If they’re going to take you for $3,000 — for stitches! — why can’t they at least tell you the price upfront?

Dan: It’s a Saturday morning in June. Sarah Macsalka’s seven-year-old son is running in the backyard of their house in Denver, and he trips on one of the flagstones Sarah’s just put in.

And it turns out the edges of these things are SHARP.

SARAH: You hear this crazy screaming, crying, coming, you know. And sometimes kids overreact, so I’m not running to the backyard

And she knows her husband Rocky is out there.

But the screaming doesn’t let up, and it turns out the kid’s knee is a mess. Big gash. There’s actually a bit of flesh there on the flagstone.

SARAH: Like a mini-marshmallow? I dunno— I mean, it was a good hunk of meat

Sarah’s mother-in-law is a physician. They text her a picture and she’s like, yeah, you better get that stitched up.

So they go to an urgent care facility nearby— the whole family. Sarah, Rocky, seven-year-old Cameron with the big gash, and Cameron’s ten-year-old sister.

Sarah likes this place. Nice people. They tell you the price upfront. They say: Hundred and fifty bucks, flat. Sarah signs off.

The doctor comes right in, and he’s like

We can sew this up for sure. But we don’t have this topical anesthetic that you know. And Cameron is still screaming and crying. He’s— he doesn’t take pain well (laughs).

She’s thinking about one time he had stitches taken out: He screamed his head off.

The doc is like, for the anesthetic, you’re going to need to go to the ER

SARAH: And I was like: “Oh yeah, I think we better do that.” And Rocky’s like, “I don’t think we should do that.” Cause he knows— he knows, right? But I have the final say, so

They go. Good news is, the doc refunds their hundred and fifty bucks. Otherwise..

This is An Arm and a Leg— a show about the cost of health care. I’m Dan Weissmann.

Sarah originally shared her story with our partners at Kaiser Health news and their Bill-of-the-Month project with NPR.

Here on An Arm and a Leg, we are focused on financial self-defense this season, and you can probably already tell: Sarah Macsalka and her husband are working on it.

I mean, the first thing they did was to text Rocky’s mom and ask: Do we even HAVE to get a doctor involved?

And their first stop was the urgent-care place with the posted rates.

And even though they’ve decided to go to the ER, they’re going to keep doing everything they can to fight off the billing craziness.

And they’re going to find out how, basically, impossible that can be.

And today on the show, we’re going to get some clues about WHY.

Why, ESPECIALLY, you can pretty much NEVER get a price up front at a place like this hospital. Ever. Even when that price is a totally known, totally standard thing.

You ready? Let’s go.

So, once they’re checked in at the ER, a guy shows up with a laptop on a cart— to get their insurance information. Robert.

Sarah: He is the one that I drilled on what it was going to cost because you know, I’ve, I’ve heard these stories

Stories about how much an ER visit can cost.

A reporter named Sarah Kliff spent a whole year doing these stories for Vox.com— and they’re crazy. We interviewed her on the show last year. It started when a guy got charged $600 dollars for a band-aid, and he sent her the bill to see what she thought.

SARAH K I did not understand this bill, but I decided to find out

She found out that the band aid itself was only $7, which is a lot for a band aid, but the rest, the rest was for something called a “facility fee.” Like a cover charge just for walking in. Which turned out to be A Thing. Not something regular people knew about— not even a reporter like Sarah Kliff.

She asked readers to send in their ER bills. More than a thousand people did. Turns out, facility fees can be in the thousands of dollars.

So our Sarah, Sarah Macsalka, asks Robert: Hey how much is this going to cost? What can you tell me?

Sarah: And he said, oh, I don’t know. You know, just walking through the ER costs, you know, $600.

Yeah, 600 bucks just for walking through the door.

To Sarah Macsalka— our Sarah, who has read all those ER-bill stories — that sounds like a facility fee. A cover charge.

And who knows what other charges there might be? She pushes Robert: Really, what might it cost for stitches? He’s like, really: I don’t know.

Sarah: And he sympathizes like, I know, you know, it’s crazy, but no, I don’t, I can’t give you, I don’t know what the cost is. You know, you could tell he knew that this, it was ridiculous.

Sarah starts doing math in her head. Maybe it’ll be a thousand bucks. But Robert says her insurance seems to cover ER charges, maybe even 80 percent.

So that’s not THAT much more than an urgent care visit was gonna be. And what’s she gonna do— drive her son back to urgent care now?

Sarah: You know, this kid’s still screaming and crying and his knee is a mess. And it’s just one of those things you’re like, fine, we’ll just take our chances.

Sarah: And you know, I used all the cards I had. That’s all I had.

They go for it. She signs something.

Oh, and guess what: The anesthetic? Doesn’t seem to work very well. Because Cameron screams his head off. It takes a while— remember, it’s a jagged, awful cut.

Sarah: Yeah, Cameron’s lungs did not let up. Those are very healthy lungs

Sarah: It was horrible. I actually apologized to them afterwards and they’re like, oh no, it’s okay. You know, they hear it all the time. And I’m thinking, what the [expletive] did we come in here for? Because clearly the whole reason we came here was so this wouldn’t be like this and it, and it was

But it ends. Doc says Cameron can go to soccer camp the next day, he’s gonna be fine. They’re grateful.

A few weeks later, they get a bill from the doctor — he billed 760, but their insurance has negotiated a discount to two hundred and 214.

And they’re on the hook for that, because they haven’t paid their deductible: that’s the thing from your insurance policy where, in a given year, you have to pay a certain amount for medical stuff before your insurance kicks in. They haven’t paid that deductible, so they’re on the hook for the two hundred and fourteen.

Sarah: So fine. It costs more than the urgent care, but it wasn’t that much more fine. We paid it. I figured that was the end of the story. I guess I failed to read this part

DAN: Which says. Which says:

SARAH: Let’s see.

DAN: These charges

SARAH: are for the emergency physician services and are not included in your hospital bill. And I was like, well, what else? What else is there?

DAN: I mean

SARAH: like

DAN: this is for the guy who came in and did the job.

SARAH: So what else would I be paying for?

Well, apparently something else: 2800 bucks worth of something else. That’s what it says on the bill Sarah gets a couple weeks later.

I’ve seen the bill, it’s one line. Not very clear. Basically says: 2800 bucks. Pay up.

Sarah calls the hospital, ends up talking with someone named Victoria in billing, and Sarah’s like: Are you sure this isn’t a mistake?

Sarah: She’s like, oh no. She goes, no, that, that’s right. And she goes and she says, you know, just going through the doors of an emergency room is $2,600 I think is what the number she gave me— and I was like WHAT?

Actually, the amount seems to be more than 42 hundred. That’s what it says on a statement Sarah got from insurance— it’s the amount before the insurance discount.

Sarah: And she’s like, yeah, yeah that’s just the flat fee. Like just to walk through the doors of the emergency room.

Just to walk through the doors of the emergency room. There it is. A facility fee.

Sarah: And I go, really? Because when I was in your hospital, the gentlemen that I spoke to said just walking through the doors was $600. And she goes, oh, no, no, no, you know this, you know, and she’s very confident.

And this is the first thing that I love about this story so much. Because it’s a totally standard fee. And if Sarah had gotten that information upfront, that is information she could have acted on.

Sarah: I would’ve said thank you very much. And walked out and gone back to our lovely urgent care and been like, Cameron, bite on this stick. We’re gonna do this pal. We’re gonna do this together as a family.

And Robert knew this fee was there. It’s just that the real one is SEVEN TIMES what he thought it was.

We’re gonna come back to this point. It is a really, really big one.

But there’s this other thing too, that I mentioned right at the start: Sarah KNOWS the medical system is full of financial potholes, she is WATCHING for them, and she is TRYING everything she can to steer around them. And she’s not done trying.

She tries this other line of questioning with Victoria — problem-solving, really.

Sarah: I was like, well, what if I just want to pay you cash? Like if I just pay it all today, what can we do? And she’s like, oh no. She goes, well If you didn’t have insurance, this is what she said, if you didn’t have insurance, um, we could probably bring it down 90%.

Basically, they just want to make sure they get SOMETHING.

SARAH: And I was like, cool, fine, I’ll take that. You know, I’m pissed off cause I’m still thinking that’s about $600. It’s way more than I’m planning, but I’m, I’m not paying $3,000. I was like, fine, cool, I’ll take it. And she’s like, oh no you can’t because it’s already gone through your insurance company. So that’s not an option for you.

In other words: Our contract with your insurance company says that we get 28 hundred bucks. We don’t care who we get it from. According to your insurance company, you haven’t paid your deductible, so it’s coming from you.

Sarah calls her insurance company and she’s like, can we do something about this?

Sarah: I was like, you guys are my advocate so this is an and the woman straight up said. She said, “We are not your advocate.” And I was like, “ooooh…”

And you know it’s there in black and white. Sarah and I looked together at the insurance paperwork on this little episode— where it shows how much the hospital said it wanted to charge, and the discount the insurance company got.

DAN: How’s it labeled? What is it labeled? Does it say Sarah’s discount or does it say plan discount?

SARAH: Right, right.

So, it’s back to the hospital billing department. The one thing they do for her is, they offer to put her on a payment plan.

Sarah: It’s like okay, I can set you up to pay 200 and so and so dollars a month. And I was like, no, no, I’m going to pay you $10 a month.

Sarah: And she’s like “Oh no, I’m sorry. But hospital’s set it up that if you take more than two years to pay it off, they’ll send you to collections.”

And we’ll wreck your credit.

That was it, the end of the line. So she set up automatic payments — the lowest amount they would take, 110 bucks a month. In fact, the day we talked, Sarah had gotten an email from the hospital

Sarah: The very first payment just went through two hours ago and I was like, that’s of course it did.

SO I’ve seen the bill. I’ve seen the insurance statement. I’ve seen the hand-written notes Sarah took while she was on the phone with Victoria from billing.

But I wanted to talk to Victoria. Or to Robert, the guy from the emergency room who said it could be six hundred bucks. Or somebody from the hospital.

So, I called. I talked to a spokesperson named Mari. She wouldn’t go on tape.

DAN WITH DENVER HOSP: Hey Mari, it’s Dan Weissmann.

I laid out Sarah’s story in all the particulars.

DAN: And it, that bill is for two-thousand, eight hundred and twenty four dollars…

And I asked the basic questions, like: That 4200 dollars, is that a facility fee, or what?

And the big one: If there’s a facility fee, a cover charge, and Robert — the guy who took Sarah’s insurance information— he knows there is one: why would he think that cover charge was six hundred dollars?

DAN: how is it possible that the person, you know, at the emergency department— it’s not just that he doesn’t have it, but that he has an inaccurate, you know, version of it.

I put all the questions in writing too.

I asked: Hey, can you look up what Robert’s job title would be? What are people in that job trained to tell patients who ask about prices?

I had Sarah send the hospital paperwork, authorizing them to discuss her story with me. (They always make you do that.) I waited and waited.

And the answer was… general: Amounted to, sucks for the family their insurance deductible is so high. But our contract with their insurance says this is what we get.

“We always work with patients on billing inquiries and provide our patients with flexible options such as payment plans.”

Nothing about how people like Robert are trained. I asked again, got a version of the same response.

But I talked with someone who has been on the inside of hospitals like this, top to bottom.

And I got some answers about WHY it is so impossible to get a price out of these people in a situation like this. Even when that information is super-straightforward, like a cover charge.

That’s right after this.

This season of An Arm and a Leg is a co-production of Public Road Productions and Kaiser Health News, that’s a non-profit newsroom that covers health care in America. Kaiser Health News is NOT affiliated with the giant health care provider Kaiser Permanente. We will have a little more on Kaiser Health News at the end of this episode.

OK. I talked with an insider and got some answers.

Lisa BELL-uh-MAH-vitch is a doctor who now runs a consultancy for hospital systems called Gist Healthcare.

Gist calls itself a “strategic advisory service that provides objective insights and guidance to healthcare leaders in a rapidly evolving industry.” So, fancy.

And their basic line is: Hospitals have to pay attention to — and adapt to — what people need from them. And that includes things like *value.* So, Lisa is paying attention to the kinds of questions I’m interested in.

And I asked her: Why doesn’t Robert know what the cover charge is, for this emergency room?

And her first answer was kind of what you might expect from somebody whose clients run hospitals:

LISA: what happened here is the guy who is performing that interaction is solely there to get her insurance and financial information and perhaps collect a copay. So he doesn’t have an access to information about her insurance, about pricing. So that is not the right conduit.

DAN: Why not?

LISA: That’s not his job

DAN: Well, wait a minute. Well wait a minute. Wait a minute. Why not?

I mean, I might’ve gotten a little pushy. And we still had to get really to the heart of the question cause it’s not, “Why can’t he tell her what her bill’s going to be?” Because he’d have to basically talk with her insurance to get that answer.

But the real question is: Whatever insurance covers or doesn’t, whatever discount the insurance might get, the cover charge is the cover charge. Why doesn’t Robert have that information to give out?

Lisa’s a straight shooter. She came around.

LISA: If I am a hospital, why do I want— it is not in my best interest to tell a patient you could pay…

… some epic amount of money. Patient would run screaming. And the hospital doesn’t KNOW that a given patient will pay that epic amount— lots of people still have insurance that protects them from those crazy amounts.

But now lots of us don’t. We have deductibles in the thousands of dollars like Sarah.

So I asked Lisa: If I DID want to— if I’m running a hospital and I DO want to get patients better information about prices, what’s stopping me?

She said, getting patients better information costs money.

LISA: You know you’re probably looking, you know, we’ve known health systems that have put in place what I would call a central pricing office, uh, that you know, has probably somewhere between five and 10 people whose full time job is to put together good price estimates.

Again, she calls that a Central Pricing Office— a place where patients can get an estimate of what their care is gonna cost. And she’s seen a FEW hospitals set one up. So she breaks down what it would take for the hospital where Sarah went to try it.

In a hospital in Denver, she says, you’d probably want five or six people in an office like this. And they are not entry level.

LISA: Someone who is very well versed in the reimbursement system, uh, you know, has the enough health care knowledge to put together a comprehensive price quote. You know, someone like that is probably making $100,000 a year.

She’s like, tack on another 50 thousand for benefits, and then all the rest: Office space, blah blah blah. Call it 200 thousand dollars a head. Six people, that’s a million-two. Then you need somebody to be the boss:

LISA: Yeah, you probably have a person who is on top of it, who’s, you know, making, uh, you know, 150% of the people who are, you know, doing the day to day legwork.

This is sounding like a million-five. A year. That I’m spending on this if I run the hospital. Which gives you an idea of why Lisa says 99 percent of hospitals haven’t done this.

Oh, and of course those people need 24 hours to crank out an answer. Lisa says this is mainly because they’re trying to connect with people’s insurance providers and — this’ll be a real shocker — people from insurance companies can be hard to get on the phone!

So they need 24 hours.

AND none of them would be working on Saturday anyway, when Sarah brings her kid and his split knee to the ER and asks Robert what it’s going to cost.

So if Lisa and I are running the hospital, we want to do better, we spend the million-five… we haven’t helped Sarah— or Robert— at all.

LISA: Yeah. We haven’t helped Robert in the emergency room. Of course, the Holy grail of having those five or six people in a central pricing office is that more and more of what they do can be automated, in which case a robber would be able to tap into it 24, seven.

DAN: Well, how far are we from that?

LISA: We are, the capabilities are there.

DAN: I mean the capabilities are there for a computer to win Jeopardy, but my laptop isn’t gonna win Jeopardy.

Lisa: Yeah.

And of course most hospital administrators see this kind of transparency as antithetical to their interests. Lisa and I agree, it’s kind of depressing.

LISA: And as you’re finding out, as you talk to dozens of patients who are in similar situations yeah. Is that every story has its own wrinkle. And so in trying to you know iron it out and create a simple,

DAN: This is like the least wrinkled story I’ve come across though, you know what I’m saying? This is like the least wrinkled cause we’re not even talking about the price of treatment. We’re talking about the cover charge, the walk in the door charge and the guy with the laptop knows that there is one

LISA: um hmm.

DAN: He just has a completely infinitesimally wrong. He has a completely wrong number for what it is.

LISA: [Six-second pause]

LISA: Yeah. And you have a patient who knows what they’re talking about and is motivated and is educated you know about the system works as much as you could hope anyone walks in the door would be.

[MUSIC … LETS THAT THOUGHT HANG FOR A MINUTE]

YEP.

You know, when Sarah sent me her bills and her insurance paperwork, she sent something else too: An article from Vox.com, by Sarah Kliff— the reporter who uncovered all the craziness about emergency room bills and facility fees.

This one was called How to fight an outrageous medical bill, explained. And Sarah had tried pretty much everything in it:

• Challenge the bill and how it was coded. Ok.

• Ask for a prompt-pay discount. She did try this— she said they offered her thirty bucks off.

• Call. Then Call again. And again.

• Consider hiring a professional. She did look at this— but it’s only worth it if you’ve got like a gazillion-dollar bill, which, luckily, she didn’t have.

• Go public— well, here we are. But I’m too late, she’s paying

So the last person I called for this story was: Sarah Kliff, the reporter who collected more than a thousand ER bills. She’s at the New York Times now.

She was like, YEAH. This stuff does not always work. That was one of the points of her story.

SARAH K: I wanted to give people what I had learned from the patients I had interviewed about what had been successful, but I also didn’t want to give them false hope about the battle that they’re getting into.

And it is a battle. The people she cited in that story sometimes went to extremes— called every day for months— with big dollar amounts at stake. And one of them said she broke into a rash.

And the last section of that story had the heading: Be aware that negotiating may not work— and may backfire. And it was about a guy who tried getting his insurance to help fight a bill— and ended up paying MORE.

Kind of like Sarah Macsalka in Denver. We looked at that story together. And it ends with a quote from that guy:

DAN: Pretty poor if the only thing you have to do to get a better price is not to get insurance.

SARAH: There you go.

The fact that insurance actually worked against her— the idea that that’s an actual THING that can happen— it gave Sarah an idea while we were talking.

SARAH: if I had known that and Robert had come in the room, I wouldn’t have given him my insurance information. Or is that insurance fraud? If you just don’t want to use your insurance?

DAN: What a good question?

SARAH: Like what if you just don’t want to use your insurance and be like, no, I want to be the cash client right now and we’re gonna not, we’re going to put that. Is that legal or is that illegal?

I ran that by Lisa Bielamowicz, the hospital consultant. She said that would have been hard to get away with. And the reason kinda ties a bow on this whole mess.

LISA: I bet that if the patient came in and without an, you know, didn’t show their insurance card, said they had no insurance but still gave up their social security number, that’s one thing you can run the nums on. And, uh, the system will find out if I have insurance.

DAN: So that exists! I can’t –

LISA: That does exist and it exists because the insurance companies don’t want to be paying bills they don’t have to pay. They’re, this started because they’re worried that you might be covered somewhere else. And if someone should be splitting the bill with them, they want to know it. So you’re coverage eligibility can be sussed out.

DAN: That’s good. But if you want to know how it plays out for you financially, Oh, whoops. Nobody’s invested in the infrastructure. It would take, it would be so complicated.

DAN: Yeah uh.

DAN: So she would have had to give a fake social.

LISA: Yeah. Yeah. Which then she’d be in for fraud so.

So yeah. Can’t beat the system.

By the time I met her, Sarah knew: She didn’t like all this stuff, but she was going to live with it. Writing the email that brought me here? That was the catharsis she needed.

SARAH: You know so thanks. Thank you. You know and now it’s like, cool, we’re just going to deal, you know, we’re not going bankrupt. We’re not losing the house. This is injustice, but it’s not life, you know, destroying.

Not for her, right? I mean there are households where an extra hundred-and-ten bucks a month causes a serious ongoing problem for the family budget.

And that’s one of the things I think about a lot, doing this show: The question of what A LOT of money is. What’s a serious annoyance to some households is life-destroying to others.

[MUSIC BEAT]

Meanwhile, here in Denver, we’ve got a happy ending. Sarah tells me her story in the morning, and in the afternoon I stop by to meet Cameron. He actually put together a show-and tell project about the whole incident for school. Not the bills, just his knee.

And there’s a laminated card with pictures of all the various stages

DAN: So what do we got here?

CAM: So that’s when it got opened, and then that’s how it got stitched up and then that’s a little bit after and then that’s only a couple of days ago.

And he’s got the actual stitches in a plastic bag.

CAMERON: Ah

DAN: Are they in this bag?

CAMERON: Yeah.

DAN: Can you show them to me? I can’t really see too good.

CAMERON: Right there.

DAN: Oh my gosh. Wait, I can’t see them.

SARAH They’re so tiny.

DAN: No really?

SARAH: A thousand dollars each

Next time on An Arm and a Leg— a segment I’ve been wanting to do since we first started. I just didn’t know what to call it for a long time. Now I do. It’s CAN THEY FUCKING DO THAT??

Because all kinds of stuff happens— we get crazy bills, and we’re like: Is that even legal? Who do I even ask?

Like this one: Woman visits a fertility clinic. Gets a bill, pays it. Then gets … another bill. This one’s in a Hot Pink envelope, which is weird looking, from some company she’s never heard of. And they want thirty-five bucks for some lab work.

And then she gets ANOTHER notice, same company. It says: You don’t pay this right now, it’s going up to 1300 bucks.

MIRIAM: Which was so outrageous that I thought this is definitely bullshit. Sorry, can I say that?

DAN: Yes, absolutely. Yeah.

Except, they weren’t kidding, and the next notice came from a collection agency.

And the whole thing makes you go: Can they F*cking DO that?

In this case, I found out.

Felt pretty good. Good story too.

That’s next time on, An Arm and a Leg.

If you’ve got a crazy story, you should send it in. We love getting your crazy stories. And I like running this stuff down.

Go to armandalegshow dot com, slash, contact. You can upload a voice memo there too.

Or you can send a voice memo to stories at arm and a leg show dot com.

One other thing you can find at our website? A way to support the show— two, actually: You can make a monthly pledge via patreon— OR you can make a one-time, tax-deductible donation.

And we could use it— we’ve got big plans for 2020— and we need your help to make it happen.

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So help keep this thing going. Arm and a leg show dot com, slash, support.

Thank you. I’ll catch you next week.

Till then, take care of yourself.

This episode was produced by me, Dan Weissmann. Our editor is Ann Heppermann, our consulting managing producer is Daisy Rosario. Our music is by Dave Winer and Blue Dot Sessions. Adam Raymonda is our audio wizard.

This season of An Arm and a Leg is a co-production with Kaiser Health News— a non-profit news service about health care in America that’s an editorially-independent program of the Kaiser Family Foundation.

Kaiser Health News is NOT affiliated with Kaiser Permanente, the big health care provider— they share an ancestor, that’s it. It’s a fun story.

You can find out more at arm and a leg show dot com, slash Kaiser

Diane Webber is National Editor for Broadcast and Taunya English is Senior Editor for Broadcast Innovation at Kaiser Health News— they are editorial liaisons to this show.

Finally, thank you to some of our new backers on Patreon— I literally could not make this show without you. Pledge two bucks a month or more, you get a shout-out right here. Thanks this week to:

Jackie Williams, Kristina Bockmon, Robin Jane Gentry

Laurie Jo Reynolds, Jonathan Krieger, Divina Del Fierro,

Sadie Mae, and Christian Gonzalez

I really cannot thank you enough or tell you what it feels like when I see you pledging to support the show. It’s like. That’s good! Thank you.