Back to the healthcare debate

Megan Rothbauer would rather be discussing an impending engagement, her future marriage and eventually, children. However, the 30-year-old Madison resident is instead scouring the Internet looking for solutions to stave off bankruptcy.

A project manager for a manufacturing company, she is one year removed from a cardiac arrest and the subsequent physical recovery is being dwarfed by a near-impossible fiscal recovery. She was sent last Sept. 9 to the emergency room at St. Mary's Hospital, which was out of her insurance network, instead of to Meriter Hospital, three blocks away, which was covered by her insurance. It's the difference between a $1,500 maximum out-of-pocket expense and the now-$50,000-plus she's facing in bills.

"I was unconscious when I was taken to the hospital," she said. "Unfortunately, I was taken to the wrong hospital for my insurance.

"I was in a coma. I couldn't very well wake up and say, 'Hey, take me to the next hospital.' It was the closet hospital to where I had my event, so naturally the ambulance took me there. No fault to them. It's unfortunate that Meriter is in network and was only three blocks away from St. Mary's," Rothbauer said.

A News 3 investigation revealed Rothbauer's situation -- what's called "balance billing," where patients receive the balance between the hospital charge and what insurance companies will cover -- is not unique. While the local insurance companies that represent roughly 80 percent of those who have insurance in our area will offer out-of-network patients in-network rates during emergency room visits, there remains no guarantee they won't face hefty bills on the back end depending on the treatment they receive.

"My strong suspicion is this happens more frequently than you think," said Meg Gaines, who runs the Center for Patient Partnerships, a consumer health care advocacy group at the University of Wisconsin-Madison Law School. "I mean every time someone goes down, they don't have someone around who knows what their insurance is."

In Rothbauer's case, her insurer, Blue Cross Blue Shield, said it paid St. Mary's 100 percent of its in-network rate or $156,000 to cover part of the original $254,000 bill that she incurred during 10 days in a medically-induced coma and another six days in the cardiac unit. St. Mary's negotiated with Rothbauer to reduce the remainder of her $98,000 bill by 90 percent. This is separate from the bills she received from the doctors, the ambulance, the therapist and others.

Gaines said consumers have little chance to negotiate against the parties in the health care industry as they don't have the necessary tools.

"I mean, I know this business. I've been doing this for a while, knocking on doors, trying to understand this data and I have no ability to do it. None," Gaines said. "When they don't even disclose the cost (of services), there's the cost. There's the price. There's the charge. There's the accepted payment. Lions, tigers and bears, oh my. How do you even know what's what in this world?”

"It is totally random, and it is the problem with saying consumers have to go to the right hospital and you say, 'What if you're unconscious?'" Gaines said.

Rothbauer's insurance company placed the blame for her situation on St. Mary's Hospital and its cost for services.

"(Megan) received care by a hospital that is not in our Wisconsin network," Scott Larrivee, public relations director for Anthem Blue Cross Blue Shield, wrote in an email to News 3. "Since we have no contract with this hospital, we have very little influence over what the hospital is charging in this situation."

The hospital, meanwhile, said it empathizes with Rothbauer's situation, but that it already wrote off tens of thousands of dollars in costs and that the conversation should also focus on the fact its doctors and nurses saved Rothbauer's life.

"When you're looking at saving a life, you're not looking at whether or not you can save them money," said Cyn Gunnelson, manager for Managed Care Contracting for the Wisconsin region of SSM Health Care. "I can only do so much. The hospital can only do so much. And I think the best outcome is the person walked away from the emergency room."