Maxwell Kruzic said he was in such “crippling” stomach pain Oct. 5, 2023, that he had to pull off the road twice as he drove himself to the emergency room at Mercy Regional Medical Center in Durango, Colorado. “It was the worst pain of my life,” he said.
Kruzic was seen immediately because hospital staff members were pretty sure he had appendicitis. They inserted an IV, called a surgeon and sent him off for a scan to confirm the diagnosis.
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But the scan showed a perfectly normal appendix and no problems in his abdomen. Doctors racked their brains for other possible diagnoses. Could it be a kidney stone? Gallstones? Here was a 37-year-old man in agony, but nothing really fit.
Then someone asked what Kruzic had eaten the night before. He said he had consumed tacos with some hot sauce that he had made from a kind of scorpion pepper, grown from seeds he ordered from a chile pepper research institute.
The peppers measure over 2 million Scoville heat units on the spiciness scale, he noted, compared with a jalapeño at up to 8,000 or a habanero at 100,000 to 350,000.
The peppers are among “the world’s hottest, incredibly hot,” Kruzic said. “Delicious.” He loves spicy food and had never had a problem with it, but apparently this was just too much burn for his digestive system.
Kruzic spent much of the night on a gurney in the ER. After about four hours, the pain decreased, and he was sent home with medicine to treat nausea and vomiting.
Then the bill came – about two years later.
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The medical procedure
Kruzic underwent bloodwork and a CT scan of his abdomen during his ER visit for acute abdominal pain.
Consuming very spicy foods can cause painful inflammation and irritation of the digestive system. The discomfort typically resolves on its own.
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The final bill
$8,127.41, including $5,820 for the CT scan. Kruzic paid $97.02 during his visit to the hospital, which was in-network under his insurance. After insurance payments and discounts, he owed $2,460.46 – the remainder of the $1,585.26 he owed toward his plan’s deductible and $972.22 he owed in coinsurance.
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The billing problem
This September, Kruzic received a bill for his pepper-induced ER visit in 2023.
Unfortunately for patients, there are no uniform rules for timely billing.
Anticipating a bill, Kruzic repeatedly checked the hospital’s online portal, as well as that of his insurer, UnitedHealthcare. He noted that the insurer said the claim had been processed shortly after his treatment. For about eight months, he kept checking the hospital portal’s billing section, which indicated he owed “$0.” He called UnitedHealthcare, and Kruzic said a representative assured him that if the hospital said he owed nothing, that was the case.
It is unclear what caused the nearly two-year delay. At least part of the problem seems to have involved protracted disagreements between the insurer and the hospital over how much his visit should have cost.
Lindsay Radford Foster, a spokesperson for CommonSpirit Health, the hospital system, said in a statement: “United Healthcare, the insurer responsible for the medical claim, underpaid the account based on the care provided. As a result, CommonSpirit contacted UnitedHealthcare’s Payer Relations Department to rectify the underpayments.”
Asked why it had taken two years, she cited a reorganization at UnitedHealthcare and a change in the insurer’s representative assigned to the case.
But UnitedHealthcare contested that view. “This was paid accurately,” said Caroline Landree, a spokesperson for the insurer.
But those explanations don’t satisfy Kruzic, a geological consultant: “Receiving a bill two years after the service wouldn’t fly in any other industry. We could never contact a client two years after we completed a project and say, ‘By the way, we missed this charge.’”
“How could this be considered anything but surprise billing?” he added.
The federal No Surprises Act doesn’t protect against all types of medical bills that patients find surprising. It primarily protects patients from out-of-network charges when they visit an in-network hospital, or in an emergency.
But in medical billing, what’s legal and what’s reasonable are two very different issues.
“The bill certainly sounds outrageous,” said Maxwell Mehlman, co-director of the Law-Medicine Center at the Case Western Reserve University School of Law. “The question is whether it’s legal.”
That, he said, “is a matter of state law and the terms of the insurance policy, and the agreement between the hospital and the insurer.”
In Colorado, there are extensive regulations about how long health care providers have to file a claim and bill a patient. For instance, claims for Medicaid patients must be filed within 120 days from the date of service. For patients with private insurance, the terms may be outlined in their insurers’ contracts with individual providers.
If a hospital submitted a proper claim, and the provider and insurer were working out payment in good faith, then a patient can be billed for their share of the costs years later.
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The resolution
Within hours of Bill of the Month contacting the hospital’s media relations department for this article, Kruzic got a call from a hospital executive telling him his bill had been adjusted to zero.
Blaming administrative changes at the insurer, Radford Foster of CommonSpirit said that UnitedHealthcare had taken so long to properly pay the bill that the hospital couldn’t collect from the patient. She said that Kruzic’s statement balance “was to be adjusted to zero, but due to a clerical error, a statement was sent to the patient in error.”
UnitedHealthcare’s Landree said that “given the significant delay, we are addressing this issue directly with the physician’s office.”
“Mr. Kruzic will not be responsible for any additional costs related to this bill,” she said.
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The takeaway
Bill of the Month receives complaints every year about ghost bills – bills that arrive long after a service is rendered.
Sometimes it’s because the insurer and hospital are haggling over payment, and the patient’s responsibility – usually a percentage of that number – can’t be calculated until the dispute is resolved. Other times, insurers audit old bills and, determining they overpaid, try to claw back the money, resulting in the patient (or even the patient’s surviving spouse) being billed for the difference.
For now, the legality of billing long after treatment depends primarily on the fine print of insurance contracts.
An insurer’s word that a claim has been “processed” doesn’t mean that the insurer has agreed to pay and that the billing is resolved. It could also mean that the insurer balked at the bill or completely denied payment.
As for Kruzic and his affinity for hot peppers? He said he still loves spicy food, but in his cooking, “I will not use scorpion peppers again.”
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Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol and at the White House.
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