Tara Haelle remembers the moment she opened her hospital bill about two months after giving birth to her son in 2010. Stealing a few minutes alone in her favorite bagel shop in Arlington, Texas, Haelle stared at the pages of itemized charges for her labor and delivery in total confusion. Although she had been an educator and a health journalist, Haelle could not make sense of the bill—it was the most complicated one she had ever seen. What was each charge for? How much would her insurance company cover? What did she actually need to pay? It was as if it had been arranged that way intentionally to confuse her.
One item jumped out from the list of charges related to Haelle’s post-delivery hospital stay. It was nearly $1,000 and identified as an "anesthesiology consult." Haelle couldn’t remember anything like this, so she called her hospital in Austin to get more information. Reaching the billing department, she was told this charge was for a follow-up visit by her anesthesiologist to monitor her reaction to anesthesia. Haelle was sure the visit had never taken place, but the representative insisted that it had. Racking her brain, Haelle finally remembered:
“I was attempting to breastfeed with a nurse or my mom or just talking with visitors” Haelle says, “and a doctor stopped briefly by the door. Without stepping into the room—which was fine since I had people in there—he said, ‘I'm the anesthesiologist. I wanted to be sure you're feeling okay today?’ I said, ‘Yes, I'm fine, thanks.’ He nodded and walked off. The entire exchange took less than 15 seconds.”
Realizing this was the “consult” she was being charged for, Haelle remembers thinking, Oh hell no. She fought the charge and eventually managed to get it removed from her bill. “I told them there was no way I was paying—or letting my insurance company pay—$1,000 for a 15-second interaction with a single question,” she says.
The price tag for giving birth in the United States is by far the highest in the world. A 2016 study by the healthcare information company Castlight Health put the average cost for a vaginal delivery at $8,775 and $11,525 for a C-section. Each price reflects what employer-sponsored health plans paid plus patients’ out-of-pocket expenses. However, averages can be misleading since maternity care costs vary widely by state. The study found that a vaginal delivery in the most expensive city, Sacramento ($15,420) was more than double the price of one in the cheapest city, Kansas City ($6,075).
Facing a charge she saw as irrational, Haelle says that she wasn’t angry with her anesthesiologist or even with the hospital. They were simply using the same convoluted fee-for-service system of medical coding, and allowed insurance fees as every other hospital in the country. Her outrage was with the system itself, and she wondered how any new parent–regardless of the level of familiarity with this system—could be expected to cope.
Receiving complicated medical bills days or weeks after bringing home a newborn, many parents experience this type of sticker shock and confusion. The stacks of paperwork can seem like a menu of creative ways for hospitals to inflate their charges. Parents find steep prices for basic supplies like diapers or over-the-counter medications, ambiguous language used to identify services and procedures, and sometimes billing or insurance errors that can add up to thousands of dollars. Mention the phrase “hospital bill” in a private Facebook group for mothers, and the stories immediately spill out:
“I was charged $600 per night for ‘nursery care’ when there was no nursery,” Kaylie Matos Stewart, a mother in New Hampshire says.
“$400 for Motrin and one stool softener,” Cassidy Walla, from Maryland says.
“We got a bill for something like $3,000 for a private delivery room! Here's the catch: The hospital where I delivered doesn't have shared rooms. The only choice is private rooms,” says Ramsey Hootman, a mother in California.
“I was charged for an epidural…when I never had one. My insurance covered everything even after I disputed. No one cared but me,” Darlene Maggiolo, a mother in New Jersey says.
“My insurance tried to deny coverage of my epidural because the anesthesiologist that did it wasn't in network. Did they seriously expect me to ask if this doctor was in my network in the throes of labor?” says Sky, a mother in California.
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Steven Weissman, now a Florida attorney who served as interim president of a Miami hospital in 2013, believes these experiences represent the entire system of US healthcare pricing, which he calls “predatory.” “With pregnancy, you have a lot of lead time. It’s the ideal scenario where you should be able to shop around,” Weissman says, adding that it’s very hard to get a direct answer when you ask how much something costs. “First, they have to see what insurance policy you have and if you’re in network and what that particular hospital has contracted with that insurance company before they can tell you the price. And there’s no consumer protection.”
In order to verify Weissman's comments, I reached out to 22 hospitals across the US requesting comment about the billing system for maternity care. My editor reached out to the publicity department for eight more. All we both asked was how administrators decide what goes on a post-birth bill. That was our entry point, which seemed harmless enough. All of them declined to comment or didn't respond. After the flurry of "sorry, we can't help you" responses, one publicist told us that it's hard to find this answer at a hospital because it has "many layers" of bureaucracy and that we should try to contact a private practice for some insight.
With insurance deductibles and facility fees often charged separately for mother and baby, as well as “surprise” charges for out-of-network doctors, what you find on a maternity care bill can be impossible to predict—even if you have “good” insurance. For parents who are uninsured, have poor maternity coverage, or complications during birth, the financial burden is even greater.
Carol Sakala, director of Childbirth Connection Programs at the National Partnership for Women & Families, calls the medical pricing system “arcane” and objects to the general focus on profit rather than outcome. “One of the most important things about fee-for-service is not just getting paid for what you do, but also not having it tied to any kind of value,” Sakala says, asserting her belief that doctors and hospital staff use billing codes for every single action, even mistakes. “It doesn’t matter if you don’t do a very good thing or a very appropriate thing. In some cases, like having a baby in a NICU, if there’s a bad outcome, [the hospital] is rewarded handsomely.”
However tedious it might be, Sakala recommends that people thoroughly investigate their options for insurance coverage even before getting pregnant, if possible, and request detailed information about out-of-network providers, deductibles, and other out-of-pocket costs. She also encourages women to consider using midwives and birth centers, which typically involve lower costs. However, over the past few years, several US hospitals have quietly closed their birth centers and midwifery practices in favor of more standard labor and delivery units.
Going through a medical bill line by line, let alone finding time to dispute it, while caring for an infant can be a challenge. The difficult process of contesting a charge can also seem like a calculated move by hospitals or physicians. When Massachusetts mother, Elizabeth Collins received a bill last year for two hospital discharge visits on two different days by two different doctors (she was only discharged once), the appeal process took months. “It was like a full-time job,” Collins says, “and with three kids, it drove me nuts.”
Other charges on Collins’ bill hadn’t been properly billed to her insurance company, and when Collins finally got these corrected, she celebrated by burning the entire stack of paperwork. “We pay through the nose for insurance” Collins says, “why is it that we have to also work so hard to make sure they’re doing what we pay them to do?”
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