of the rules and regulations, so it’s understandable that patients are going to have issues.” He says one of the biggest misconceptions he sees is that patients get a bill with a very high number, and think they are expected to pay it all in full. “There are many legal and contractual reasons that the charges are so high; it confuses patients, or makes them upset or angry,” he said. “In the case of insured patients, the total in-network charges will be contractually reduced to an amount negotiated with your insurance company. For uninsured patients, they will be asked to pay more out of pocket, but they also qualify for significant discounts. The difference approximates the amount the insurance company would have paid the provider.”
Sable’s Story
Sable Moya is a McAllen resident who is all too familiar with the difference having insurance can make. She became pregnant while uninsured, so her baby’s care and delivery at McAllen Medical Center were covered by Medicaid, but her subsequent complications were not. “After the C-section my blood pressure went up, so I had to stay for a few days,” she said, remembering that when it was finally low enough for them to be released, her new son Luke had also just been cleared from the NICU. “On the way home I waited in the car while my husband, Adam, went into a gas station. When he got back to the car, I was having a stroke.” He immediately rushed her back to the hospital because she couldn’t speak or move her right side at all. “I had a seizure while Adam was trying to check us in,” said Moya. “They did bedside surgery to drain the blood clot and I was put in a medically induced coma for two weeks. Then I was transferred to Houston, where I was in the hospital for two months, then two months in a neurorehab facility.” Moya says that they were able to get insured before the transfer to Houston thanks to the Affordable Care Act. “Because of Obamacare, my life was probably saved,” said Moya. “We saw a bill that said the neurological rehab center was $1,200 a day, but thankfully that was completely covered. I was there for two months, so you can imagine what our debt would be if it wasn’t.” Three years later, Luke is doing well and Moya’s health is fully recovered, but it’s not the same case for the family’s finances. She worries because despite being aware of the importance of having insurance, rates are going up and she is not currently covered. “Adam makes just enough for us to not qualify for Medicaid but we can’t afford insurance on our own right now,” says Moya. “In case something massive like this happens, it’s so important. But what can we do?”
Uninsured but not Alone
Mallon says that they see uninsured patients coming into the Emergency Department, where they are
stabilized as required by the federal Emergency Medical Treatment and Labor Act (EMTALA), regardless of their insurance status or ability to pay. “It doesn't mean they get care for free, but the physician will see them and In the case of assess them, then discharge them with uninsured instructions to seek a clinic. If they’re patients, they unable to pay at that time we’ll send will be asked a bill.” to pay more out Sable Moya says that the bills of pocket, but incurred in those two weeks before they also qualify she got insured had to be paid out of for various pocket, but they were fortunate that discounts. her husband is a local musician who was able to throw fundraiser shows to help with the cost. “He ended up raising thousands, but it all went to my bills, every penny,” she said. “We’re so grateful. If the community hadn’t helped us, we’d be in such tremendous debt.” Online, it’s not uncommon to see individuals creating GoFundMe or other crowdfunding accounts to cover their medical bills. Rio Grande Regional Hospital also has a charity program that helps the uninsured, but operates on a case-by-case basis. Uninsured direct admission patients not having an emergency (those sent to the hospital directly by their primary care provider for any reason) do not fall under EMTALA and hospitals do not have to admit them if they are unable to pay. Mallon explains that complications may arise that may impact the cost of care for these patients. They are given the best estimate prior to the procedure, but no two cases are exactly alike. The initial estimate is just that — an estimate, not a guarantee.
The Value of Knowing
If you do have the opportunity to get insurance, it’s important to understand it to make the best choices for your health and finances. Your doctor and your insurer are there to provide answers which should bring comfort and resolution. Like all hospitals, Rio Grande Regional Hospital has employees who are dedicated solely to explaining billing and helping patients understand the financial aspect of the treatment they received. However, it is helpful when the patient can meet them halfway with the information. “If we can issue a clean bill with all the proper data and information, we can process a clean claim and hopefully the patient’s outcome is also a clean bill of health,” Mallon said. Even though it can be confusing, it’s important for insured patients to sit down with their HR representative or insurance agent to form a complete understanding of their part of the responsibility — ideally before they need to use their insurance. Adriana Morales, Director of Community
MARCH/APRIL 2017
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