She had Medicaid insurance. After a car wreck, a Miami hospital billed her for $20,000

Jan. 17--Courtney Wilson had 14 broken bones when she was airlifted to Miami's Jackson Memorial Hospital in August 2018 after a severe car accident in St. Thomas in the U.S. Virgin Islands.

After about 3 1/2 weeks in the hospital, Wilson, 34, was discharged. She took a flight home to Paso Robles, California, to begin a long recovery.. Still in a neck brace, Wilson had to use an oxygen tank and was unable to get out of bed on her own, so her mother quit working to take care of her.

When she got home, Wilson signed up for MediCAL, California's Medicaid program, on a backdated plan that would cover her emergency treatment in Miami. But then she got a nearly $20,000 bill from the University of Miami Health System, also known as UHealth, whose doctors staff Jackson's trauma center. Rather than bill the California Medicaid program, they'd billed Wilson directly. And when she didn't pay, they sent $14,000 of her debt to a collection agency.

It wasn't that Wilson had ignored the bill. Though she was uninsured at the time of the crash, she gave UM her insurance information after she enrolled in MediCAL in late August, shortly after her discharge. But the health system told her it does not bill out-of-state Medicaid programs outside of neighboring states like Georgia and Alabama. Wilson said she called the hospital with the help of a family friend more than a dozen times trying to convince them to make an exception in her case, but the answer remained the same: No.

"It was just one more thing I thought about every single day that I couldn't do anything about," Wilson said. "That was the hardest part, not knowing what to do about it when I'm trying to figure out how to start my life all over."

Experts say hospitals typically don't bill out-of-state Medicaid programs -- unless the program is from a nearby state and they get a large number of patients from there -- because the amount of paperwork outweighs the potential for collecting money. UM, while declining to detail its decision in Wilson's case, offered the same explanation of its typical billing process.

Jackson Health System, a public hospital, made a different calculation. It billed MediCAL about two months after Wilson was treated there, and received payment less than a week later, a spokesperson said.

"This is a strange situation since, from [UM's] perspective, they don't accept or believe they have any obligation to enroll in the Medicaid plan," said Sara Rosenbaum, a Medicaid expert at George Washington University's Milken Institute School of Public Health.

Rosenbaum said the case raises questions about a hospital's duty to pursue insurance coverage before billing a patient. There could have been a financial incentive for UM to present Wilson's case as bad debt as opposed to seeking reimbursement from MediCAL, she added.

"Putting aside all the legalese, [UM's] behavior is totally inexplicable and unforgivable," Rosenbaum said.

Benjamin Sommers, a health policy professor and Medicaid expert at Harvard University's T.H. Chan School of Public Health, said that while hospitals don't typically enroll in out-of-state Medicaid programs, the billing decision in this case concerns $20,000 for trauma injuries, not an elective visit to an out-of-network provider.

In such cases, Sommers said, hospitals could elect to shoulder the burden of paperwork "instead of causing financial ruin for this patient."

"It certainly seems like there was another option here that wouldn't put the patient through the wringer before they get paid," Sommers said.

After the Herald inquired about Wilson's case, she said UM reversed its billing decision.

Federal and state laws generally restrict hospitals from billing Medicaid beneficiaries directly, though those rules usually apply to in-state programs. For out-of-state situations like Wilson's, the decisions are often made on a case-by-case basis by the healthcare provider.

A spokesperson for California's Department of Health said that Medicaid beneficiaries covered under its plans should not receive bills from healthcare providers. The spokesperson added that out-of-state hospitals, even those far from the West Coast, regularly bill MediCAL for emergency treatment.

Although Jackson Health System and UM have an operating agreement that reimburses UM for staffing Jackson, a UM spokeswoman noted that "many services that UHealth physicians provide at Jackson are not covered by the [agreement]."

For Wilson, the financial workings of the hospitals are hard to fathom. She had moved to St. Thomas about three years before the accident "for a change in, well, everything: scenery, culture, weather, people, way of life and of course the beauty of it."

She found work as a waitress and later a general manager at a restaurant, and held that job -- without insurance -- until she was airlifted off the island.

"My entire life was taken from me in that second, besides my breath," Wilson said. "All I was trying to do was get [UM] their money. .... I wanted to do the right thing, but no one would take that extra step to help me."

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