It was late January and heavy snowfall made for hazardous conditions as Carol Ruth, 70, and Richard Ruth, 79, made their way to Mercy Hospital. The roads were so bad that Carol pulled out her cellphone to call her doctor and say she would have to postpone her appointment.
When she returned home, Carol noticed a new text message.
It was from Centura Health, the corporation that owns Durango’s largest hospital. And it informed her that she owed the company $447.51.
A phone call to the health care corporation’s billing department clarified only one thing: When Carol had called that morning to cancel the appointment, her phone number’s appearance in the system flagged an outstanding charge for a physical therapy appointment she had on July 27, 2022.
A paper bill arrived in the mail a few days later.
The Ruths were puzzled.
Between her Medicare coverage and supplemental insurance, Carol was not supposed to be responsible for any charges relating to the July 27 appointment.
Just up the road from the Ruths’ home, Virginia O’Neill, 78, keeps a card table behind her living room couch. Atop it sits several piles of documents. The retired English teacher calls it her “Mercy desk,” with an embittered chuckle.
She has received so many bills for care she received at Mercy last spring that she cannot keep track of them all.
But, she has saved enough of them to assemble a mosaic that tells the story of her battle with the hospital over bills it seems she never should have received.
The stories of these two patients are not unique, nor are they surprising to the experts who advocate on behalf of patients. The complexity of the country’s fragmented health care system, which silos off patients from their providers, billing departments and even third-party billing companies, promotes system illiteracy.
And when patients face an illegible system that uses incessant billing and the threat of a collection agency to extract payment, most of them acquiesce. Neither Mercy Hospital nor Centura Health are outliers; the problem is systemic, experts say.
But despite their system illiteracy, O’Neill and the Ruths smelled that something was not right.
A spokesperson for Centura Health declined to comment for this story.
Carol Ruth attended a physical therapy appointment on July 27, 2022.
A Medicare summary notice – the document outlining claims to a patient’s Medicare plan – dated Aug. 31 details that Medicare received a claim for the July 27 appointment. The provider charged $473, but the Medicare-approved amount totaled only $127.49.
When a provider treats a Medicare patient, the provider agrees to accept only the Medicare-approved amount as payment.
Medicare paid $101.02 of Ruth’s bill. The remaining $25.49 was the maximum Ruth could be billed – and a footnote said the balance would first be sent to Ruth’s supplemental insurance.
When Ruth received a bill on Jan. 28 for her July 27 appointment, she owed $447.51. The amount reflected the total $473 charge for the visit minus the $25.49 that her supplemental insurance had already paid.
Believing the bill to be a mistake, the Ruths contacted Centura’s billing department.
Richard Ruth, a retired attorney, wrote letters and emails. At first, the corporation affirmed that the charges were correct.
“Charges are supported and reported appropriately,” concluded a Feb. 13 email from Centura’s Customer Service Revenue Management.
The exact cause of the problem remains unclear, but what is known is that Medicare received duplicate bills for Carol’s visit. Medicare requested that Centura repay Medicare as a result of “overpayment.”
“The reason it (the claim) had been denied was that it had been submitted three times and already been paid,” Richard Ruth said after a February conversation with Medicare.
A customer service representative at Medicare told the Ruths it was probable that Medicare had paid multiple times on the claim.
A consumer health advocacy expert who examined the case was not initially able to determine what may have caused the complication.
When Richard informed Centura’s customer service department that Medicare had been billed multiple times, he was told the company would hand the problem over to the revenue department.
The Ruths never heard back. But the bills and notifications kept coming.
“I got quite a few texts. They can be pretty persuasive,” Carol said. “I can see why people would just pay to get them to go away.”
When Carol Ruth logged onto her payment portal on March 27 – three days after The Durango Herald reached out to Centura for a comment on Carol and O’Neill’s situation – the balance had been wiped.
“If Richard hadn’t been an attorney, we probably would have just walked away from this and paid it,” Carol said. “We wouldn’t have known what to do, like so many people”
On Feb. 15, 2022, O’Neill received an injection in her knee at Mercy Hospital to address her chronic joint pain. The spry septuagenarian would go on to receive subsequent injections on March 29, June 21 and June 28.
But in April, O’Neill began to receive bills by mail and text messages warning her of the balance on her account. And at first, they did not concern her.
“They’ve always paid, the supplemental insurance covers everything; I’ve never had a bill,” she said. “I thought they’d get it together and I’ll hear eventually that BlueCross BlueShield came through.”
But she didn’t hear that, and the bills and warnings kept coming.
On May 23, unsure of what to do, O’Neill paid a bill she had received for $180.68. The balance was labeled as a deductible for which she was responsible, although she later learned this may not have been true.
Something still was not right. She continued to receive bills for spring appointments.
On June 17, O’Neill called Centura and spoke with a customer service representative named “Lynn.”
She called Centura again on Aug. 22 and spoke with someone named “Frank.”
“They didn’t know anything about it, they didn’t have any resources,” O’Neill said. “But they said they’d call me back.
Nobody ever did.
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When O’Neill reached out to her insurance company, she was stunned to learn that her plan had already paid for the bills she continued to receive.
The $180.68 she had paid to Centura on May 23? Her Medicare supplement had received a claim in the same amount, for the same care, nearly three months earlier. BlueCross BlueSheild paid Centura $180.68 on March 10. O’Neill even had the number on the insurance company’s check.
The Herald reviewed O’Neill’s bills, Medicare expense summary and supplemental insurance expense summary to verify the sequence of events.
She sent Centura a letter on Nov. 3 detailing these facts, but never got a response.
On April 28, BlueCross BlueShield paid Centura $72.77 for O’Neill’s March 29 injection. But on Sept. 4, O’Neill received a $72.77 bill for that visit. She received another on Oct. 2.
On Jan. 7, 2023, she received a letter from USCB America, a debt collections agency, trying to collect $38.98. The letter was vaguely worded and did not specify from which bill the debt originated. But it said O’Neill owed $638 as of March 29 – the same amount as the total charges for her March 29 visit.
Fearing the impact it could have on her credit score, she paid.
O’Neill’s BlueCross BlueShield summary of expenses also indicates that the insurance provider paid two $37.66 charges, a total of $75.32, to cover her June 21 and June 28 injections. But O’Neill received a $75.32 bill for those two visits on three different dates: Nov. 24, Jan. 19 and Feb. 23.
She never received any follow-up from Centura.
“I never hear anything (in response) but bills in email, texts and mail,” O’Neill said.
Despite the relatively small-dollar amounts on the bills that flooded their mailboxes, Ruth and O’Neill said they took up a defensive stance with Centura in the interest of others, who may not have the time or capacity to do so.
“It’s still really confusing for me, but I spent a long time trying to figure it out,” O’Neill said. “Some people are just going to pay it, and they are probably overpaying. And of course I overpaid.”
Experts in consumer health advocacy affirm that statement.
“These examples are not unique,” said Mannat Singh, executive director of the Colorado Consumer Health Initiative. “These are examples we see all the time.”
CCHI works to address inequities in health care and has a free Consumer Assistance Program that helps patients resolve issues with health care billing.
Singh said Ruth’s and O’Neill’s examples do not represent the most unjust cases of billing malfeasance – but the complications through which these patients have waded indicates that the system is fragmented, rendering it unnavigable for patients.
“The idea that the consumer or the patient should know who’s paying for what, at what level and to know to look into the billing codes to figure out if it was accurately coded or not is unreasonable,” she said.
Cindy Rigot is the co-founder of ReAssured Advocacy, a Denver-based health care navigation service. She also used to work at Centura.
“It’s hard to reach a human being, and when you do, there’s not a lot of thinking logically about ‘this doesn’t make sense, let me fix it,’ because there’s so much red tape, so much is automated,” she said.
This sentiment was reflected by Ruth and O’Neill.
“Everybody is doing their job – it’s just their assigned job, as in any organization this big – and they don’t go beyond their borders; everybody’s got their own little kingdom,” Carol Ruth said.
O’Neill likened dealing with Centura to the “Wizard of Oz” – everything is “behind a big curtain.”
“A patient should be able to call up, ask a question about their bill, get a straight answer and resolve that issue in a timely way,” said Stephanie Arenales, director of Consumer Assistance Program. “It shouldn’t be so hard.”
Part of the problem, advocates say, is there is no singular problem. A technical glitch, a human error or a miscommunication between insurance providers can result in the situations that Ruth and O’Neill face.
The Consumer Assistance Program maintains a productive relationship with Centura, Singh said. She declined to disclose the exact number of cases the CAP has handled stemming from the provider’s billing practices.
“The reason why we have a working relationship with Centura is also because of the number of cases that we receive (regarding) Centura,” Singh said.
The problem is not unique to hospitals owned by Centura. Advocates say the causes are rooted deep in the country’s health care system. As a result, even reforms within a corporation such as Centura, which operates 19 hospitals and generates over a half-billion dollars in gross revenue annually, can have a limited impact.
“We would love to see hospitals and health systems not just follow the rules as new policy is implemented, but ... lead on something that is innovatively protecting consumers and that is innovatively changing the way we pay for coverage,” Singh said.
According to a recent study conducted by the Consumer Financial Protection Bureau, over 12% of Coloradans have medical debt owned by a collection agency.
Although recent legislation and actions by credit agencies indicate that some positive changes are afoot, action is rarely, if ever, championed by health care industry representatives.
“Hospitals have, on multiple occasions, spent significant resources opposing legislation that would establish patient protections in the health care billing and collections process,” said Julia Char Gilbert, a policy advocate at the Colorado Center on Law and Policy.
She added that even nonprofit hospitals frequently behave like for-profit entities.
“Often, when we see involvement in the legislative process ... that involvement is informed by what’s good for folks’ bottom line,” she said.
As of Wednesday, medical debt under $500, such as that accrued by Ruth and O’Neill, will not appear on credit reports following scrutiny of credit agencies by the CFPB.
And SB23-093, a bill passed on Thursday by the Colorado House, would bolster consumer protections by capping medical debt interest at 3%, pausing the collections process during an insurance appeal and mandating more transparency into the debt-collection process.
Another bill under consideration in the Colorado Senate, HB23-1126, would ban consumer reporting agencies from making reports that include any information concerning medical debt. Gilbert said the Colorado Hospital Association officially supported the bill.
All of these efforts take aim at lessening the crushing burden of medical debt and disabling the pressure tactics used to extract payment.
“While it’s technically not illegal, we know that it is an unfair, unjust system that is designed to be opaque and difficult to navigate,” Singh said.
And so for the two Mercy Hospital patients who stepped up to navigate through the web of confusion, their crusade was more motivated by principle than financial necessity.
“I see so much of this happening, and I feel like it’s a bullying tactic,” O’Neill said. “... This is a scam. There are people out there my age who are having to go through the same thing I am. It’s not right.”