She was pregnant and had to find $15,000 overnight to save her twins
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KFF Health News
When she was pregnant with her twins, Sara Walsh was diagnosed with a serious complication and had to pay thousands upfront before a specialist would see her.
It was Labor Day weekend 2021 when Sara Walsh, who was 24 weeks pregnant with twins, began to experience severe lower back pain.
On Wednesday, a few days later, a maternal-fetal specialist near her home in Winter Haven, Florida, diagnosed Walsh with twin-to-twin transfusion syndrome, a rare complication that occurs when multiple fetuses share blood unevenly through the same placenta. The doctor told her that the fetuses were experiencing cardiac issues and that she should prepare for treatment the following day, Walsh said.
Her OB-GYN told her that, without immediate surgery, her twins had a high chance of perinatal death and she could also die.
Both doctors referred Walsh to a fetal surgeon about four hours away, describing him as an expert on the condition.
As Walsh prepared to leave, she received a call from the surgeon's practice, the Fetal Institute. Walsh said a billing representative told her that before Dr. Ruben Quintero would see her, she needed to pay in full for the consultation, surgery, and postoperative care a total estimate of $15,000.
Although Walsh had insurance, the biller said the surgeon was not in any private insurance networks nor did he offer payment plans.
"I burst into tears," Walsh said. "I don't want to lose these babies."
Her mother agreed to give her money, and Walsh also called her insurer, who advised her to apply for a waiver that could allow them to reclassify the care as in network.
Late Wednesday, Walsh and her husband checked into a hotel near the practice's office in Coral Gables. The next morning, she handed her credit card and then her mother's credit card to the clerk at the Fetal Institute. Quintero said her case had advanced to stage 3, meaning there were problems that could cause heart failure in one or both fetuses.
He performed surgery later that day at a hospital about 90 minutes away. On Friday morning, she traveled back to his office for a follow-up. In the following weeks, she had two more consultations.
About five weeks after the surgery, Walsh gave birth to twin girls. They were premature but otherwise healthy.
Then she waited for her insurance reimbursement to come.
The patient:
Sara Walsh, 39, is covered by Blue Cross and Blue Shield of Texas through her employer, a national newspaper publisher.
Medical service:
Fetoscopic laser surgery for treatment of twin-to-twin transfusion syndrome, as well as pre- and postoperative evaluations and X-rays.
Service provider:
The Fetal Institute in Coral Gables, Florida, a practice that specializes in treating rare pregnancy complications.
Total bill:
$18,610 over multiple visits for surgery; pre- and post-surgical consultations; and two follow-up consultations for potential complications that didn't ultimately require more treatment. Walsh ended up putting $14,472.35 on her and her mother's credit cards. Her health plan eventually paid the Fetal Institute $5,419.44. Walsh was later partially reimbursed but ultimately paid more than $13,000 out-of-pocket.
What gives:
Walsh's case falls into a gray area of medical billing between emergency and elective care. Despite being insured, Walsh paid most of the full charges upfront and out-of-pocket for care that three doctors said she urgently needed to save her twins. And she knew the surgeon was an out-of-network provider.
Within 20 hours, Walsh gathered the thousands of dollars she was told she needed to pay before the surgeon would meet with her and prepared to undergo surgery in an unfamiliar hospital. "That 20 hours was just insanity," she said.
When Walsh called BCBS before her procedure, a representative told her that Quintero was in its network at a few facilities but not at his private practice, where he would evaluate her. Laura Kersey, a billing representative with the Fetal Institute, confirmed to KFF Health News that the practice accepts Medicaid which covers nearly half of all births in Florida but does not contract with private insurance.
"Our highly specialized practice sees patients from across the globe," Quintero said in a statement to KFF Health News and NPR. "It would be impractical to join all health plans. If any patient is unable to pay in full for a procedure, we offer them CareCredit or an alternative payment plan, on a case by case basis."
Neither option was available to Walsh. Approval for CareCredit, a medical credit card, would not have come in time for her next-morning procedure. Walsh said the Fetal Institute denied her request to pay half of the bill upfront and the rest over time.
Kersey said requiring upfront payment is the Fetal Institute's "normal practice." She said they are transparent about their billing practices and disclose them to potential patients ahead of time. If someone cannot pay, she said, the Fetal Institute sends the person back to the referring physician to find another option.
Walsh said the BCBS representative advised her to complete a waiver intended for patients who receive urgently needed care from an out-of-network provider when it is not feasible to see an in-network provider. Walsh did not have the days or even weeks needed to undergo the insurer's formal preauthorization process, which could tell her in advance whether BCBS would cover the claim. Walsh and her mother had paid the Fetal Institute nearly $13,000 related to her surgery, hopeful that BCBS would reimburse them.
In the weeks before Walsh gave birth, the specialist in Winter Haven sent her back to Quintero twice. Both times Quintero evaluated Walsh and sent her home without further treatment. She paid nearly $1,475 more for those visits.
Walsh said she had trouble getting all the documentation BCBS had said she needed. In early November, she received the letter of medical necessity explaining the diagnosis.
The letter, signed by Quintero, said that twin-to-twin transfusion syndrome, when left untreated, results in pregnancy loss in 95% of patients.
But Walsh's situation didn't count as the type of emergency that could have qualified her for federal billing protections, said Erin Fuse Brown, a law professor and the director of the Center for Law, Health & Society at Georgia State University.
Walsh sought care that was "knowingly out of network, even though there was a figurative gun to her head," Fuse Brown said, referring to the potential loss of her twins or even her own life.
The federal No Surprises Act, which took effect last year, months after Walsh's surgery, protects patients who receive emergency services inadvertently from out-of-network providers and only in certain settings particularly emergency departments and urgent care centers. It also covers nonemergency services received from out-of-network providers, but only at in-network facilities.
Federal laws requiring public access to emergency services apply only to hospitals, not individual providers in their offices, F
Thursday, April 27, 2023 at 9:00 am