Maxwell Krusic said he had such “severe” abdominal pain on Oct. 5, 2023, that he had to drive off the road twice while driving to the emergency room at Mercy Regional Medical Center in Durango, Colorado. “It was the worst pain of my life,” he said.
Kruzic was immediately examined because hospital staff were almost certain that he had appendicitis. They put him on a drip, called a surgeon and sent him for a scan to confirm the diagnosis.
But the scan showed a completely normal appendix and no problems in the abdomen. Doctors puzzled over other possible diagnoses. Could this be a kidney stone? Gallstones? Here is a 37-year-old man suffering, but nothing really worked.
Then someone asked what Kruzic had eaten the night before. He said he ate a taco with a hot sauce he made from a type of scorpion pepper grown from seeds he ordered from a chili pepper research institute.
He noted that peppers have more than 2 million Scoville heat units, compared with jalapeños at up to 8,000 or habaneros at 100,000 to 350,000.
According to Kruzic, these peppers are among the “hottest, incredibly hottest in the world.” “Delicious.” He loves spicy food and has never had a problem with it, but apparently it burned his digestive system too much.
Kruzic spent most of the night on a gurney in the emergency room. After about four hours, the pain subsided and he was sent home with medication for nausea and vomiting.
Then the bill came—about two years later.
Medical procedure
Kruzic underwent blood tests and a CT scan of the abdomen during an emergency room visit for severe abdominal pain.
Eating very spicy foods may cause painful inflammation and irritation of the digestive system. The discomfort usually goes away on its own.
Final bill
$8,127.41, including $5,820 for CT scan. Kruzic paid $97.02 during a visit to a hospital that was part of his insurance network. After premiums and discounts, he owed $2,460.46—the remainder of the $1,585.26 he owed toward his plan's deductible and the $972.22 he owed on coinsurance.
Problem: ghost bills for past visits
In September of this year, Kruzic received a bill for a 2023 emergency room visit caused by eating peppers.
Unfortunately for patients, there are no uniform guidelines for timely billing.
Anticipating the bill, Kruzic repeatedly checked the hospital's online portal as well as that of his insurance company, UnitedHealthcare. He noted that the insurer advised that the claim was processed shortly after his treatment. For about eight months, he continued to check the billing section of the hospital portal, which indicated that he owed “$0.” He called UnitedHealthcare, and Kruzic said a representative assured him that if the hospital said he didn't owe anything, that was true.
It is unclear what caused the nearly two-year delay. At least part of the problem appears to stem from a long-running disagreement between the insurance company and the hospital over how much his visit should cost.
Lindsey Radford Foster, a spokeswoman for the hospital system CommonSpirit Health, said in a statement to KFF Health News: “United Healthcare, the insurance company responsible for the medical claim, underpaid the bill based on the care provided. As a result, CommonSpirit contacted UnitedHealthcare's payer relations department to correct the underpayment.”
When asked why it took two years, she cited a UnitedHealthcare reorganization and a change in the insurance company representative assigned to the case.
But UnitedHealthcare disputed that view. “This amount was paid accurately,” said Caroline Landry, a spokeswoman for the insurance company.
But these explanations do not satisfy Kruzic, a geological consultant: “Receiving an invoice two years after the service was not required in any other industry. We could never contact the client two years after the completion of the project and say, 'By the way, we missed that payment.'
“How can this be considered anything other than a surprise bill?” he added.
The federal “No Surprises” law does not protect against all types of medical bills that patients consider unexpected. It primarily protects patients from out-of-network costs when visiting an in-network hospital or in the event of an emergency.
But in the medical billing industry, what's legal and what's smart are two very different issues.
“The bill certainly sounds outrageous,” said Maxwell Mehlmen, co-director of the Center for Legal Medicine at Case Western Reserve University School of Law. “The question is whether it's legal.”
That, he said, “is a matter of state law, the terms of the insurance policy and the agreement between the hospital and the insurer.”
Colorado has extensive rules regarding how long health care providers must file a claim and bill the patient. For example, claims for Medicaid patients must be filed within 120 days from the date of service provision. For patients with private insurance, the terms may be outlined in their insurers' contracts with individual providers.
If the hospital filed a proper claim and the provider and insurance company calculated the payment in good faith, the patient may be billed years later for their share of the costs.
Resolution
Hours after KFF Health News contacted the hospital's media relations department for this story, Kruzic received a call from a hospital executive saying his account had been reduced to zero.
Blaming the insurance company for administrative changes, CommonSpirit's Radford Foster said UnitedHealthcare took so long to properly pay a bill that the hospital was unable to collect from the patient. She said Kruzic's statement balance “should have been reduced to zero, but due to a technical error, the statement was sent to the patient in error.”
UnitedHealthcare's Landry said that “given the significant delay, we are addressing this issue directly with the doctor's office.”
“Mr. Kruzic will not be responsible for any additional costs associated with this bill,” she said.
Conclusion
KFF Health News' Bill of the Month series receives complaints every year about “ghost bills”—bills that arrive long after a service has been provided.
Sometimes this happens because the insurer and hospital are in a dispute over payment, and the patient's liability—usually a percentage of that amount—cannot be calculated. until the dispute is resolved. In other cases, insurers review old bills and, finding that they were overpaid, try to refund the money, causing the patient (or even the patient's surviving spouse) will be invoiced for the difference.
Currently, the legality of billing long after treatment depends primarily on the fine print of insurance contracts.
An insurer's statement that a claim has been “processed” does not mean that the insurer has agreed to pay and that billing has been resolved. It could also mean that the insurer has refused to accept the bill or has refused payment entirely.
As for Kruzic and his passion for hot peppers? He said he still likes spicy food, but “I won't use scorpion peppers anymore” when cooking.
“Bulletin of the Month” – a crowdsourced investigation conducted by KFF health news And Prosperity Washington Post who analyzes and explains medical bills. Since 2018, the series has helped many patients and readers reduce their medical bills and has been cited in statehouses, the U.S. Capitol, and the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!
KFF health news is a national newsroom that produces in-depth journalism on health issues and is one of the core operating programs of KFF, an independent source of health policy research, polling and journalism. Find out more about KFF.
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