Erica Kahn faced a US$20,749 bill after a bat encounter led to rabies treatment. Photo / The Washington Post
In retrospect, Erica Kahn realises she made two big mistakes.
The first was choosing to temporarily forgo health insurance when she was laid off from her job.
The second was screaming when a wild bat later landed on her face.
The bizarre encounter happened last August, while the Massachusetts, United States, resident was photographing the night sky during a holiday at the Glen Canyon National Recreation Area in Arizona.
Kahn, now 33, noticed a few bats flying around but didn’t worry about them – until one flew up to her and got tangled between her camera and her face.
She screamed, and part of the bat went into her mouth. She doesn’t know which part or for how long, though she estimates it was for only a few seconds. “It seemed longer,” she said.
The bat flew away, leaving Kahn shaken.
She didn’t think the animal had bitten her.
Regardless, her father, who is a physician and was travelling with her, said she should go to a hospital within a day or so and begin vaccinations against rabies.
Figuring she would be covered as long as she obtained insurance before going to the hospital, Kahn said, she found a policy online the day after the bat incident.
She said she called the company before she bought its policy and was told that services related to an accident or “life-threatening” emergency would be covered.
Kahn went the next day to a hospital in Flagstaff, Arizona, where she started rabies prevention treatment. Over the next two weeks, she received the rest of the rabies shots at clinics in Arizona and Massachusetts and at a hospital in Colorado.
Then the bills came.
Kahn received a total of four doses of the rabies vaccine. The doses are administered over the course of 14 days. With her first vaccination, she received three shots of immunoglobulin, which boosts antibodies against the virus.
Rabies is typically transmitted through bites or scratches from an infected animal.
Experts recommend precautionary measures when a person has been potentially exposed to rabies, because once the neurological disease causes symptoms, it is fatal.
The Centres for Disease Control and Prevention says post-exposure rabies treatment has reduced the number of human fatalities to fewer than 10 per year in the US.
According to explanation-of-benefits statements, Kahn owed a total of US$20,749 ($35,216) for her care at the four facilities.
Most of the charges were from the hospital where she was first treated, Flagstaff Medical Centre: $17,079, including $15,242 for the rabies and immunoglobulin shots.
Kahn’s policy did not pay for any of the services.
“The required waiting period for this service has not been met,” said an explanation-of-benefits letter she received in December.
Kahn was stunned. “I thought it must have been a mistake,” she said. “I guess I was naive.”
When Kahn was laid off from her job as a biomedical engineer last summer, she had the option to temporarily stay on her former employer’s insurance under a Cobra plan, at a cost of about US$650 per month.
As a young, healthy person, she gambled that she could get by without insurance until she found another job. She figured that if she needed medical care, she could quickly buy a private policy.
According to the Centres for Medicare and Medicaid Services, those who qualify for Cobra must be given at least 60 days to sign up – and if they do, the coverage applies retroactively.
Kahn, who was still within that period at the time of the incident, said recently that she did not realise she had that option.
The policy she purchased after the bat episode, which cost about US$311 a month, was from a Florida company called Innovative Partners LP.
Documents Kahn provided to KFF Health News say the policy has a 30-day waiting period, which “does not apply to benefits regarding an accident or loss of life”.
Kahn said that after receiving notice that her claims were denied, she called the company to ask how she could appeal and was told that a doctor would have to file paperwork.
She said she wrote a letter that was signed by a doctor at Flagstaff Medical Centre and submitted it in March but was unable to reach doctors at the other facilities.
Kahn said she was given conflicting answers about where to send the paperwork. She said a representative with the company recently told her that it had not received any appeals from her.
Benefits statements Kahn received in early July show Innovative Partners LP had not paid the claims. The company did not respond to requests for comment.
Sabrina Corlette, co-director of the Centre on Health Insurance Reforms at Georgetown University, said most health coverage plans take effect on the first day of the month after a customer enrols.
“The insurance companies – for good reason – don’t want people to wait to sign up for coverage until they are sick,” she said, noting the premiums healthy people pay help balance the costs of paying for healthcare.
The Affordable Care Act requires insurers to cover pre-existing conditions, such as diabetes or heart issues. But that doesn’t mean they have to pay for treatment of an injury sustained shortly before a person enrols in coverage, she said.
Corlette, who reviewed a brief benefits overview provided by Kahn, said the policy appears to have been a limited, “fixed indemnity” plan, which would pay only set amounts towards treatments per day or another period regardless of total expenses incurred. Such plans have been around for decades and aren’t required to meet ACA standards, she said.
But she said even if Kahn had bought comprehensive health insurance, it probably wouldn’t have covered treatment received so soon after she had purchased it.
David Shlim, a travel medicine specialist in Wyoming who studies rabies, said Kahn made the right choice by promptly seeking treatment, even though she didn’t feel the bat bite her.
The disease is deadly, and the fact that the bat went into her mouth meant she could have been infected from its saliva, he said: “You could hardly have a more direct exposure than that.”
Shlim, who recently co-wrote a federal advisory about rabies prevention, added that healthy bats don’t normally fly into people, as the one in this case did. The animal’s entanglement with Kahn suggests that it could have been sick, possibly with rabies, he said.
Rabies prevention treatment is much more expensive in the US than in most other countries, Shlim said. The priciest part is immunoglobulin, which is made from the blood plasma of people who have been vaccinated against rabies.
The treatment is often administered in hospital emergency rooms, which add their own steep charges, Shlim noted.
Kahn said she is employed again and has good health insurance but is still facing most of the bills from her misadventure at Glen Canyon.
She said she paid a doctor bill from Flagstaff Medical Centre after negotiating it down from US$706 to US$420. She said she has also arranged a US$10-a-month plan to pay off the US$530 she owes for one of her rabies shots at another facility.
She said she plans to continue appealing the denials of payment for the rest of the bills, which total more than US$19,000.
In a statement on behalf of the Flagstaff hospital – where Kahn incurred the highest charges – Lauren Silverstein, a spokesperson at Northern Arizona Healthcare, said that the health system does what it can to limit costs.
“We have less ability to control the prices of critical supplies that we use to treat patients, including pharmaceuticals, biologics, diagnostics, and medical devices made by other companies,” she said.
Silverstein said the hospital needs to keep immunoglobulin on hand to prevent rabies, even though such cases are relatively rare and the drug is expensive.
Cobra insurance policies, named for the Consolidated Omnibus Budget Reconciliation Act of 1985, enable many people who lose job-based coverage to pay to stay on those plans temporarily.
There is a 60-day window to choose Cobra coverage, and once a beneficiary pays for it, the coverage applies retroactively – meaning that medical care is covered even if it occurred when the person was uninsured.
Corlette said Kahn’s predicament illustrates why people need to make sure they have health insurance.
She said people who lose employer-based coverage should consider enrolling in individual insurance plans sold on federal or state marketplaces. Many people who buy such policies qualify for substantial ACA subsidies to help pay premiums and other costs.
“If you are losing your job, Cobra is not your only option,” Corlette said.
Kahn wishes she had signed up for insurance coverage when she was laid off, even though she felt confident that she would find another job within a few months.
“That’s a very big lesson I learned the hard way,” she said.
Her wildlife encounter did not destroy her love of the outdoors. She even sees humour in it.
“I know what bats taste like now. It’s an earthy, sweet kind of flavour,” she joked.
“It’s actually a pretty funny story – if it weren’t for the horrible medical bill that came with it.”