A Medicaid patient in Florida had a heart attack while traveling. He was owed $77,000.

On Christmas Day at Wataiki Indoor Water Park, Hans Wort was chasing his son up the stairs and got caught up in a water slide.

Wirt’s breath became more labor after returning to the nearby hotel where they and Wirt’s girlfriend were staying while visiting their family in Rapid City, South Dakota.

He then turned pale with nausea. Wirt believed this was due to the change in altitude between his home on the edge of Deltona, Florida (33 feet above sea level) and the Black Hills in Rapid City. However, his 12-year-old son was worried and called for an ambulance.

“In his eyes, I knew there was something a little more to this,” Walt said. “So I’m grateful to my son for saving his life.”

It was revealed that the 62-year-old had a heart attack. “A poor Christmas present,” Walt said.

Medic stabilized Wirt before taking him to Monument Health, the only hospital in Rapid City who was treated for two days and was treated for emergency care.

Then came the bill.

Medical procedures

Paramedics used defibrillators to restore normal heart rhythm. Hospital doctors gave them various medications, used electrocardiograms and other diagnostic and monitoring devices, and inserted stents into his arteries to improve blood flow to his heart.

Final bill

$95,523.73 includes $32,998.90 for medical supplies primarily related to stents, and $28,879 for treatment at the cardiac catheter measurement lab. After the bill’s unspecified hospital adjustment, Wirt was owed $77,574.44.

Claims: Medicaid across state boundaries

Wirt is covered by Florida’s Medicaid program through its managed care plan, Sunshine Health. However, South Dakota Hospital refused to submit the bill to an out-of-state Medicaid plan, and instead sent it to WIRT, and ultimately threatened to send it to collection agencies.

Medicaid is a government health insurance program primarily for low-income and people with disabilities, and is jointly funded by the federal government and states. The state is in charge of Medicaid management and has most contracts with private insurance companies like Sunshine Health.

Federal law says state Medicaid programs must provide reimbursements to out-of-state hospitals to care for beneficiaries in emergencies.

Many hospitals are requesting out-of-state Medicaid plans in such circumstances. Medicaid winners probably won’t be able to buy the larger bill, so there’s a risk that they won’t be refunded at all, said Katy Debriere, the legal director of Florida’s Health Justice Project when he spoke to KFF Health News in April.

But there is no federal law that requires them to do so, she said.

Federal court opinions point out that even if Medicaid is accepted, there is no need to request Medicaid from every individual beneficiary the hospital treats.

Monument Health did not cover Bill Wirt as a Florida Medicaid healthcare provider, according to hospital spokesman Stephany Chalberg. She told KFF Health News that the monument only billed Medicaid plans for South Dakota and four cross-border states, and only planned in Wyoming, Montana, Nebraska and Minnesota.

Medicaid patients who are not registered in one of these states are “responsible for the fee,” according to the hospital’s website.

“Due to the important qualification requirements of our multiple hospitals and hundreds of doctors, we are not part of every state,” a hospital representative wrote in a message to WIRT.

According to the Florida Medicaid website, out-of-state providers who handle one of the subscribers will need to request the program five documents, including a six-page application, a copy of the provider’s license, and a request form.

The process differs from state to state, with many Medicaid programs reimbursing out-of-state providers at a lower fee than in-state providers, according to the Medicaid and Chip Payment and Access Commission, a federal agency that advises Congress.

The provider’s registration barrier “will prevent access to legally qualifying coverage as the beneficiaries are in an unacceptable situation,” Charberg said.

Wirt decides to bring his bill to the Medicaid plan himself. However, he said Sunshine Health could only process invoices received directly from the provider.

Sunshine Health spokesman Elizabeth Boyd told KFF Health News that staff contacted the hospital on Wirt’s behalf. When asked why the plan could not process the bills submitted by the patient, or whether it could be done to help Wirt, she did not respond.

Solution

A few days after KFF Health News emailed Monument Health officials for this story, Wirt noticed that his balance had dropped from over $77,000 to $0.

Chalberg told KFF Health News that Monument Health covered Wirt’s bill through its charity care program. She said that “appropriate patients” will be notified of the program and “before the bill is sent to the collection to determine whether the patient is eligible for our financial support policy.”

To maintain non-exempt status, non-profit hospitals need a program that provides free or discounted care to patients who are unable to purchase bills.

However, Wirt said that when he first contacted Monument Health after receiving the bill and said he couldn’t afford it, officials did not mention the program. He said when asked if there were any external groups that could help him pay the bill, they didn’t share resources. Wirt said hospital staff only recommended setting up payment plans, but said monthly bills were too high enough for him to afford. “There’s a reason I’m in Medicaid,” Walt said. “It’s beyond me that they can expect someone with Medicaid to come up with such money. That’s unrealistic.”

Take home

Sarah Summers, legal director for the National Health Act Program, said “cogs in the Medicaid system” were not working properly in Wirt’s situation. “No one is enough to smooth this person’s path.”

Summers said the state is the main “COG” because it is in charge of Medicaid management. She said Medicaid managed care companies are also supposed to intervene.

Summers and Debriere said Medicaid recipients who receive the bill would have a managed care plan for them, with Medicaid recipients who don’t think they should file a complaint with the country’s Medicaid program, and if they have one. You can also ask if there are Medicaid or managed care caseworkers who can advocate for them.

The lawyer said patients should also contact legal aid clinics or consumer protection companies specializing in medical liabilities. Debriere said these organizations can help them file complaints and communicate with hospitals.

Debrierre said that if she was supporting Wirt, he would have stopped the claim and either sign up with Florida Decade and file a bill, or send a letter to the memorial to order it, to provide charity care.

Wort said the doctor who treated him and the medical care he received at the memorial health was amazing. He said he spoke about hospital billing practices because he didn’t want others to endure the same experience.

“If I get sick and have a heart attack, I have to be sure I’ll do it in Florida, not in other states,” he joked.

Bill of the Mont is a study of KFF Health News and Washington Post’s Well+Beeding Beeding by Beeding of the Washington Post, explaining medical costs. Since 2018, the series has helped many patients and readers cut healthcare costs and has been cited in state houses at the Capitol, the White House. Are there any confusion or outrageous medical costs you want to share? Please tell me about that!

KFF Health News is a national newsroom that produces detailed journalism on health issues and is one of KFF’s core operating programs. It is an independent source of health policy research, voting and journalism. Find out more about KFF.

Details of this series

Details from this month’s building