In January 2019, Mark Gottlieb was in a car accident that damaged four vertebrae in his spine and smashed six of his teeth. But despite being covered by both auto and medical insurance, Gottlieb—who received more than $700,000 in medical bills—may still be on the hook for nearly $90,000, Julia Appleby reports for Kaiser Health News (KHN).

Learn the 3 major factors driving surprise billing

A car crash—and $700K in medical bills

After the crash, Gottlieb got his six teeth crowned and received injections, chiropractic care, and physical therapy for his neck pain, Appleby reports. When the pain persisted, staff at the facility where he was receiving care—Bergen Pain Management—recommended surgery at Hudson Regional Hospital.

At Hudson, Gottlieb underwent an anterior cervical discectomy and fusion in which the damaged discs in his neck were replaced with bone grafts or implants to stabilize his spine.

Since the injuries were the result of a car accident, Gottlieb's car insurer, Geico, was primarily responsible for negotiating and paying the insurance part of his medical bills, Appleby reports. Before his surgery, Gottlieb spoke to Geico about what hospitals were in network, but the insurer said they had no information for him. And while Gottlieb wasn't able to get a cost estimate for the procedure, he said he wasn't too concerned, because he knew he still had $190,000 in his personal injury protection (PIP), Appleby reports.

Then, Gottlieb received his bills—$445,995 from the hospital for his surgery, and $264,444 from Bergen for the main surgeon. Geico ultimately negotiated the hospital bill down to $133,778 and the Bergen bill to $141,548, but the company paid only $52,365 toward the Bergen bill before Gottlieb's PIP fund ran out.

Geico then told Gottlieb that Bergen was "still entitled to the $89,183 balance of the billing," which he could either pay himself or submit to his insurer. Accordingly, Gottlieb submitted the balance to Aetna, his secondary insurer, who told him neither the doctor nor hospital was in his insurance network.

Ultimately, Aetna said it would allow a $4,051 out-of-network payment for the surgery, which according to Ethan Slavin, a spokesperson for Aetna, was based on Gottlieb's policy, which states physician payments would be around 10% higher than Medicare out-of-network care rates.

Since Gottlieb hadn't met his out-of-network deductible, he was responsible for the $4,051 bill. Gottlieb then withdrew his request for payment from Aetna, as he wanted to see if Bergen would pursue him for the balance of the bill, Appleby reports.

According to Appleby, Gottlieb is still unsure whether Bergen will seek the balance of the bill from him, Appleby reports. Neither Bergen nor Gottlieb's surgeon has sent his bill to collections or sued him for the balance, and neither responded to KHN's requests for comment.

Geico declined to answer KHN's questions, citing policyholder privacy.

Did Geico pay too much for care?

According to Appleby, Gottlieb's charges from the hospital and surgeon after Geico's reductions were around eight times higher than what Medicare would have paid.

Specifically, according to Rand Corp., which analyzed Gottlieb's bill, Medicare would have paid around $29,500 for the surgery, with about $1,800 of that going to the surgeon, in comparison to the nearly $245,000 Geico recommended and partially paid.

Barry Silver, from Healthcare Horizons Consulting Group, said the fee was higher than what private insurers would have paid as well. After comparing Gottlieb's bill to hundreds of similar claims, Silver found that what Geico paid the hospital was around what employers paid and was less than the two highest fees in his database. But the highest surgeon's fee Silver found was $87,549.

According to Robert Passmore, a VP at the American Property Casualty Insurance Association, car insurers "typically pay more for some of the same services" than health insurers do. That's in part because car insurers don't have a broad network of health care providers who have agreed to discounted rates like health insurers do, Appleby reports, meaning patients typically end up out-of-network.

In a statement, Ron Simoncini, a spokesperson for Hudson Regional, said the hospital "charged the state-mandated fee" where it was applicable, and where the fee wasn't applicable, "the charges were reasonable." Hudson said it's not seeking out additional payment.

For his part, Gottlieb has filed several complaints about the bills with state regulators, lawmakers, and his insurance companies (Appleby, Kaiser Health News, 4/22).