Bicyclist Phil Gaimon ended up with hospital bills totaling more than $200,000 for surgeries after a bike crash during an Olympic trial. (Heidi de Marco/KHN)
#保險買錯 #奧林匹克男子自行車 #男子自行車比賽冠軍 #菲爾蓋蒙 #Phil Gaimon #男子自行車冠軍摔傷 #奧運男子自行車冠軍賬單 #巨額醫療賬單 #菲爾蓋蒙賬單
加州一名自行車手在一次比賽時嚴重受傷，被送進了重症監護病房，盡管他有兩份醫療保險，但仍要支付15萬元的天價醫療費。
據CBS報道，2019年，菲爾·蓋蒙(Phil Gaimon)在賓州參加奧運會資格賽時與另一名自行車手相撞。當時正以40英裏時速沖刺的蓋蒙從自行車上飛出，摔斷了七根骨頭。他被緊急送往賓州阿倫敦（Allentown）的利哈伊谷醫院（Lehigh Valley Hospital）急救，當時已失去知覺。
蓋蒙接受采訪時說：“所以當我醒來的時候，感覺非常痛苦。我右側的所有肋骨都斷了，還有鎖骨，還有……我的肩胛骨。”
蓋蒙在利哈伊谷醫院接受了鎖骨手術，随後轉院到紐約特殊外科醫院(Hospital for Special surgery)接受了第二次手術修複肩胛骨。
手術後，蓋蒙一直在家中休養，順利康複，但賬單也随之而來。兩家醫院的賬單共計20萬元，他的兩份保險總共隻支付了5.2萬元，這意味着他需要自己承擔其中約15萬元。
蓋蒙這才意識到，利哈伊谷醫院不在他的保險網絡中，他的肩部手術被歸類爲“選擇性”手術，而不是“緊急”手術，後者本來可以爲他省下一大筆錢。
蓋蒙說：“當你幾乎沒有精力處理任何事情的時候，他們給你寄來這些賬單。我每個月都會收到一堆賬單。我每天都收到催款通知。”
《凱撒健康新聞》主編羅森塔爾（Elizabeth Rosenthal）在接受采訪時談到了這一情況，她表示：“醫院賬單上布滿了地雷。菲爾遇到了其中的三個問題——網絡外醫院、高昂的費用，而他的最大問題是——一個州的保險在另一個州往往不很管用。”
羅森塔爾說，蓋蒙遇到了“差額收費”（balance-billing），也就是意外賬單，在這種情況下，醫院會向患者收取保險未涵蓋的金額。她解釋稱：“你去了一家不在網絡内的醫院看病，根據許多州的意外賬單法，在緊急情況下，你隻應該被收取與在網絡内醫院相同的費用。所以，菲爾位于加州的保險公司，支付了他們認爲合理的費率……但兩家醫院都想要更多的錢，所以他們給菲爾開出了差額賬單。
如果他在加州遇到這種事，這就是非法的，因爲加州的意外賬單法很好。但因爲他在賓州和紐約州就診，而且保險是由這些州監管的，醫院可以這麽做。”
英文報道版請見下文：
It was a race in Pennsylvania that could have sent cyclist Phil Gaimon to the Tokyo Olympics; instead, a serious crash-landed the Californian in two hospitals on the East Coast.
Gaimon knows accidents are, unfortunately, part of the sport. He had retired from competitive road cycling three years earlier, but a recruiting call came in the spring of 2019 from a coach of the USA Cycling track team.
The coach needed speed for a four-man event. At the time, Gaimon was making a name for himself — and money — by mountain racing, and he was setting records.
“It was a dream come true,” said Gaimon, 35. “A chance at a second career in racing.”
But his Olympic dreams were short-lived. In a sprint with a pack of riders at the velodrome track in eastern Pennsylvania, Gaimon sailed over his handlebars after colliding with a fellow racer. Gaimon hit the ground hard. The result: a fractured collarbone, five broken ribs, a partially collapsed lung and a broken scapula — injuries worse than any he had suffered in the 10 years he had raced on pro road teams in the U.S. and Europe.
An ambulance whisked him to Lehigh Valley Hospital in Allentown, Pa., which is part of the health system that sponsored the cycling event. Emergency doctors admitted the athlete, and he underwent surgery on his collarbone. He also needed surgery on his scapula (shoulder blade), which he said felt “like a collapsed taco.” But that surgery would happen days later, after he was discharged from the Pennsylvania hospital and a friend helped him find a surgeon in New York.
He chronicled the whole ordeal on his social media channels, and soon he was recuperating — painfully, but successfully — back home. And then the bills came.
The patient: Phil Gaimon, 35, a former professional cyclist, a YouTuber and blogger who earns most of his income through sponsorships. He paid about $500 a month for his insurance policy with Health Net through Covered California, the state’s health insurance exchange. He also had a secondary health insurance policy with USA Cycling.
Total bills: $151,804 from Lehigh Valley Health Network and $49,526 from the Hospital for Special Surgery. He had additional bills from various physicians. Health Net has paid approximately $27,000 to Lehigh Valley, according to Gaimon. His secondary insurance, with USA Cycling, paid $25,000 to the Hospital for Special Surgery and his surgeon there.
Service providers: Lehigh Valley Hospital-Cedar Crest in Allentown, Pa., part of the nonprofit Lehigh Valley Health Network; and the Hospital for Special Surgery, an academic medical center, in Manhattan, New York.
Medical procedure: surgery for a fractured collarbone at Lehigh Valley Hospital and surgery for a broken scapula at the Hospital for Special Surgery.
What gives: Gaimon collided with three health system dangers in this physically and financially painful crash: an out-of-state emergency, out-of-network care and gold-plated prices from both hospitals that treated him. Gaimon said he could sell his house and pay these bills, “but I shouldn’t have to. I have insurance.”
His situation is a scenario that many patients have encountered when they need emergency care outside their provider’s network. It’s known in medical jargon as “balance billing.” Hospitals and insurance companies without mutual contracts often don’t agree on the price of services, and the patient is left to pay the difference.
While at least 33 states have enacted laws intended to protect consumers from balance billing, many don’t apply to out-of-state patients, said Maanasa Kona, an assistant research professor at the Center on Health Insurance Reforms at Georgetown University.
For example, in Gaimon’s home state of California, state law protects enrollees in state-licensed health plans from balance billing, but their authority is limited to California doctors and hospitals.
“These state laws depend upon the state having jurisdiction over the providers involved,” Kona said. “So nothing is going to stop out-of-state providers from sending bills and hounding the patient. It’s a major gap.”
In Gaimon’s case, the validity of the hospital’s charges is also questionable. Lehigh Valley Health Network is notorious for big markups on care for out-of-network patients, said Dr. Merrit Quarum, chief executive of WellRithms, which scrutinizes medical bills for self-funded employers and other clients nationwide. “There’s no rhyme or reason as to how they’re charging compared to their costs,” Quarum said.
WellRithms reviewed Gaimon’s bills in detail at the request of KHN and determined that a reasonable reimbursement for the care he received at Lehigh Valley Hospital would have been $21,000. That’s $6,000 less than what Health Net has already paid.
In an email to KHN, Lehigh Valley Health Network spokesperson Brian Downs called the calculations by WellRithms “flawed” and said it is not appropriate to use Medicare-based rates to determine medical costs because they “are not reflective of the actual cost incurred by a provider in rendering any specific medical service.” WellRithms didn’t use Medicare rates, however. It looked up the amounts that Lehigh told Medicare it costs the health system to perform a wide range of services.
One reason cited by WellRithms for Gaimon’s high bill: Lehigh Valley Hospital charged him $25,915 for a night in the intensive care unit and $29,785 for a night in the burn unit, according to an explanation of benefits sent to Gaimon by Health Net in January 2020. Gaimon understood he was placed in these specialty units because of a lack of space in other parts of the hospital. But Downs, in his statement, said Gaimon needed the burn unit due to his abrasions and the ICU after his collarbone surgery.
Still, the charges are big markups compared with the costs Lehigh reports to Medicare: $13,038.82 for an ICU patient night and $18,036.92 for a burn ICU patient night, according to WellRithms.
“$25,000 a day for a charge for an ICU is absolutely ridiculous,” Quarum said.
Gaimon’s $49,526 bill from the Hospital for Special Surgery posed other patient-billing land mines.
Phil Gaimon knows accidents are part of his sport. He had retired from competitive road cycling three years earlier, but a recruiting call came in the spring of 2019 from a coach of the USA Cycling track team.
Heidi de Marco/KHN
He recalled representatives from the hospital and his insurance plan telling him that he would be billed as an out-of-network patient, but they assured him that he could file an appeal because of the extenuating circumstances. And he had secondary insurance offered by USA Cycling that would cover $25,000 for the shoulder surgery, which it did, according to billing records.
He expected his primary insurer, Health Net, to pay some of the cost too.
But in an Oct. 19, 2019, letter, Health Net denied Gaimon’s appeal because he “self-referred” himself to a surgeon in New York. It also described the surgery as “outpatient” even though he spent the night at the hospital. The letter went on to say the Hospital for Special Surgery had categorized the surgery as elective.
Given his level of pain and the fact that surgeons at the first hospital didn’t perform the scapula surgery during his stay, he figured there was nothing “elective” about it. “I needed this surgery, and no one else could do it,” Gaimon said.
Health Net spokesperson Darrel Ng declined to comment, saying it doesn’t comment on specific member cases, even though Gaimon gave written permission for his case to be discussed.
A reasonable reimbursement for Gaimon’s out-of-network scapula surgery would have been $13,908, according to WellRithms. Historically, the hospital’s average charge for that surgery was nearly $11,000, even though it cost only $3,094 to perform in the year that Gaimon had his surgery, WellRithms found in the 2019 annual cost report that the hospital submitted to the federal government.
Resolution: Battling these bills became Gaimon’s full-time job as he recovered from surgery. And almost two years after the crash, he still faces huge bills from both hospitals despite both hospitals having been paid tens of thousands of dollars through Gaimon’s insurance coverage.
After a reporter made inquiries, a representative from the Hospital for Special Surgery (HSS) called Gaimon, offering to help him apply for financial assistance based on his income.
In a statement, HSS spokesperson Noelle Carnevale said, “We regret Mr. Gaimon’s dispute with his insurance provider’s classification of the surgery as elective.” And she added, “We are optimistic for an easy resolution, and look forward to celebrating his continuing achievements.”
Gaimon spent months calling and writing letters to Health Net to persuade it to cover the emergency room visit and the collarbone surgery. So far, he has been unsuccessful.
Congress last December passed legislation intended to protect patients like Gaimon against unexpected bills from out-of-network providers. Starting next year, when the law takes effect, patients can be charged only up to the amount of their deductible or copayment when receiving emergency care at any hospital.
The takeaway: The federal protections against unforeseen medical bills for emergency care kick in Jan. 1, 2022. So if you travel out of state this year, you should be aware that many state-based insurance plans might not cover you fully or at all in another state.
If you’re in possession of a surprise or balance bill for out-of-state emergency care, contact your health insurance plan and make sure representatives understand that it was an emergency. Call the hospital and ask about financial assistance or charity care.
And be aware that the new federal law doesn’t cover everything. Should you be taken to the hospital by a ground ambulance service that’s not in your insurance plan’s network, for example, you could still be on the hook for a large bill.
“There will always be some surprises because the hospital or the doctors are going to find a way to get you uncovered by the law,” said Gerard Anderson, director of the Center for Hospital Finance and Management at Johns Hopkins University’s Bloomberg School of Public Health. “It’s always a game of whack-a-mole.”
Stephanie O’Neill contributed the audio profile with this report.
Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us?
蒙特梭利學校的好處 一般的 Montessori 私立學校每年可能需要數萬美元或更多的學費。然而,紐約市第一所免費的 Montessori 學校具有多重重要意義。首先,它為許多沒有足夠經濟能力以精英方式撫養孩子的父母提供了一個公平的機會。其次,如果申請就讀這所學校的人數很高,統計數據將向紐約市教育委員會展示,應該投入更多資源在全市建立這樣的學校。 一般的 Montessori 學校學費每年從2萬到4萬美元不等。被錄取到這所學校就像獲得了一張價值20萬美元的免費彩票。這對於許多家庭來說是一個難得的機會,可以讓他們的孩子接受高質量的教育,而無需承擔沉重的經濟負擔。這所免費的 Montessori 學校不僅惠及個別家庭,也為整個社區帶來了積極的影響,為更多孩子提供了接受優質教育的機會。
家庭醫生是照顧整個家庭的醫生。 許多醫生接受專科醫學培訓。然而,家庭醫生接受所有醫學領域的培訓。無論您的年齡或性別如何,他們都會照顧您整個人的各個階段。這包括對您身體、心理和情感健康的關心。家庭醫生會了解他們的病人。他們與您和您的家人建立關懷的關係。他們會傾聽並記錄您的健康史。這有助於他們更好地理解如何幫助您做出有關健康的正確決定。 您的家庭醫生負責診斷和治療急性和慢性疾病。他們還提供常規健康篩查和生活方式改變的諮詢。這有助於在健康問題出現之前預防它們。如果您需要專科醫生的護理,您的家庭醫生會將您轉介給專科醫生。他或她將幫助協調您護理的各個方面。 通往改善健康的道路 每個人都應該有一個家庭醫生,即使他們目前沒有健康問題。家庭醫生接受預防醫學的培訓。預防或避免健康問題比治療或管理健康問題更好。您的家庭醫生可以幫助您和您的家人保持健康。 家庭醫生接受所有護理領域的培訓。 這些包括: 從嬰兒到老年人的護理 慢性疾病,如糖尿病、哮喘和心臟病 耳、鼻、喉護理 心理和行為健康護理 骨骼和關節護理 眼部護理 婦女保健和計劃生育 基本檢測,如X光…
美國醫療保險概覽 在美國,人人皆知醫療保險費用高昂,但擁有醫療保險卻是不可或缺的。由於美國醫療費用更加昂貴,一旦發生意外而沒有保險,你需要支付的醫療費用肯定遠超過保險費用。 然而,美國醫療保險公司眾多,醫療保險計劃更是多達數百上千種。在如此複雜的情況下,該如何選擇適合自己的計劃呢? 在美國,如果你需要自行購買包含必要醫療保障的醫療保險或是奧巴馬醫保,就必須在特定的公開期(Open Enrollment Period)內登記購買。錯過了這個時間,就需要等待下一年。 你可能聽過這樣一個段子:出國在外的人如果在暈倒前還會大叫「千萬別叫救護車」。從這個段子中,你肯定能猜到若沒有保險,美國的醫療費用將有多麼昂貴。 此外,川普總統剛剛頒布了一項新政策:要求申請美國簽證的移民必須證明自己有足夠的經濟能力負擔醫療費用,或已獲得經批准的醫療保險,否則可能會被拒絕入境。 「點看」白卡“公共負擔”新規 醫保公開期(Open Enrollment Period) 什麼是美國醫療保險公開期(Open Enrollment Period)…
2025 最新 - 聯合健康保險/又名牛津醫療保險(包什麼/不包什麼: 更新中)... 如果使用使用以下化驗中心,可以省更多 本文是關於我們對聯合牛津團體醫療保險的全面評價（利與弊），還包含 聯合健保/牛津團體醫保2025計劃詳細信息 聯合健保/牛津團體醫保計劃如何付款 聯合牛津團體醫保計劃申請表（紐約） 聯合牛津團體醫保計劃申請表（康州） 聯合牛津團體醫保計劃(Commonly Used Forms)常用表格 聯合牛津醫保計劃聯繫電話…
聯合牛津臥騰 OptumRx OptumRx 是一家專門提供處方藥物管理和優質藥物照護的美國領先企業。成立於2012年，公司的宗旨是通過提供創新的藥物療法方案和病人支持服務，幫助患者獲得更好的健康狀況。作為一家全面的藥物管理解決方案提供商，OptumRx 致力於為患者提供最佳的價值和滿意度。 OptumRx 的業務範疇廣泛，從處方藥物的審核、採購、分發，到患者教育和藥物療法管理。公司擁有先進的技術和專業的團隊，為客戶提供定制的藥物療法方案，幫助降低醫療成本，提高患者健康。透過與藥品製造商、保險公司和政府機構的合作，OptumRx 確保患者能夠獲得安全、有效和經濟實惠的藥物療法。 在藥物療法管理方面，OptumRx 提供專業的藥師支持，幫助患者了解處方藥物的使用方式和副作用，以確保藥物安全合理地使用。此外，公司還提供藥物治療評估服務，對患者的藥物療法方案進行全面評估，確保其安全性、有效性和成本效益。這些服務不僅有助於改善患者的健康狀況，還可以降低整體醫療成本。 聯合健康保險(UHC）會員，使用OptumRx好處 作為聯合健康保險（United Health Care，簡稱UHC）會員，使用OptumRx可以帶來許多好處。以下是一些主要的優勢： 節省藥物開支：OptumRx與UHC緊密合作，為會員提供優惠的藥物價格。他們通過大量購買、議價和合同簽訂等方式，確保會員能夠以最低價格購買所需的藥物。這有助於降低醫療成本，減輕家庭經濟負擔。…
唱卡拉OK好處多？究竟有咩好處呢？ 不少人都喜歡約一大班朋友去唱卡拉OK，開心之餘更能增進彼此之間的感情。但原來除了為我們帶來歡樂，唱K還有很多好處。最重要的是，原來唱歌亦可以幫助減肥。一齊睇下唱K還有什麼好處！ 1. 減肥 台灣著名歌唱家蘇麗文在《用生命歌唱》一書中撰文，表示唱歌是一項動用到全身肌肉的運動，正確運用「腹式呼吸法」，能達到減肥功效。以一個重60公斤的人為例，唱一分鐘歌能消耗熱量2千卡，唱兩小時就能消耗240千卡。 而任職醫院院長的福田伴男所著的《卡拉OK健康法》一書，亦提及唱一首歌的氧氣消耗量相當於跑100米所消耗的氧氣，卡路里消耗量亦大致相同。福田院長同時提醒，脂肪燃燒唱歌法唱歌不是用喉嚨大喊大叫，這樣做不但無法達到瘦身效果，還會損及喉嚨，形成息肉，造成反效果。 2.增強免疫力 美國加州大學一項研究發現，每次唱詩班排練後，成員們體內一種名為IgA的免疫球蛋白含量增加了150%。公開演出後，這種免疫球蛋白更是增加了240%。 羅伯特貝克教授對唱歌的作用進行了長期研究，表示壓力會影響人體的免疫系統，如果對自己做的事情感覺良好，免疫系統會增強。即使從來沒有經過聲樂訓練，也能通過唱歌受益。堅持唱歌的老人去醫院看病和吃藥的次數更少，也更不容易摔倒。 3.按摩效果 眾所週知，唱歌能在一定程度上紓解壓力。這是因為唱歌相當於有節奏的體內按摩，能衝開人體橫膈膜。唱較低音的歌曲可以使血壓安定；唱節奏快的歌曲可以令人身心愉悅；而拉長音的歌曲可以消除壓力。另外，放聲高歌對強迫症、抑鬱症的治療都有輔助作用。 4.增進感情 有研究顯示，人在唱歌時，大腦會釋放出一種名為催產素的荷爾蒙。剛生下孩子的媽媽在給寶寶餵奶時，大腦裡也會釋放出這種荷爾蒙。戀人深情互望時，他們的大腦都會釋放出這種荷爾蒙，能增進大家之間的感情。 5.改善便祕 唱歌時運用「腹式呼吸法」，能鍛鍊腹肌，亦可以刺激大腸的蠕動，從而改善便秘。…