Insurers’ secretive deals with hospitals can force patients to pay exorbitant rates
Michael Frank has worked for health insurance companies for decades, doing the actuarial science which determines how much people should pay in monthly premiums. He knows insurers are supposed to be his “advocate” to restrain costs and get him a fair rate—so he was shocked when Aetna agreed to pay $70,000 to NYU Langone Medical Center in New York City for his partial hip replacement.
In a story co-published by ProPublica and NPR, Frank details how he was stonewalled when asking for answers on why his insurer had agreed to pay a rate more than three times what Medicare would pay for the same surgery. His coinsurance left him with a $7,000 bill which the hospital and Aetna likely expected he would begrudgingly pay.
“As bad as NYU is,” Frank said, “Aetna is equally culpable because Aetna’s job was to be the checks and balances and to be my advocate.”
Instead, Frank thoroughly examined his hospital and Aetna’s explanation of benefits, which arrived a month after his surgery. The in-network rate was pegged at $70,882, but his insurance experience allowed him to see red flags on his bill. He was being charged for physical sessions which never took place, drugs he hadn’t received and his implant cost $26,000 at a “member rate,” even though the maker of the implant said the hospital would have paid only $1,500.
Aetna and NYU Langone wouldn’t budge, with the insurer saying the payments were appropriate and the hospital refusing to explain its charges. After seven months, NYU Langone turned over his bill to a debt collector. After a year, it sued him for the unpaid sum.
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John joined TriMed in 2016, focusing on healthcare policy and regulation. After graduating from Columbia College Chicago, he worked at FM News Chicago and Rivet News Radio, and worked on the state government and politics beat for the Illinois Radio Network. Outside of work, you may find him adding to his never-ending graphic novel collection.