Mom blames Florida Blue, Broward Health dispute for daughter’s $11,500 ER bill

Go to the nearest ER first, figure out billing later.

That’s often the advice people hear when it comes to potential medical emergencies. A federal law requires health insurers to cover care for medical emergencies at in-network rates, including at out-of-network emergency rooms.

But, as Pompano Beach resident Kendra Fletcher has learned, ER doctors and health insurers don’t always agree on what qualifies as a medical emergency.

Fletcher is in the middle of an $11,517 billing dispute with a Florida Blue-affiliated health plan and Broward Health over her daughter’s visit to the ER for a potential appendicitis scare.

“This has been like a part-time job during daytime hours that I’m trying to resolve this,” said Fletcher, who works full time and is a mother of two.

Fletcher took her 16-year-old daughter in December to Broward Health Medical Center due to severe abdominal pain, worried it was appendicitis, a potentially dangerous medical situation that requires surgeons to remove the appendix or risk it bursting, leading to infections and other complications.

ER doctors ordered X-rays, MRIs and CT scans before ruling out appendicitis. Fletcher was relieved.

Then, the South Florida mom was struck with the pricey bill for out-of-network care. It was a shock to Fletcher, who told the Miami Herald she didn’t know Broward Health, the Fort Lauderdale hospital her family had long relied on for care, was no longer an in-network provider in her health plan.

There’s an ongoing contract dispute between the public hospital system and Florida Blue, one of the largest health insurers in the state. Fletcher has Blue Cross Blue Shield of Texas, an affiliate of Florida Blue and part of the Blue Cross Blue Shield Association, which encompasses all Blue Cross plans in the country. Anyone with a Blue Cross Blue Shield plan who seeks care in Florida does so through the Florida Blue network.

Fletcher believes her daughter’s symptoms were severe enough to potentially be a medical emergency and that the visit should be fully covered at in-network rates under federal law.

The health insurer, which paid $5,000 toward the ER visit, isn’t budging and told Fletcher she either needs to pay up or get Broward Health to absorb the nearly $12,000 loss, the mom said.

Broward Health, in a statement to the Herald, did not comment on Fletcher’s situation due to patient privacy laws. However, it reiterated that it will provide care to everyone, regardless of their ability to pay, and that the health insurer is the one that “makes the final determination concerning what is deemed an emergency with in-network rates,” though federal and state law “do dictate that the ‘prudent layperson standard’ sets the standard for what is deemed in network for emergency situations.”

“Regardless of whether or not the physician deems it an emergency, the determination concerning in-network benefit coverage rests with the insurance company,” said the hospital, which recently took Florida Blue to court over allegations that it has underpaid or refused to pay for emergency care provided to patients within the Florida Blue network.

Blue Cross Blue Shield of Texas, in an email Friday, declined to discuss Fletcher’s situation, stating that it “does not discuss the specifics of member inquiries.”

“Blue Cross and Blue Shield of Texas is committed to expanding access to quality, cost-effective care at all stages of life,” the health insurer said, noting that its “team is committed to working directly with our members to help resolve their concerns.”

Moving forward, Fletcher doesn’t know what else to do. She feels like she’s out of options.

“I pay out of pocket $1,600 a month for health insurance ... and now I’m cut out,” said a frustrated Fletcher, who blames the ongoing Broward Health/Florida Blue dispute for her own payment dispute.

“They’re supposed to be taking care of the community and offering options, and it’s a two-way street,” she added. “I understand both of them have their position in the negotiation, but I feel like the responsibility is on them to come to an agreement so those of us in South Florida can get the care that we need for people who are paying our premiums and doing our part.”

Fletcher said she turned to the No Surprises Act help desk and Florida’s Agency for Health Care Administration for assistance. She filed a fraud claim with Blue Cross Blue Shield. No one has been able to help her.

Everyone is bouncing her around. The federal No Surprises Act help desk told her to file a complaint with Florida’s Agency for Health Care Administration, which regulates hospitals in the state. The Florida agency then redirected her to the No Surprises Act help desk due to it being a “federal billing complaint.”

She’s not the only one facing a financial strain due to contract disputes between a Broward hospital and the insurer.

Amarah Duffy and her husband in late April began paying an additional $250 every month for a supplemental health insurance plan through Florida KidCare to make sure their daughter can continue treatment at Joe DiMaggio Children’s Hospital, a Hollywood pediatric hospital that is no longer in-network with Florida Blue due to a similar contract dispute. Joe DiMaggio is part of Memorial Healthcare System, the public health system that provides care mainly to southern Broward, and it has also been out-of-network with the health insurer since last year.

“We can’t keep driving down to Miami,” said Duffy, whose 6-year-old daughter needs frequent monthly blood work as part of her post-transplant care and has been undergoing treatment at Jackson Memorial Hospital in Miami since Joe DiMaggio went out-of-network. Her daughter was born at Memorial Regional Hospital in Hollywood and has always received care at Joe DiMaggio, where she underwent a kidney transplant at age 2.

Jackson is about an hour away from the family’s Pembroke Pines home. Joe DiMaggio is about 20 minutes away.

What used to take a few hours has now become an all-day event between traveling through rush hour and waiting at Jackson, Duffy said. Having to change doctors and nurses has also been a tough transition for her daughter.

“She lost the only place that she felt safe getting her treatment done ... so to take her out of the place she knows, to take her to some hospital she doesn’t know — people who are sticking her with a needle that she doesn’t know — it’s very scary for her and then, as a parent, I feel such guilt, I feel so bad, and there’s nothing I can do,” said Duffy.

Duffy and her husband will now pay about $650 a month just for health insurance — their existing Florida Blue plan, plus the supplemental Florida KidCare plan — to ensure their daughter gets the care she needs at Joe DiMaggio. It’s an extra expense Duffy’s family didn’t have to budget for when Memorial and Joe DiMaggio were in-network.

“It’s not your primary [doctor] you see once a year for an annual,” Duffy said. “I think that’s what they forget about — that they’re affecting people like my family.”

It’s not uncommon for hospitals and insurers to go back and forth over reimbursement rates, prior authorization and other factors. But it’s unusual that the dispute has lasted so long, and that it led to the exit of both Broward public health systems from Florida Blue’s network.

Longtime Florida Blue network member Anne Davies-Vicino of Boca Raton can speak to that.

She said she has previously received notification letters about contract disputes between providers and Florida Blue, including from Joe DiMaggio. But the disputes were always resolved shortly after — until now. She never expected the Joe DiMaggio specialists who have long cared for her son’s rare genetic condition to no longer be in-network.

Her 17-year-old son, after years of doctors’ visits, was diagnosed in 2016 with Shwachman-Diamond Syndrome, a rare genetic disorder that primarily affects the pancreas, bone marrow and bones and increases the person’s risk of blood cancer and other potentially life-threatening blood disorders. He takes medication with every meal and has to visit his endocrinologist, gastroenterologist and hematologist frequently for treatment and monitoring, including blood work every three months and an annual bone marrow biopsy, she said.

He used to get all of his care at Joe DiMaggio. Now, his specialists are scattered across Palm Beach, Broward and Miami-Dade counties. Davies-Vicino takes a folder to every appointment with all of his test results, medications and other care documents to avoid duplicate exams and to “advocate for my son” since his doctors are no longer part of the same health system, meaning they can’t easily track and check changes to his overall treatment plan.

She’s also had to help her son, who has autism, prepare for the changes, showing him photos of the hospitals, walking him through what the day will be like and packing activities for him to do in the car to help manage the long drive to Alex’s Place, a clinic for childhood cancer and blood disorders that is part of Sylvester Comprehensive Cancer Center in Miami.

It also wasn’t easy to find new specialists. Davies-Vicino, who herself is a psychologist, remembers searching Florida Blue’s online provider list for new in-network specialists. But the online provider list was out-of-date, she soon learned, explaining to the Herald that doctors she contacted no longer accepted her health plan or were only accepting adult patients, not pediatric patients. Eventually, a health insurer representative helped her find care for her son, miles away from her home.

It’s like “OK, here’s one more thing that I have to deal with,” Davies-Vicino said, explaining that she didn’t even attempt to try and get the insurer to agree to pay for his now out-of-network JoeDiMaggio specialists at in-network rates because of a previous failed attempt for another medical situation.

Both Broward health systems and Florida Blue continue to say that negotiations are underway and that they want to reach a deal.

Still, it’s left Florida Blue members searching for doctors elsewhere, though pediatric patients can now get in-network care with doctors who are part of Nicklaus Children’s Health System at select Broward Health facilities. That’s because Nicklaus Children’s is now Broward Health’s pediatric provider, part of a deal that was made several years ago.

“As health care and other costs continue to rise, our priority remains ensuring our members receive the care they need while keeping their costs under control,” Florida Blue said in a statement. “Discussions continue with the leadership teams from both trusted health systems, and we welcome the chance to collaborate towards a sensible and sustainable outcome.”

Broward Health, similarly, told the Herald it remains “hopeful” that Florida Blue “will return to the negotiating table so we can reach a fair market value agreement.”

As for Fletcher, she’s recruited her retired dad to help her fight with Broward Health and Blue Cross Blue Shield. But the ongoing dispute has also left her worried about what the next bill could look like if she or her children, who travel all over with their sports teams, ever need emergency care and are taken to an out-of-network hospital. She now has a list of in-network hospitals and ERs in her and her children’s phones, just in case they need to go somewhere during an emergency.

That list came in handy in late December, a few weeks after Fletcher was hit with the surprise bill for her daughter’s stomach pain ER visit. On Dec. 23, her daughter’s elbow dislocated. As her crying daughter was put into an ambulance, paramedics told her the nearest ER was Broward Health.

“And I said, we can’t go to Broward Health because we’re not in-network,” said Fletcher, who recalled asking them to take her daughter to Holy Cross Hospital in Fort Lauderdale, which was farther away but was in-network. The paramedics complied, though it wasn’t protocol; they usually take patients to the nearest ER that is capable of treating the person’s injury or condition.

“They can’t even take us to the nearest ER,” Fletcher said.

Are you a Florida Blue patient who can no longer get in-network care at Broward Health or Memorial Healthcare System in South Florida? Tell us about it:

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