RACHEL MARTIN, HOST:
Anyone who suffered serious injuries in a car accident knows how challenging recovery can be, and the ordeal is only made worse by huge medical bills. That's what happened in our next bill of the month. Dr. Elisabeth Rosenthal from our partner Kaiser Health News is here to tell us about it. Dr. Rosenthal, welcome back.
ELISABETH ROSENTHAL: Thanks for having me.
MARTIN: Who are we meeting today?
ROSENTHAL: Today, we're meeting Mark Gottlieb. He's a 59-year-old marketing consultant from New Jersey. For two years, he's been dealing with the aftereffects of a car accident on his health and on his finances.
MARTIN: OK. Reporter Stephanie O'Neill spoke to Mark. Let's listen to her piece.
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STEPHANIE O'NEILL, BYLINE: Mark Gottlieb of Little Ferry, N.J., was taking his mother to a doctor's appointment in January of 2019 when a teenage driver ran a red light and plowed into the driver's side of his Chevy Cavalier.
MARK GOTTLIEB: And just wham - got hit, and I thought that was going to be the end. And luckily, I survived, but I ended up getting really messed up.
O'NEILL: His mother escaped with minor injuries. His were far more serious - six smashed teeth and damage to four vertebrae in his neck and back. His initial treatment lasted months.
GOTTLIEB: I went through everything from seeing chiropractors, seeing physical therapists for my jaw, my arms, legs, back, neck, you name it, all kinds of doctors and all kinds of pain management.
O'NEILL: That care cost about $60,000 and was paid for by his car insurance. In New Jersey and in 12 other states, personal injury protection, or PIP coverage, in auto insurance policies is designed to pay for car accident injuries. And Gottlieb had the maximum amount possible...
GOTTLIEB: ...Which is $250,000 in the PIP coverage.
O'NEILL: Enough, he believed, to also cover the next surgery recommended by his doctors. And because he had nearly $200,000 remaining, Gottlieb wasn't really concerned about exhausting his coverage.
GOTTLIEB: I was under the impression that that should cover an hour-and-a-half surgery at the hospital. Even after the surgery was done, I spoke to the person in charge of the numbers over there, and he's like, oh, you're going to have no problem. It's all going to be covered.
O'NEILL: Except that it wasn't - not even close. Together, the hospital and surgeon billed more than $700,000. GEICO, his auto insurer, knocked it down a bit, but still permitted them to bill about a quarter million dollars. That's eight times more than Medicare would pay for the same procedure.
GOTTLIEB: I think they should have fought it, and they should have said, you know, these bills are absolutely outrageous.
O'NEILL: But they didn't. Instead, they used all of his remaining coverage to pay the inflated bill and left him on the hook for $89,000.
GOTTLIEB: So we were like, this can't be. It's impossible. How can this be? And we did everything we could to protect ourselves. GEICO, we want to know how much it's going to cost. We want to make sure we have enough money there. And they wouldn't answer. They had nothing to say, so I had no way of knowing. So I was totally in the dark.
O'NEILL: Gottlieb has complained about the billing to government agencies, but despite laws intended to protect against overbilling, there are loopholes, and his situation falls into one, leaving him anxious, he says, to seek further care he still needs.
GOTTLIEB: I have days when I feel horrible, and, you know, I'd love to go to a doctor if I know that it's covered by insurance, but I don't want to go through the same nightmare again.
O'NEILL: Meanwhile, Mark Gottlieb is waiting to find out whether the health provider will come after him for the $89,000 balance. For NPR News, I'm Stephanie O'Neill.
MARTIN: Wow. OK, so $89,000 that Mark Gottlieb still may owe, and that's after his insurance coverage paid $250,000. How, Elisabeth - how does this happen?
ROSENTHAL: Well, welcome to American health care. Most people don't realize that for injuries sustained in car accidents, auto insurance pays health care costs first, and it often doesn't synchronize very well with your health insurance. Now, Mr. Gottlieb had good policies for both, but he still got these crazy bills.
MARTIN: The other driver was at fault in this case. Why didn't their insurance cover this?
ROSENTHAL: Well, New Jersey is a no-fault state, so the driver's own coverage kicks in. Some states like New Jersey do have set amounts that should be paid for different types of care. They're called fee schedules. But doctors can bill items not on those schedules. Mr. Gottlieb's surgeons did that, and then the sky's the limit on what can be charged.
MARTIN: So what about health insurance? I mean, did Mark Gottlieb have a health insurance policy?
ROSENTHAL: Sure, he did, and when the exorbitant charges for the surgery blew past the quarter million dollar limit of his auto insurance, his health insurance did kick in. But, surprise, the health insurance had different doctors in its network than GEICO. And that network didn't include the hospital and the surgeon for his surgery. So his health insurer didn't cover all of the balance, not even a tiny fraction of it.
MARTIN: And what does the hospital have to say about these exorbitant charges?
ROSENTHAL: Well, the hospital says it's within its right to charge these amounts, but we should point out that Medicare would have paid about $30,000 for this surgery, and Mr. Gottlieb was charged about eight times that by the hospital and the surgeon.
MARTIN: So if this happens to you, if you're in a car accident and you're thinking about, oh, what does my car insurance cover, what does my health insurance cover, what should people know?
ROSENTHAL: Well, your mind should be spinning, but first, that auto insurance is primary. Second, that with our high prices in the U.S., you can easily blow past those insurance payout limits, so check with your health insurer right away to make sure that the doctors treating you are also in its insurance network and as always, try to get an estimate beforehand. If it seems unreasonably high, walk away and go elsewhere.
MARTIN: Dr. Elisabeth Rosenthal, thank you as always.
ROSENTHAL: Thank you.
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MARTIN: If you've got a confusing medical bill, go to NPR's Shots blog. We want to hear about it.
(SOUNDBITE OF GLOWWORMS' "CONTRAILS") Transcript provided by NPR, Copyright NPR.
