An intubated coronavirus patient was declining rapidly when doctors decided to airlift her to a hospital with better critical care resources.
"It's life or death," the family of the 60-year-old woman recalled being told when it happened in April. "We have to transfer her now."
The patient was flown by helicopter from one Philadelphia hospital to another 32km away. She spent six weeks at the new hospital and survived. When she came home, a letter arrived: The air ambulance company said she owed US$52,112 ($78,362) for the trip.
Last year, Congress abandoned its attempt to prevent surprise bills like this one, and coronavirus patients are now paying the price. Bills submitted to The New York Times show that patients often face surprise charges from out-of-network doctors, ambulances and medical laboratories they did not pick or even realize were involved in their care.
The plan to ban these kinds of bills was popular and bipartisan, and it was backed by the White House. It fell apart at the eleventh hour after private-equity firms, which own many of the medical providers that deliver surprise bills, poured millions into advertisements opposing the plan. Committee chairs squabbled over jurisdictional issues and postponed the issue. Then the pandemic struck.
'How am I going to pay this all off?'
The Pennsylvania patient had no way of knowing that her helicopter, which transported her between two in-network hospitals, did not have a contract with her health insurance plan. Nor could she have known that the air ambulance service, owned by a private-equity firm, faces multiple lawsuits over its billing tactics.
Her health plan, Independence Blue Cross, initially said it would pay US$7,539 ($11,336) of the bill, according to billing documents reviewed by The Times, but then rescinded the money. The patient, housebound because of lingering coronavirus symptoms, was left with the full amount.
"She was intubated and on a ventilator when her providers felt it was necessary that she be transferred," said Leslie Pierce, a division chief at the Pennsylvania Insurance Department, who handled the complaint that the patient submitted to the agency. "She had no decision in the selection process."
About 450,000 Americans have been hospitalised with the coronavirus. Even for those covered by robust health insurance, hospitalisation can generate significant medical bills. To understand the true cost of coronavirus hospitalisations, and the impact these medical bills have on patients, The Times has been inviting readers to share their bills.
The resulting database, which now includes more than 350 reader submissions, shows that coronavirus patients are encountering the same surprise medical bills that have plagued the health system for decades. While President Donald Trump told the country "not to worry" about the disease after his three-day coronavirus hospitalisation, other survivors say the cost of care causes tremendous anxiety at a moment when they want to focus on recovery.
Some patients report feeling overwhelmed by the pile of bills that greet them at home. One-third of coronavirus patients reported an altered mental state after contracting the disease, according to the largest randomised study to examine neurological symptoms. Many patients struggle to do basic tasks, such as cook or pay bills.
Alice Navarro, 40, spent 10 days in July receiving coronavirus treatment at an in-network hospital in Austin, Texas. Many doctors who saw her there were out-of-network, and her health plan has denied about US$4,000 ($6,000) of their charges.
Navarro, 40, has been filing appeals with her insurance at the same time that she is suffering from short-term memory loss because of coronavirus.
"I think about the bills several times a day," she said. "How am I going to pay this all off? My parents were like, 'Don't worry about this right now, focus on getting better,' but that's easier said than done."
Surprise medical bills happen when patients receive care from an out-of-network provider they did not choose. These charges are common in certain corners of the health system like the emergency room, where 20 per cent of patients are vulnerable to surprise medical bills.
The bills are especially pervasive after ambulance trips: One recent study found that as many as 71 per cent of those rides could result in surprise, out-of-network bills.
"We were shocked to see that," said Dr. Karan Chhabra, a surgical resident at Brigham and Women's Hospital and the lead author of the study.
Gaps in the pandemic protections
After failing to pass comprehensive billing reform, Congress tried in relief packages passed this spring to shield coronavirus patients from surprise charges. It set up a US$175 billion provider relief fund to aid hospitals and doctors on the front lines of battling coronavirus. As a condition of accepting those funds, medical providers agreed not to send surprise medical bills to their patients.
Many health insurers have promised to cover plan members' coronavirus hospital stays in full, another effort to hold patients harmless.
But these protections leave significant gaps, as patients are beginning to find. While many hospitals and doctors received provider relief funds, a number of medical laboratories and ambulance services did not. That leaves those providers free to bill however they'd like.
Insurers' policies that cover coronavirus hospital stays, meanwhile, sometimes do not include the ambulance ride it took to get there — or follow-up care to treat long-term symptoms.
"The government is telling people if you have coronavirus, you cannot get surprise-billed," Chhabra said. "It's incredibly counterproductive if people cannot trust the policies meant to protect them when they're getting care for this illness."
Air ambulance bills are often the most costly type of surprise medical bills. Chhabra found a median charge of more than US$38,000 ($57,000), leaving the typical patient responsible for more than US$21,000 ($31,500) after the insurance payout. The prices are quickly increasing, too, rising about 15 per cent each year since 2015.
In recent years, numerous states have enacted laws that restrict surprise out-of-network billing similar to the one Congress nearly passed. But states cannot regulate air ambulance fees. Courts have repeatedly interpreted the 1978 Airline Deregulation Act as protecting air ambulances from any state rate setting.
Only the federal government can intervene by amending the Airline Deregulation Act. The congressional package would have done that, even though the air ambulance industry has generally opposed this policy.
The Pennsylvania patient, who asked not to be identified because she was recovering, was transported by Conemaugh Medstar, an air ambulance serving southwest Pennsylvania. The private equity firm American Securities owns its parent company, Air Methods, which is among the largest air ambulance services in the United States. Air Methods currently faces six separate class-action lawsuits in federal court, where patients describe expensive charges and aggressive debt collection tactics.
In one case, the company sought to garnish US$53,034 ($79,761) from a patient's bank account.
Air Methods contends that those bills are six to eight years old, and that it has since reformed its debt collection practices.
Ground ambulances, another source of surprise bills for coronavirus patients, have also largely escaped billing regulations. California passed legislation in 2017 that barred most types of surprise medical bills, but it excluded ambulances. The congressional deal that nearly passed also did not include ambulances. Legislators may be reluctant to regulate ambulances because many are run by local and municipal governments, which rely on the charges for revenue.
Widowed and facing a bill
Lynne Lerner, a patient in California, was surprised to receive two US$1,471 ($2,212) medical bills for the Los Angeles Fire Department ambulances that took her and her husband to a hospital 1.6km from their house.
Lerner had called the ambulance for her husband, Larry, when his coronavirus symptoms worsened in late March. The paramedics suggested that Lerner, who also had the coronavirus, seemed ill enough to require hospital care as well.
The two were put in separate ambulances. Larry Lerner died after nine days in the hospital. When the first ambulance bill arrived, Lynne Lerner thought, "Please let this be for the both of us."
"They took us around the corner," she said. "I could have walked."
She had expected her insurance to cover all costs related to the coronavirus. Instead, it ended up paying 90 per cent of the ambulance bills, leaving Lerner with US$294 ($442) to pay.
The Los Angeles Fire Department did not respond to multiple messages seeking comment.
Air Methods said the document received by the Pennsylvania patient, which stated the "amount due" above a box to write in a credit-card number, was not a bill but rather "an update on where things stood" with her insurance company. The company estimates it has transported 3,300 coronavirus patients over the course of the pandemic, and said that it had a "special process" for handling their billing.
"Our patient advocate teams work closely with our patients to ensure they have guidance through the reimbursement process," said Doug Flanders, a spokesman for Air Methods.
The Pennsylvania patient ultimately filed a complaint with the state's insurance commissioner, Jessica Altman. While Altman's office has no authority to regulate air ambulance bills, her staff did make a phone call to the insurer. The situation then resolved quickly. Independence Blue Cross said in a statement that it had already begun reprocessing the claim by the time the regulator called.
The health insurer initially sent the patient documents stating, "You are responsible to pay the amount the provider may bill you."
Shortly after the regulator's inquiry, the patient learned the health plan would cover the bill completely.
Written by: Sarah Kliff
Photographs by: Miranda Barnes and Andrew Burton
© 2020 THE NEW YORK TIMES