healing.
St. David's charged $19,708 apiece for two Synergy stents made by device giant Boston Scientific. Two other stents used were far cheaper.
The $20,000 price tag represents a significant markup of what U.S. hospitals typically pay themselves for stents. The median price paid by hospitals for the Synergy stent was $1,153 over the past year, according to the nonprofit research company ECRI Institute.
"St. David's charge of over $19,000 for those stents is absolutely outrageous," Quarum said.
St. David's declined to comment on its markup for the stents or what it actually paid the manufacturer.
Resolution: For now, Calver still faces a bill for $108,951.31, with none of the parties involved in his treatment or coverage providing significant redress.
In fact, the hospital's debt collector sent the Calvers a letter Aug. 3 demanding payment in full.
After a reporter made inquiries, St. David's said collection efforts were put on hold, and a hospital representative called Calver, offering to help him apply for a discount based on his income.
In a statement, St. David's said, "We work with all patients needing financial assistance to help determine their eligibility for this discount."
Calver said that approach doesn't address the balance billing or whether the charges were appropriate.
A spokeswoman for Aetna said, "We are actively working to rectify the situation on behalf of the member." But the health plan hasn't shared any further details. The Austin school district declined to address this specific case.
Calver said the whole ordeal has been incredibly stressful for him and his wife.
"I am stuck in the middle of this convoluted, flawed system," he said. "I've never owed a large amount like this or had credit card debt. What does it mean if this goes on my credit report?"
The takeaway: Faced with a surprise bill or a balance-billing situation, don't rush to pay any medical bills you receive. First, let the insurance process play out completely so you're sure what the health plan is paying the hospital and doctors — and what you ultimately might be responsible for, in terms of coinsurance or copayments.
Ask for an itemized bill. Review the charges carefully and talk to your insurer, your employer and the hospital if the prices seem out of line. Arm yourself with estimates you can find online of the average prices charged in your area as you negotiate with all the players.
If the bills keep coming, talk to your employer's benefits department or the state insurance department about your legal protections. The situation will vary depending on the type of health insurance you have and the state you live in. Tell any debt collection agencies that may contact you that you are contesting the bill.
With any of these entities, you can always appeal to reason, with this argument: You had no choice but to go to an out-of-network hospital in the case of a life-threatening emergency, so the insurer and the hospital should work out payment and hold you harmless from financially crippling bills.
This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. Kaiser Health News is not affiliated with Kaiser Permanente.
Ashley Lopez, who contributed to the audio story, is part of NPR's reporting partnership with member station KUT and Kaiser Health News.
DAVID GREENE, HOST:
Every month, NPR and Kaiser Health News take a close look at medical bills that you send us. And this week, you're going to be hearing the word surprise a lot. And that is never a word you actually want to hear in the same sentence as medical bill, especially if you are just coming back from emergency heart surgery and the bill is for a six-figure amount that you apparently owe. Elisabeth Rosenthal is the editor-in-chief of Kaiser Health News, and she is back in our studios. Hi, Elisabeth.
ELISABETH ROSENTHAL: Hi, great to be here.
GREENE: This is making me nervous just thinking about it. You have heart troubles. You go for emergency surgery. And now when you're just recovering, you're told that you owe a ton of money.
ROSENTHAL: Yeah, it's scary. Our August bill of the month is for a Texas man's medical costs after the insurance company has already reimbursed the hospital - crazy. His name is Drew Calver. He's a high school teacher and swim coach in Austin, Texas. And we'll hear Drew tell his story in a moment, but what he faced that day was a really common financial issue. When the hospital and insurer can't agree on a price, the patient is left holding the bag.
GREENE: And stressed out at a moment when he's recovering from a heart attack. I mean, that sounds unfair.
ROSENTHAL: Right, this insurer had already paid out $55,000, which from what we can tell is a very reasonable, generous price to pay for his procedure. But the hospital thought that his care was worth much, much more. And so they tried to bill about $150,000 and billed him for the difference. So that's called balance billing, the balance after insurance paid. We're talking about an amount that's double his teacher's salary. For him, it was an unexpected bill that, as far as he understood, was not covered under the terms of his insurance. So it was what we call surprise billing.
GREENE: OK. So these terms, just so I understand it, balance billing - when the hospital tries to make up for what they think they are owed. Once that balance billing ends up in Drew's mailbox, that's called surprise billing.
ROSENTHAL: Balance billing is one form of surprise billing.
GREENE: All right, well, let's actually meet Drew Calver. Ashley Lopez from member station KUT in Austin went to pay him a visit. And he took her back to the day of his heart attack.
ASHLEY LOPEZ, BYLINE: A little more than a year ago, Drew was taking out the trash on a Sunday morning. His wife, Erin, was heading to the store with one of their daughters. He remembers waving at them.
DREW CALVER: And then as I turned the corner from the driveway, I just had that back pain.
LOPEZ: Drew says he started to keel over. He then stumbled back inside the house where he saw Eleanor, his older daughter.
D. CALVER: And I literally said to her, Eleanor, I think I'm dying.
LOPEZ: Through waves of pain, Drew managed to reach his wife who then got a neighbor to drive him to a hospital that's less than a mile away. Turns out, Drew was having a particularly dangerous kind of heart attack known as the widow-maker. And this was a huge surprise because just a few months before, Drew was in a half-Ironman.
D. CALVER: I mean, I was a swimmer in college - high school and college, so always been in pretty good shape.
LOPEZ: Once Drew was stabilized at the hospital, doctors planned to put stents in to open up his blocked arteries. Before the actual procedure, he made sure to ask whether his insurance would cover all of that.
D. CALVER: And they said, yeah, with - your insurance is - accept it. You know, we've called them, and they've given us the OK.
LOPEZ: All together, Drew was in the hospital for four days.
ERIN CALVER: Those are from the ninja place.
LOPEZ: Life is pretty much back to normal these days, he says. Drew's wife, Erin, and his two daughters, Eleanor and Emory, ages 7 and 6, are getting ready to walk to school. He says surviving a heart attack has made him appreciate this time with his family even more. But there is one big thing that is still hanging over them. That's those hospital bills that came flooding in right after his heart attack.
D. CALVER: I've got some different sets in some of these.
LOPEZ: According to the hospital, Drew owes almost $109,000.
D. CALVER: It just kind of got real all of the sudden. They're like no. Hey, your insurance isn't going to pay this. You owe this.
LOPEZ: This medical debt is raising a lot of questions.
LOPEZ: While walking their daughters to school, Drew and Erin say they don't know how to plan their finances.
E. CALVER: Will we be able to get a car loan? Will they come after our 401(k)? You know, just all this stuff, and just thinking, like, this cannot be right.
LOPEZ: And for Drew, this massive hospital bill isn't making it any easier to recover from his heart attack.
D. CALVER: For me, I'm trying to reduce that stress in my life. That's part of my doctor's recommendations, you know, my doctor's orders.
LOPEZ: And Erin says they've been dealing with the worry of all this for a year now.
E. CALVER: I just think that the bill in itself is so reprehensible.
LOPEZ: In the meantime, they say there's just no way they can pay that bill.
GREENE: All right. The reporting there you just heard was from Ashley Lopez at NPR member station KUT in Austin. I am still with Elisabeth Rosenthal, the editor-in-chief of Kaiser Health News. Elisabeth, what can Drew Calver do here?
ROSENTHAL: Well, the first thing everyone should know is try to go to an in-network hospital. However, if you're having a heart attack...
ROSENTHAL: ...You're not Googling, you know, who's in network?
ROSENTHAL: You just go to the nearest place. So that's step one. The second step is don't just write the check. When you get a bill - a surprise bill or a balance bill that seems outrageous, fight back with this because in many states now, including Texas, there are laws that protect patients from surprise bills. And basically what those laws say is if the provider - in this case, the hospital - and the insurer can't agree on a price, then the patient cannot be held responsible. He is held harmless, and the two of them will have to work it out among themselves.
GREENE: So this is good news for Drew.
ROSENTHAL: Well, except there's a big loophole in those laws. And that is that about 60 percent of plans are what we call self-insured, meaning you may have a network like Cigna or Aetna, but they are really just administering the plan. And the problem is those state laws don't apply to those self-insured plans. So even though Texas has a great law, it did not cover Drew's situation and hold him harmless.
GREENE: OK. So, Drew Calver, the lesson is don't pay yet. Try and fight it, but it's not clear that you will win. You might be stuck paying this money somehow.
ROSENTHAL: Well, maybe, but one thing that I advise people to do is if your state has that law, download the forms. Send them to the hospital. Send them to your insurer. And say, hey, look, this is a weird loophole. You know this is the right thing to do, and it does work sometimes. I've used that, and it worked in New York for me.
GREENE: Elisabeth Rosenthal is the editor-in-chief of Kaiser Health News. Thanks as always for bringing these stories to us. They're really good lessons.
ROSENTHAL: Thanks for having me.
GREENE: Hey, if you have an interesting medical bill, we would love to take a look at it. You can go to NPR's Shots blog to share your bill with us and with Kaiser Health News.
(SOUNDBITE OF SYNTH4EVER'S "FLOATING THROUGH THE PLANES OF EXISTENCE") Transcript provided by NPR, Copyright NPR.