The investigators allege that some insurers effectively set up “ghost networks” of psychologists, psychiatrists, and other mental health professionals who purportedly have agreed to treat patients covered by the publicly financed Medicare and Medicaid plans. In fact, many of those professionals do not have contracts with the plans, do not work at the locations listed, or are retired, the investigators said.

The Office of Inspector General for the Department of Health and Human Services, which oversees the giant Medicare and Medicaid health programs, released its findings

The report focuses on insurers the government pays to cover people in Medicare Advantage plans and in privately managed Medicaid plans. About 30% of all Americans are covered by such insurance, the report says. The government pays the insurers hundreds of billions of dollars annually.

The companies are paid set rates per person they cover and are allowed to keep whatever money they don’t spend on patient care. The insurers are required to have adequate numbers of health care professionals under contract to serve patients in each region they cover.

But the new report found that 55% of mental health professionals listed as in-network by Medicare Advantage plans were not providing such care to any of the plans’ members. The figure was 28% for Medicaid managed care plans.

Some mental health professionals told investigators they shouldn’t have been listed as in-network care providers for the insurers’ members, because they no longer worked at the locations listed or because they didn’t participate in the Medicare Advantage or Medicaid managed care plans. Others said they were working as administrators and no longer providing patient care.

In one case, the report says, a private Medicaid plan listed a mental health professional as providing care in 19 practice locations. But when the investigators checked, a receptionist at one of the clinics said the person had retired a few years ago.

Jeanine Simpkins of Mesa, Arizona, learned how skimpy the networks can be when a 40-year-old family member was in crisis this fall. Simpkins struggled to find a drug rehabilitation program that would accept the Medicare Advantage insurance the relative is on because of a disability.

Simpkins said she contacted about 20 rehab programs, none of which would take the Medicare insurance plan. “You feel kind of dropped,” she said. “I was pretty surprised, because I thought we had something good in place for her.”

Simpkins’ relative eventually enrolled in part-time hospital care instead of an inpatient rehabilitation center.

It can be challenging for patients to find timely, nearby care, for all kinds of health problems, from colds to cancer.

But Jodi Nudelman, a regional inspector general who helped write the federal report, said in an interview that the stakes can be especially high for patients seeking mental health care.

“They can be particularly vulnerable,” she said. It can be daunting for people to acknowledge they need such care, and any roadblock can discourage them from trying to find help, she said.

She added that taxpayers aren’t getting their money’s worth if insurers fail to meet obligations to provide sufficient care options for Medicare and Medicaid participants in the plans.

The federal report focused on a sample of 10 counties in five states: Arizona, Iowa, Ohio, Oregon, and Tennessee. It included urban and rural areas. It did not identify the insurers whose networks were checked.

Susan Reilly, vice president of communications for the Better Medicare Alliance, a trade group representing Medicare Advantage plans, said managed care companies support federal efforts to improve access to mental health services. “While this report looks at a small sample of plans, we agree there’s more work to do and are committed to continuing that progress together with policymakers,” she said in a statement.

The report’s authors said their sample was a good representation of the national situation. It looked at 40 Medicare Advantage plans and 20 Medicaid managed care plans.

The report recommends government administrators make more use of medical billing data to confirm whether health professionals listed as in-network are providing care to patients covered by private Medicare and Medicaid insurance plans.

The watchdogs also recommend that federal regulators create a national, searchable directory of mental health providers, listing which Medicare and Medicaid insurance plans each one accepts. Such a directory would help patients find care and would make it easier to double-check the accuracy of plans’ listings of in-network providers, they said.

Federal administrators overseeing Medicare and Medicaid have taken steps toward creating such a directory, the authors said. Reilly, the industry representative, said managed care companies support the effort.

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

When the Affordable Care Act was passed in March 2010, the goal was to help more Americans get health insurance. And, indeed, the establishment of online marketplaces and a broadening of the eligibility guidelines for Medicaid accomplished that.

Fifteen years later, however, that system is anything but user-friendly.

Young adults looking for health insurance will likely benefit from talking with so-called navigators who work for the online marketplaces. But if you want to go it alone, here are some tips about shopping for a plan, based on the advice of policy experts and people who have spent hundreds of hours helping others navigate this unwieldy set-up.

Buckle up.

Start Here

Begin your search at least two months before your 26th birthday. In some cases, you can sign up for a plan in advance so that it takes effect on your birthday.

First, find out if your family plan ends on your birthday or at the end of your birthday month. A few states allow young adults to stay on their family plan until they are 29, with certain conditions and, generally, higher costs. A navigator will know more.

You may have the option to stay, for a limited time, on your family’s plan under that allows those with group health plans to extend their coverage past age 26. Odds that you will be approved for an extension are even higher if you can claim a disability.

Be aware, though, that this option will involve a considerable expense, since you will be required to pay the entire premium (the employer will no longer pay what is usually a substantial share). Those who claim a disability can often stay on the family plan after age 26, depending on the type of insurance the family holds.

If you’re undergoing medical treatment and can’t change hospitals or doctors, paying this premium may be your best course. You don’t have this option, however, if your family is insured through an Obamacare plan.

Before you start your search, make a list of the medicines and physicians you rely on, and highlight those you can’t do without. Rank them, even.

It’s quite likely that you will have fewer choices on the marketplace than you had on a parent’s plan. Be prepared to make some switches and trade-offs.

Find the Right Marketplace

Thirty-two states have adopted the federal marketplace as the place residents can go to compare and buy insurance policies. The rest run their own online marketplaces. You can for insurance policies in your state.

Make sure you land at an official ACA website. There are many look-alikes run by private insurance brokers. The federal marketplace is found at and nowhere else.

Note that official state marketplaces sometimes have unusual names. The New York State of Health, Kynect (Kentucky), Covered California, and CoverMe (Maine) are examples.

In states that use the federal marketplace, shoppers can . On the state-based marketplaces, there is often a “find local help” button or a tab that directs you to a person who can help you find a good plan.

You will generally be asked to choose a broker, who is paid a commission if you sign up, or an “assister,” who provides the service at no cost. Assisters have received special training in the marketplace they serve, and, because they provide the service free, they have no financial incentive to steer you to a plan that pays a commission to the seller.

Assisters are often navigators who are funded by the marketplace, but in some cases they work for hospitals, health plans, or local nonprofits. You’ll have to ask.

While navigators are generally a surefire option for sound advice, they may become harder to find now that the Trump administration has cut funding for them in states that rely on the federal marketplace. (States that run their own marketplaces are unaffected.)

Many nonprofits and states run excellent programs that offer free assistance. And if, for example, you’re in the middle of cancer treatment, an assister affiliated with your hospital may offer better advice on picking a plan, since they will know which ones have contracts that may cover more of your expenses.

Ideally, these experts will walk you through the process and know which buttons to push to ensure you get the best coverage for your needs at the best rate for which you are eligible.

Sign Up

Once you’re on an official website that markets plans under the ACA, you will be asked to enter your personal information as well as an estimate of your income.

Forty states and the District of Columbia cover single young adults with no children under Medicaid if their income is low enough to qualify. If you’re eligible, you should be redirected to the Medicaid website to start the enrollment process, or you may enroll directly on the marketplace site.

But be aware that the Republicans’ recently passed domestic policy bill has increased the requirements and the paperwork required to get on, and stay on, Medicaid.

Medicaid, a joint federal and state program that provides health insurance to low-income Americans, does not charge its members a premium, and it covers medications at a nominal cost or free. The caveat is that those enrolled in the program have a smaller number of in-network doctors and hospitals to choose from.

If your income is above the threshold for Medicaid, you will need to shop on the marketplace for a policy.

On most sites, a search tool allows you to check whether your doctor or hospital is in a particular plan’s network. But beware: The directories on which this search relies are notoriously inaccurate, despite federal laws mandating otherwise.

So, before you select a plan, call the doctor or hospital to confirm they accept the insurance plan you’re considering purchasing.

Do the Math

When it comes to the math, it’s better to work on a computer than a phone. Generally, you can compare the costs of, and coverage offered by, only three plans at a time.

The following factors include premiums (taking account of any subsidy you get based on your income), as well as other expenses you’ll have to pay, called collective cost sharing:

• The deductible 鈥� the amount you generally have to pay out-of-pocket before your insurance kicks in. (You may get a few “covered” visits with a primary care doctor; these won’t count against the deductible.)
• Copayments 鈥� a fixed payment that you owe for any visit to a doctor or emergency room.
• Coinsurance (this one can break the bank) 鈥� a percentage of the total bill, generally applied to hospital bills, that you have to pay. The plan may make it sound small, say, 10% to 30%. But if you have, for example, the common 80-20 split (in which the insurer pays 80% and you pay 20%), that can add up to a substantial sum. A single day in the hospital can cost tens or even hundreds of thousands of dollars, and 20% percent of that is a large amount.
• The out-of-pocket maximum 鈥� the most you’ll have to pay out in a year, so long as you stay in network and pay the deductible.

Doing the math means looking at this holistically, balancing what you can pay in a premium against what you can afford for the above charges. If the deductible is over $3,000 and the out-of-pocket maximum allowed yearly is $9,200 鈥� do you have that much money on hand?

Generally, the lower the monthly premium in a plan, the higher the share of costs you’ll have to pay should you need medical care. Note that an insurer may offer very different plans on the same marketplace, with different payment policies and networks.

People with incomes up to 2陆 times the poverty level may gain some relief from cost-sharing charges, but only if they sign up for silver plans. Plans are typically labeled bronze, silver, gold, and platinum; each tier reflects the percentage of your medical expenses that your plan pays overall. Bronze plans offer the least amount of coverage.

Choose Wisely

Once you’ve narrowed your choices to a few plans, study each closely.

A plan with a low deductible might require a $1,000 daily copayment, or 50% coinsurance (you pay 50%) for hospital stays. A plan that lists your desired hospital system as in-network may include only some of its locations, and not necessarily the ones close to you or that offer the type of care you need.

When looking at a plan’s details, make sure to scroll down and read its “summary of benefits and coverage” for examples of the plan’s coverage of common medical needs. Pay close attention to which services require preauthorization and, for example, how many physical therapy visits they’ll cover each year. Preauthorization can be a long and cumbersome process.

Generally, the lower the premium, the more preauthorization will be required and the more limited the coverage will be. And check what drugs the plan covers (called the formulary) to see if yours are included, as well as its network of providers, to see whether your doctors are in it.

Marketplace plans tend to have limited offerings compared with job-based insurance; there aren’t as many doctors and hospitals to choose from. Click on the “provider directory” to see if an insurer’s network includes doctors and specialists you’re most likely to need, and hospitals that are acceptable and accessible to you.

Check to see if the policy offers any coverage for out-of-network providers. Some will pay, say, 60% or 70% of approved charges. It’s a useful perk if you need to see an out-of-network specialist, or if the wait for an in-network appointment is too long.

One that patients with marketplace plans have access to only 40% of doctors near their home, on average, and in some areas that figure was as low as 25%. It’s quite likely even lower for mental health providers.

A Backstop

If you’ve tried to choose a plan and you’re still confused, look for one of the “easy pricing” or standard plans. These conform to certain basic standards laid out by the federal Centers for Medicare & Medicaid Services, which oversees the marketplaces for the federal government. These plans offer some primary care appointments before you have to start paying the deductible.

The government says these “easy pricing” on federal marketplace sites. But they may be identified differently on state-run marketplaces. In New York state, for example, they are simply marked with an ST (for standard).

Still, funding for premium subsidies is in place for this year at least, and free expert assistance is still out there, so don’t delay. There are good deals to be had, if only you put in the work.

Good luck.

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

That is the age at which the Affordable Care Act declares that young adults generally must get off their family’s plan and figure out their coverage themselves.

When the ACA was voted into law in 2010, what’s known as its dependent coverage expansion was immediately effective, to millions of young Americans up to age 26 who would otherwise not have had coverage.

But for years, Republicans have whittled away at the infrastructure of the original ACA. Long gone is the requirement to buy insurance. Plans sold in the ACA’s online insurance marketplaces have no stringent quality standards. Costs keep rising, and eligibility requirements and subsidies are moving targets.

The erosion of the law has now created an “insurance cliff” for Americans who are turning 26 and don’t have a job that provides medical coverage.

Some, scared off by the complexity of picking a policy and by the price tags, tumble over the edge and go without insurance in a health system where the rate for an emergency room visit can be thousands, if not tens of thousands, of dollars.

Today, an estimated 15% of 26-year-olds go uninsured, which, according to a 麻豆女优 analysis, is the highest rate among Americans of any age.

If they qualify, young adults can sign up for Medicaid, the federal-state program for Americans with low incomes or disabilities, in most but not all states.

Otherwise, many buy cheap subpar insurance that leaves them with insurmountable debt following a medical crisis. Others choose plans with extremely limited networks, losing access to longtime doctors and medicines.

They often find those policies online, in what has become a dizzyingly complicated system of government-regulated insurance marketplaces created by the ACA.

The marketplaces vary in quality from state to state; some are far better than others. But they generally offer few easily identifiable, affordable, and workable choices.

“The good news is that the ACA gave young people more options,” said Karen Pollitz, who directed consumer information and insurance oversight at the Department of Health and Human Services during the Obama administration.

“The bad news is the good stuff is hidden in a minefield of really bad options that’ll leave you broke if you get sick.”

(Ethan Evans)

(Maxwell Frost)

Publicly funded counselors called “navigators” or “assisters” can help insurance seekers choose a plan. But those programs vary by state, and often customers don’t realize that the help is available. The Trump administration has cut funding to publicize and operate those navigator programs.

In addition, changes to Medicaid eligibility in the policy bill recently passed by Congress could mean that millions more ACA enrollees , according to the Congressional Budget Office.

Those changes threaten the very viability of the ACA marketplaces, which currently provide insurance to 24 million Americans.

In dozens of interviews, young adults described the unsettling and devastating consequences of having inadequate insurance, or no insurance at all.

Damian Phillips, 26, a reporter at a West Virginia newspaper, considered joining the Navy to get insurance as his 26th birthday approached. Instead, he felt he “didn’t make enough to justify having health insurance” and has reluctantly gone without it.

Ethan Evans, a 27-year-old aspiring actor in Chicago who works in retail, fell off his parents’ plan and temporarily signed up for Medicaid. But the diminished mental health coverage meant cutting back on visits to his longtime therapist.

Rep. Maxwell Frost, a Florida Democrat and the first Gen Z member of Congress, was able to quit his job and run for office at 25 only because he could stay on his mother’s plan until he turned 26, he said.

Now 28, he is insured through his federal job.

“The ACA was groundbreaking legislation, including the idea that every American needs health care,” he said. “But there are pitfalls, and one of them is that when young adults turn 26, they fall into this abyss.”

Why 26?

Back in 2010, the decision to make 26 the cutoff age for staying on a parent’s insurance was “kind of arbitrary,” recalled Nancy-Ann DeParle, deputy chief of staff for policy in the Obama White House.

“My kids were young , and I was trying to imagine when my child would be an adult.”

Before that time, children were often kicked off family plans at much younger ages, typically 18.

The Obama administration’s idea was that young adults were most likely settling into careers and jobs with insurance by 26. If they still didn’t have access to job-based insurance, Medicaid and the ACA marketplaces would offer alternatives, the thinking went.

But over the years, the courts, Congress, and the first Trump administration eviscerated provisions of the ACA. By 2022, a shopper on a federal government-run marketplace had more than 100 choices, many of which included expensive trade-offs, presented in a way that made comparisons difficult without spreadsheets.

Jack Galanty, 26, a freelance designer in Los Angeles, tried to plan for his 26th birthday by seeking coverage on the California insurance marketplace that would ensure treatment for his mild cerebral palsy and for HIV prevention.

“You’re scrolling for what feels like years, looking at 450 little slides, at the little bars, and trying to remember, 鈥榃as the one I liked No. 12 or 13?’” he recalled. “It feels like it’s nearly impossible to make a good choice in this scenario.”

(Elizabeth Mathis)

(Kayla Anderson)

Out-of-pocket expenses have soared. Complex plans in the lightly regulated marketplaces featured rising premiums, high deductibles, and requirements that patients pay a significant portion of the cost of care, often 20% 鈥� a charge known as coinsurance.

More than half of Americans ages 18 to 29 have incurred medical debt in the past five years, a 麻豆女优 Health News data investigation found. Few have the reserves to pay it off.

The networks of doctors to choose from in these plans are often so limited that an insured person struggles to get timely appointments. It can even be hard to find the official websites amid an explosion of look-alikes operated by commercial brokers.

Sharing her contact information with one site that appeared legitimate left Lydia Herne, a social media producer in Brooklyn, “drowning” in texts and phone calls offering plans of uncertain and unregulated quality. “It never ends,” said Herne, 27.

Young Invincibles, an advocacy group representing young adults, runs its own “navigator” program to help young people choose health insurance plans.

“We hear the frustration,” said Martha Sanchez, the group’s former director of health policy and advocacy. “Twenty-six-year-olds have had negative experiences in a process that’s become really complex. Many throw up their hands.”

Elizabeth Mathis, 29, and Evan Pack, 30, a married couple in Salt Lake City, turned to the marketplaces two years ago, after Pack went uninsured for a “really scary” year after he turned 26.

“Every time he got in the car, I thought, 鈥榃hat if?’” Mathis said.

The couple pays more than $200 a month for a high-deductible health plan backed by a federal subsidy (the kind set to expire next year). It’s a significant expense, but they wanted to be sure they had access to contraception and an antidepressant.

But last year, Pack suffered serious eye problems and underwent an emergency appendectomy. Their plan left them $9,000 in debt, for medical care billed at over $20,000.

“Technically, we gambled in the right direction,” Mathis said. “But I don’t feel like we’ve won.”

The Affordability Problem

The ACA was supposed to help consumers find affordable, high-quality plans online. The legislation also tried to expand Medicaid programs, which are administered by states, to provide health insurance to low-income Americans.

But the Supreme Court ruled in 2012 that states could not be forced to expand Medicaid. Ten states, led mostly by Republicans, have not done so, leaving up to 1.5 million Americans, who could have qualified for coverage, .

Even where Medicaid is available to 26-year-olds, the transition has often proved precarious.

Madeline Nelkin of New Jersey, who was studying social work, applied for Medicaid coverage before her 26th birthday in April 2024 because her university’s insurance premiums were more than $5,000 annually.

But it was September before her Medicaid coverage kicked in, leaving her uninsured while she fought a chest infection over the summer.

“People tell you to think ahead, but I didn’t think that meant six months,” she said.

(Daisy Creager)

(Madeline Nelkin)

(Valeria Chávez)

When Megan Hughes, 27, of Hartland, Maine, hit the cliff, she went without. An aide for children with developmental delays, she has a thyroid condition and polycystic ovary syndrome.

She looked for a health care plan but found it hard to understand the marketplace. (She didn’t know there were navigators who could help.) Now she can’t afford her medicine or see her endocrinologist.

“I’m tired all the time,” Hughes said. “My cycles are not regular anymore at all. When I do get one, it’s debilitating.” She is hoping a new job will provide insurance later this year.

Traditionally, most Americans with private health insurance got it through their jobs. But the job market has changed dramatically since the ACA became law, particularly in the wake of the pandemic, with the rise of a gig economy.

Over said in recent surveys that they were working or have worked in short-term, part-time, or irregular jobs.

The ACA requires organizations with 50 or more employees to offer insurance to people working 30 hours per week. This has led to a growing number of contract employees who work up to, but not past, the hourly limit.

Many companies, which say they can’t afford the rising costs of traditional insurance, offer their employees only a modicum of help, perhaps around $200 per month toward buying a marketplace plan, or a bare-bones company plan.

Young people juggling part-time jobs and insurance options face bumpy, daunting transitions.

In Oklahoma, Daisy Creager, 29, has had three employers over the past three years. Insurance was important to her, not least because her former husband had Type 1 diabetes.

As she left the first of those jobs, her husband’s endocrinologist helped the couple stockpile less expensive insulin from Canada, since they would be uninsured.

After a few months, they bought a marketplace plan, but it was expensive and “didn’t cover a lot,” she said.

When she found a new job, she dropped that plan, only to discover that her new insurance coverage didn’t start until the end of her first month of employment. The couple would be uninsured for a few weeks.

A few days later, she came home to find her husband unconscious on the floor, in a diabetic coma. After hovering near death in an intensive care unit for four days, he woke up and began to recover.

“I think I’ve done everything right,” Creager said. “So why am I in a position where the health insurance available to me doesn’t cover what I need, or I can barely afford my premiums, or worse, at times I don’t even have it?”

Kathryn Russell, 27, developed excruciating back pain two months before her 26th birthday. After extensive testing, doctors determined she needed a complex surgery, which her surgeon couldn’t schedule until after she would be off her family’s insurance plan.

Forget the pain and the fear of the operation, she said, it was insurance that kept her up at night. “There’s this impending terror of, 鈥榃hat am I going to do?’” she recalled.

(One day before she turned 26, her father’s company agreed to keep her on his plan for six more months, if he paid higher premiums.)

The idea that the ACA would offer a variety of good options for people turning 26 has not worked as well as the legislation’s authors had hoped. The “job lock” tying insurance to employment has long plagued the United States workforce.

Young adults need guidance on their options beforehand, said Sanchez of Young Invincibles. None of those interviewed for this story, for example, knew there were navigators to help them find insurance on the online marketplaces.

Experts agree that the marketplaces need stronger regulation.

In 2023, for what plans in each tier of insurance should offer, such as better prescription drug benefits, defined copays for X-rays, or coverage for emergency room visits.

Certain types of basic care, such as primary care, should require just a small copay for at least a small number of initial visits. Each insurer must offer at least one plan that complies with these new standards for every level, known as an “” option or a “standard plan.”

Most plans on the marketplaces don’t meet these criteria. Federal and state regulators had long planned to cull such “noncompliant” plans, gradually 鈥� fearing that doing so too quickly would scare insurers away from participating.

But with the priorities of the new Trump administration now in focus, and a Republican majority in Congress, it’s far from clear what course President Donald Trump, who sought to repeal the ACA outright in his first term, will take.

There are hints: Subsidies to help Americans buy insurance, adopted during the Biden administration, are set to expire at the end of 2025 unless the Republican-led Congress extends them.

If the subsidies expire, for plans sold on the marketplaces, leaving insurance out of reach for many more young adults.

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

The No Surprises Act, which took effect in 2022, was rightly heralded as a landmark piece of legislation, which “protects people covered under group and individual health plans from receiving surprise medical bills,” according to the . And yet bills that take patients like Chen by surprise just keep coming.

With the help of her software-wise boyfriend, she found the complicated “machine-readable” master price list that hospitals are required to post online and looked up the negotiated rate between Lowell General and her insurer. It was $302.56 鈥� less than she had paid out-of-pocket.

CMS is charged with enforcing the law, so Chen sent a complaint about the surprising bill to the agency. She received a terse email in return: “We have reviewed your complaint and have determined that the rights and protections of the No Surprises Act do not apply.”

When I asked the health system to explain how such a surprising off-estimate bill could be generated, Tufts Medicine spokesperson responded by email: “Healthcare billing is complex and includes various factors and data points, so actual charges for care provided may differ from initial estimates. We understand the frustration these discrepancies can cause.”

Here’s the problem: While the No Surprises Act has been a phenomenal success in taking on some unfair practices in the wild West of medical billing, it was hardly a panacea.

In fact, the measure protected patients primarily from only one particularly egregious type of surprise bill that had become increasingly common before the law’s enactment: When patients unknowingly got out-of-network care at an in-network facility, or when they had no choice but to get out-of-network care in an emergency. In either case, before President Donald Trump signed the law late in his first term, patients could be hit with tens or hundreds of thousands of dollars in out-of-network bills that their insurance wouldn’t pay.

The No Surprises Act also provided some protection from above-estimate bills, but at the moment, the protection is only , so it wouldn’t apply in Chen’s case since she was using health insurance.

But patients who do qualify generally are entitled to an up-front, good-faith estimate for treatment they schedule at least three business days in advance or if they request one. Patients can dispute a bill if it is more than $400 over the estimate. (The No Surprises Act also required what amounted to a good-faith estimate of out-of-pocket costs for patients with insurance, but that provision has not , since, nearly five years later, the government still has not issued rules about exactly what form it should take.)

So, surprising medical bills 鈥� bills that the patient could not have anticipated and never consented to 鈥� are still stunning countless Americans.

Jessica Robbins, who works in product development in Chicago, was certainly surprised when, out of the blue, she was recently billed $3,300 by Endeavor Health for a breast MRI she had received two years earlier, with prior authorization from her then-insurer, Blue Cross and Blue Shield of Illinois. In trying to resolve the problem, she found herself caught in a Kafkaesque circle involving dozens of calls and emails. The clinic where she had the procedure no longer existed, having been bought by Endeavor. And she no longer had Blue Cross.

“We are actively working with the patient and their insurer to resolve this matter,” Endeavor spokesperson Allie Burke said in an emailed response to my questions.

Mary Ann Bonita of Fresno, California, was starting school this year to become a nursing assistant when, on a Friday, she received a positive skin test for tuberculosis. Her school’s administration said she couldn’t return to class until she had a negative chest X-ray. When her doctor from Kaiser Permanente didn’t answer requests to order the test for several days, Bonita went to an emergency room and paid $595 up front for the X-ray, which showed no TB. So she and her husband were surprised to receive another bill, for $1,039, a month later, “with no explanation of what it was for,” said Joel Pickford, Bonita’s husband.

In the cases above, each patient questioned an expensive, unexpected medical charge that came as a shock 鈥� only to find that the No Surprises Act didn’t apply.

“There are many billing problems out there that are surprising but are not technically surprise bills,” Zack Cooper, an associate professor of economics at Yale University, told me. The No Surprises Act fixed a specific kind of charge, he said, “and that’s great. But, of course, we need to address others.”

Cooper’s research has found that before the No Surprises Act was passed, of emergency room visits yielded a surprise out-of-network bill.

CMS’ official No Surprises Help Desk has received tens of thousands of complaints, which it investigates, said Catherine Howden, a CMS spokesperson. “While some billing practices, such as delayed bills, are not currently regulated” by the No Surprises Act, Howden said, complaint trends nonetheless help “inform potential areas for future improvements.” And they are needed.

Michelle Rodio, a teacher in Lakewood, Ohio, had a lingering cough weeks after a bout of pneumonia that required treatment with a course of antibiotics. She went to Cleveland Clinic’s Lakewood Family Health Center for an examination. Her X-ray was fine. As was her nasal swab 鈥� except for the stunning $2,700 bill it generated.

“I said, 鈥楾his is a surprise bill!’” Rodio recalled telling the provider’s finance office. The agent said it was not.

“So I said, 鈥楴ext time I’ll be sure to ask the doctor for an estimate when I get a nose swab.’”

“The doctors wouldn’t know that,” the agent replied, as Rodio recalled 鈥� and indeed physicians generally have no idea how much the tests they order will cost. And in any case, Rodio was not legally entitled to a binding estimate, since the part of the No Surprises Act that grants patients with insurance that right has not been implemented yet.

So she was stuck with a bill of $471 (the patient responsibility portion of the $2,700 charge) that she couldn’t have consented to (or rejected) in advance. It was surprising 鈥� shocking to her, even 鈥� but not a “surprise bill,” according to the current law. But shouldn’t it be?

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

One Kansas City, Kansas, couple paid thousands of dollars out-of-pocket and up-front for care. They expected to get a partial reimbursement from their insurer. So, they were shocked when instead they got a bill saying they owed even more than what they’d already paid.

It turns out, a little-known data firm called MultiPlan was working with their insurance company to suggest cuts to their coverage. MulitPlan says it’s helping control ballooning health care costs by keeping hospitals and providers from overbilling. But it’s often patients left paying the difference.In this episode of “An Arm and a Leg,” host Dan Weissmann breaks down this confusing world of out-of-network care with New York Times reporter Chris Hamby, who recently published into MultiPlan.

Credits

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there! Paul and Kristin live in Kansas City with their two kids. Kristin and their daughter, the older kid– they have some complex medical issues, need to see some specialized folks. And some of those folks don’t take Kristin and Paul’s insurance. They’re “out of network,” so Kristin and Paul pay out of pocket– a lot. Maybe $20,000 a year. BUT their health insurance plan does reimburse some out-of-network care.听

o, in January 2023, Kristin called a help line connected with the insurance plan to find out how that was gonna work.听

Kristin H: They basically said, sure, easy peasy, you pay and then you get online and you click this form, you show what you paid, and then we send you a check and reimburse you.听

Dan: Kristin was on it. She built a whole spreadsheet to track every bill she paid, every reimbursement form she’d submitted. And she waited for the checks. The insurance company gave itself months just to process the claims. And when they finally sent statements, the statements seemed 鈥� weird. They were like:听

Kristin H: Here’s what you paid, and here’s your discounts, and here’s what you may owe.听

Dan: And Kristin was like 鈥� what?听

Kristin H: Because I was thinking, well, I don’t owe anything. We paid out of pocket, but then I was thinking, well, this must be the portion that they’re paying us back. But then the math didn’t add up.听

Dan: Yeah. Not at all. Kristin was expecting to get 50 percent back, like her plan said she would. But this amount wasn’t anything like 50 percent. And what’s this “discount” business?听

It took months– and a lot of digging from Paul, and ultimately a talk with a NewYork Times reporter– before Kristin and Paul understood what was going on, and why it was costing them thousands of dollars.听

What they didn’t know until that New York Times story came out was: Someone was making a multi-billion dollar business out of experiences like theirs. As that story made clear, LOTS of people who expected their insurance to cover them for expensive out-of-network care ended up on the hook for a lot more than they’d expected.听

That story introduced readers to a character who’s become kind of a TYPE on this show. Not a type of person, but a type of business: A middleman that works behind the scenes with insurance companies. So we’ve seen that dynamic with pharmacy benefit managers– the folks who decide what drugs you can get and for how much– and more recently, we looked at a company that uses an algorithm to justify kicking folks out of nursing homes. The middleman in this New York Times story was a company called MultiPlan.听

Reporter Chris Hamby found MultiPlan and insurance companies they worked with were leaving patients on the hook for huge amounts that they absolutely had not expected to pay. MultiPlan was also, along with those insurance companies, pocketing big fees. That story got some folks’ attention. A U.S. Senator has called for action from antitrust regulators. Those regulators might get interested. And we may wanna egg them on– so we’re gonna need to understand the whole scheme. Whothis middleman is– MultiPlan– and how they got themselves in the middle of 60 million people’s health insurance, by their own estimate 鈥� and how they make a lot of money.听

This is An Arm and a Leg, a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So, our job on this show is to take one of the most enraging, terrifying, depressing parts of American life– and bring you a show that’s entertaining, empowering, and useful.听

And this time, I’ve got help.听

Chris Hamby: My name is Chris Hamby. I’m a reporter on the investigations desk at the New York Times.听

Dan: Yeah, and of course, Chris is the one who spent months figuring out the story of this middleman company, MultiPlan.听

Chris Hamby: I was poking around a number of areas related to health insurance, and this name just kept coming up.听

Dan: Like in lawsuits.听

Chris Hamby: And it wasn’t always terribly clear what they did exactly or how they were compensated.听

Dan: Or how doctors and patients– regular people– were affected.听

Chris Hamby: So that’s why I decided to try and figure this out, and it’s sort of an opaque space as so many areas of health care are these days.听

Dan: Yeah. In fact, in order to understand this story at all– to understand who’s doing WELL in this scenario– we’ve gotta peel back a layer. It’s something we’ve talked about here before, but not for a while, and you know, not even my mom remembers everything I’ve ever said here.听

This is about the mechanics of how most health insurance people get from their job actually works: about who actually pays medical bills when your insurance settles a claim. It’s not the insurance company. It’s actually the employer paying those bills.听

Of course, employers don’t know how to actually RUN an insurance plan. [Unless the employer is Aetna, I guess]. So they hire insurance companies to administer them. You get a card that says Cigna or Blue Cross, but your employer’s funds actually pay the medical bills, so these are called “self-funded” plans. But this is all stuff most of us are just not aware of.听

Here’s Chris Hamby:听

Chris Hamby: I hadn’t, until about a year ago, even heard of a self-funded plan. And I like to think that I’m reasonably well informed on this stuff.听

Dan: Yeah, that is putting it mildly. Chris made his name and won a Pulitzer Prize covering workplace health issues. So, just park that for a minute: self-funded plan, where the employer is the “self,” actually paying the bills, and paying the insurance company a fee. The insurance company is a middleman.听

OK, now, next layer: The middleman’s middleman. In this case, the company MultiPlan that Chris wrote about. What’s their job? So in this story, the job they’re doing– their middleman job– is to address what is admittedly kind of a tough question: If you go see somebody– a doctor, a therapist– who doesn’t take your insurance, what happens?听

Chris Hamby: How do you determine what a fair amount to pay the provider is? And by extension, how much is the patient potentially on the hook for the unpaid balance? And that has long been a contentious issue.听

Dan: Because, if they don’t take your insurance, a provider could charge 鈥� absolutely anything. So is your insurer– and again, that’s often actually your employer– supposed to pay absolutely anything? How much are they supposed to pay? Figuring that out, it’s a job.听

About 15 years ago, another middleman company doing that job got sued by the NewYork state attorney general. The state said this earlier middleman’s way of figuring out what to pay was screwing over both providers and patients. And the state’s lawsuit produced a solution.听

Chris Hamby: The insurance companies agreed to fund the creation of a nonprofit entity that was going be sort of an independent, neutral arbiter of fair prices. It was going to collect data from all the insurers and just make it publicly available. Make sure it was transparent to everyone.听

Dan: This nonprofit is called FAIR Health, and its data is actually public. It still exists. Like, you can use it yourself 鈥� you can look up the going rate for a knee replacement, a blood test, whatever.听

Chris Hamby: You can plug in your zip code, plug in your medical procedure and see an estimate of what, you know, typical out-of-network charges and in-network charges would be for these.听

Dan: It’s cool! Check it out yourself; it’s useful. And all the major insurance companies agreed to use it– to use FAIR Health’s benchmarks– to decide what to pay for out-of-network stuff. But, those agreements only committed insurance companies to using FAIR Health for 鈥� five years. They expired in 2014.听

Enter middleman companies like MultiPlan, saying to insurance companies: Hey, you COULD use FAIR Health– or you could route out-of-network bills to us: Hire us to get you an even better deal– better prices.听

Chris Hamby: And it’s important to note also that this is a time when private equity is investing in healthcare, and there are some legitimate concerns about driving up those list prices to ridiculously high levels in a lot of cases. So, there were real issues that insurers were saying that they were responding to at the time.

Dan: OK, so that’s the pitch. MultiPlan is saying to insurance companies: We’ll help you hold the line. We can save you more money than if you used FAIR Health. Well, kind of. Because here’s where we come back to the whole thing about self-funded insurance. MultiPlan isn’t saying, “We can save YOU, insurance company, more money than if you used FAIR Health.” They’re saying, “We can help you save your CLIENTS– employers who do self-funded health insurance– more money. And when you save them money, you’re gonna make money. Because you can charge them a percentage of what you’re saving them. And we’ll get a percentage too.” A percentage of the savings. On every single bill. That’s a very different deal than just using FAIR Health’s data.听

Chris Hamby: FAIR Health is not taking a percentage of the savings that they obtain. They’re just selling you their data. And the insurers typically are not charging employers a fee for using FAIR Health’s data. But if they use MultiPlan’s data, both MultiPlan and the insurer typically charge a fee.听

Dan: A percentage. In examples from Chris’s story, the insurance company gets 35 percent of those savings.听

Chris Hamby: And this has become a significant amount of money for a lot of insurance companies. Overall, UnitedHealthcare, is up to, you know, around a billion dollars per year in recent years.听

Dan: UnitedHealthcare collects like a billion dollars in fees for these services, basically, for using MultiPlan specifically?听

Chris Hamby: And they couch that by saying some other out-of-network savings programs, but yes.听

Dan: Whooh!听

Chris Hamby: One thing that the insurers say is that the employers are aware of this; they’ve signed up for it.听

Dan: That employers are hiring, say, Cigna, with MultiPlan to find savings. And employers are agreeing to the fees.听

Chris Hamby: Where it gets a little bit dicier from the employer’s perspective is when you see claims where, for instance, you end up paying the insurance company more in fees than you paid the doctor for treating your employee.听

Dan: yeah, one example from Chris’s story: An out-of-network provider wanted more than $150,000 on one bill. And after the insurance company and MultiPlan did their bit, the employer, a trucking company, ended up paying $58,000. Eight thousand for the provider, and $50,000 to the insurance company and MultiPlan. So, on the one hand, the employer maybe saved $90,000. But paying $50,000 for “cost containment?” Maybe doesn’t sound like such a bargain.听

Some employers and a union that runs a health plan have filed lawsuits looking for some of that money back. And there’s also a big irony here because MultiPlan’s pitch is, you need us because sticker prices are super-wildly high. But MultiPlan isn’t doing anything to contain the sticker prices as a systemic problem. In fact, the higher providers crank up their sticker prices, the more money MultiPlan and the insurance companies they work with can make. But then there’s a big question too, which is, what happens to the rest of that bill for the sticker price? Who pays that? That’s next 鈥μ�

This episode of An Arm and a Leg is a co-production of Public Road Productions and 麻豆女优 Health News. The folks at 麻豆女优 Health News are amazing journalists. Their work wins all kinds of awards, every year. We’re honored to work with them.听

So, a provider sends a bill. MultiPlan and the insurance company say, “Woah, way too much.” And then what happens? Well, it depends. Sometimes, MultiPlan negotiates with the provider. They’ve got people who do this. And those negotiators drive hard bargains. According to Chris’s story, negotiators sometimes tell providers: Here’s my offer, you’ve got a few hours to take it or leave it, and my next offer might be lower.听

Chris talked with a pediatric therapist who said an offer based on MultiPlan’s calculation was less than half of what Medicaid pays. Less than half. And Medicaid rates– they’re notoriously pretty low. Chris talked with some of MultiPlan’s negotiators too.听

Chris Hamby: It was interesting because some of the negotiators felt that they were doing their part to hold down costs and really sort of stick it to providers and hospitals that were price gouging.听

Dan: But 鈥ne told Chris she knew the offers she made– they weren’t fair. “It’s just a game,” another one said. “It’s sad.” And maybe the difference is that some of these negotiators were thinking of a big hospital charging $150,000听 for something. And maybe some of them were thinking of someone like that therapist– the one who got offered less than half of Medicaid’s rate.听

And I’m not gonna get into the question of who should be doing this kind of negotiating, or what’s fair. I mean, not today, anyway. Because: in a lot of cases with MultiPlan, there’s no negotiation at all. Negotiation only happens when the employer has told the insurance company, look, protect my people. Figure out SOMETHING with the provider so they don’t go after my workers for the rest.听

But that doesn’t always happen. A lot of the time, what happens is: The provider sends a bill. The insurance company kicks in whatever it decides to 鈥� and that’s it.听

So Chris’s story opens with a woman who had surgery. With MultiPlan’s help, her insurance company decided to pay about $5,400. And she got stuck with a bill for more than $100,000.听

And then there’s Kristin and Paul in Kansas City. They paid their bills upfront and then looked to get reimbursed– kept a spreadsheet. But when their claims finally got processed, the numbers didn’t add up. Here’s what they saw: Like pretty much every insurance plan, Kristin and Paul’s had a “deductible”– an amount they had to pay out of pocket before insurance would reimburse anything.听

Kristin H: Then I started watching the deductible and you know, when I calculated my spreadsheet of how much we had paid out of pocket, and when we saw what was on like our out-of-network spend, those two weren’t matching.听

Dan: She really couldn’t figure this out.听

Kristin H: I just kind of handed over all of my spreadsheets to Paul, and so that’s when he started digging into the “your discount.”听

Dan: “Your discount鈥�” That was this mysterious number on all the statements from the insurance company. In addition to the provider’s rate, and what insurance might pay, the statements listed, quote, “your discount.”听

Paul H: And I’m like, what is this? I don’t understand why it’s talking about a discount. We are paying cash out of pocket to the provider at their billed rate, and our insurance is saying that there’s some sort of discount.听

Dan: After a bunch of phone calls, he figured it out: The discount was 鈥� the difference between the amount on the bill and what the insurance company– with MultiPlan’s help– had decided was a “fair price.”听

Paul H: For example, an occupational therapy bill that might be $125, this third party adjuster might come back and say, essentially what the market rate for that should be is $76. And so, your discount, quote, unquote, is $49.听

Dan: Except of course, it wasn’t a discount for Kristin and Paul. They had already paid that $49, when they paid the provider upfront. Once Kristin and Paul learned what the “discount” actually meant, they started to understand who actually got the benefit– the insurer. Because 鈥μ�

Kristin H: That discounted rate is actually what will be applied to your deductible. So you’re not going to hit your deductible nearly as quickly as you think. Right? Because we’ve essentially ignored half of your payment.听

Dan: This hits Kristin and Paul in two ways.听

First, it means they’re actually spending a lot more before their insurance kicks in. It also means that when their insurance does start reimbursing them a percentage of what they’ve spent, the insurance is only paying a percentage of that lower amount. Overall, it means the reimbursements Kristin and Paul get are gonna be thousands of dollars less than they’d expected.听

I mean, it took a LOT of work for Kristin and Paul to figure this out. At one point, Paul posted to Reddit asking for help– that’s where Chris Hamby found him. In Paul’s post, he noted how nobody ever even mentioned this third-party adjuster– not until he had already talked to his insurance company for what he said was “about 18 times.” Frequently on hold for 45 minutes or more.听

Kristin says once they finally figured out what was going on, they could figure out how to budget for it. There were sacrifices. She stopped seeing one of her providers as often. But finally figuring out what was going on also allowed them to live with it.听

Kristin H: The infuriating part was telling, like doing exactly what we were told to do, following the process, and then feeling like you are crazy. Like why, why doesn’t this make sense? You know? And so I think I’m fortunate that Paul just wouldn’t let it die and was gonna research until he figured it out.听

Dan: You did all of the work, you tracked it down, you identified the problem, and you, as you say, kind of resigned yourself to it. You’re like, okay, this Goliath is not– we don’t have the slingshot for this. Goliath is stomping all over our town, and we have to live in that reality. Having the knowledge, having done that work, gives you, it sounds like, an ability to have some peace. Like having tracked it down means that this sucks, but it’s not the same as living in a situation where like, now what? Like anything could happen.

Kristin H: Yeah, you feel crazy or hopeless. You know? Like I’ve done everything and this doesn’t 鈥� So there’s just the sense of like, am I missing something? You know, is there anything left for me to do? I recognize that everyone is not like this, but for me, knowledge is a gift.听

Dan: Chris Hamby says there’s rarely a way to get this kind of knowledge in advance. He says you’re unlikely to find these kinds of details in your insurance plan document.听

Chris Hamby: It typically will not say when you go out of network, we’re going to send your claim to a third party that you’ve never heard of to price it. It will just give some sort of vague language about competitive rates in your geographic area. And if you call up in advance of seeking the care to try and get an estimate, most of the time you will not get much more specifics than that. They tell you you have to just go and they’ll process the claim and you’ll see when the explanation of benefits comes through.听

Dan: Yeah, and look, I hate to get you even angrier, but Chris says the rules can change on you, without notice.听

Chris Hamby: A lot of people that I talk with also have seen no change in their insurance plan, but they’ve seen their reimbursement rates decline over time.听

Dan: Turns out, behind the scenes, their insurance made a switch from a service like FAIR Health, which looks at what’s getting paid in general, to a service like MultiPlan, which looks for the steepest possible price cuts.听

Chris Hamby: And the difference between those two amounts can be vast. So you have people who in some cases stop seeing their doctors because their costs doubled almost overnight.听

Dan: Oh god. And still. Better to know. Better that as many of us know as possible. That’s why Chris reviewed more than 50,000 pages of documents, and interviewed more than a hundred people for that story. And why lawyers for the New York Times helped get courts to agree to give him documents that had been under seal.听

Kristin and Paul– who had figured most of this out for themselves– they definitely appreciated all that work.听

Paul H: When Chris published the article that he did, it was very validating to know we’re not the only ones who are in this same boat. And there’s actually people who have had far worse experiences than ours. Like, ours kind of pale in comparison. And then immediately, like, within 24 hours to see 1,500 or 1,600 comments on the article talking about it. It’s like, okay, I might not have the stone that can slay the giant, but maybe The NewYork Times has the right sling and they might have the right stone to at least start the conversation.听

Dan: A few weeks after Chris’s article came out, U.S. Senator Amy Klobuchar sent the top federal antitrust regulators a letter: She wanted them to take a hard look at MultiPlan.听

Chris Hamby: She expressed concern about the potential for price fixing here.听

Dan: Actually, Chris says some providers have already filed lawsuits against MultiPlan based on antitrust allegations.听

Chris Hamby: The idea is that all the insurance companies outsource their pricing decisions to a common vendor. They’re essentially fixing prices via algorithm is the allegation.听

Dan: As we noted here a few episodes ago, these antitrust regulators in the Biden administration have gotten pretty feisty. [That was the episode about the cyberattack on a company called Change Healthcare. It was called “The Hack,” if you missed it. Pretty fun!]听

And I mean, those antitrust regulators have their work cut out for them. And a lot of targets. But I do want to egg them on here. I suspect you do too. Meanwhile, you’re egging US on.听

Listener 1: The first thought that went through my head was I’m going to fight this because this is absolutely ridiculous. I’ve already paid for this.听

Dan: A few weeks ago, we asked you for stories about your experiences with sneaky fees, often called facility fees.听

Listener 2: When the facility fee is twice the office visit fee, it’s just crazy. I mean, it’s a 10-minute appointment for a prescription.听

Dan: You came through, and now we’re making some calls, digging in for more details, and learning so much. We’re gonna have a sneak preview for you in a few weeks. Till then, take care of yourself.听

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta and Claire Davenport– our summer intern. Welcome aboard, Claire!– and edited by Ellen Weiss. Adam Raymonda is our audio wizard. Our music is by Dave Weiner and Blue Dot Sessions. Gabrielle Healy is our managing editor for audience. Gabe Bullard is our engagement editor. Bea Bosco is our consulting director of operations. Sarah Ballama is our operations manager.听

An Arm and a Leg is produced in partnership with 麻豆女优 Health News. That’s a national newsroom producing in-depth journalism about healthcare in America and a core program at 麻豆女优, an independent source of health policy research, polling and journalism. Zach Dyer is senior audio producer at 麻豆女优 Health News. He’s editorial liaison to this show.听

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor, allowing us to accept tax-exempt donations. You can learn more about INN at INN.org. Finally, thanks to everybody who supports this show financially. You can join in any time at

Thanks for pitching in if you can, and thanks for listening.

“An Arm and a Leg” is a co-production of 麻豆女优 Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,”听. You can also听follow the show on听听and听the . And if you’ve got stories to tell about the health care system, the producers听.

To hear all 麻豆女优 Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on , , , or wherever you listen to podcasts.

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

She felt a pain in her sinuses and sought a quick resolution.

Covid-19 couldn’t be ruled out, so rather than risk passing on an unknown infection to others in a waiting room, the New Yorker booked a telehealth visit through her usual health system, Mount Sinai 鈥� a perennial on best-hospitals lists.

That proved an expensive decision. She remembers the visit as taking barely any time. The doctor decided it was likely a sinus infection, not covid, and prescribed her fluticasone, a nasal spray that relieves congestion, and an antibiotic, Keflex. (The Centers for Disease Control and Prevention “are not needed for many sinus infections, but your doctor can decide if you need” one.)

Then the bill came.

The Patient: Elyse Greenblatt, now 38, had insurance coverage through Empire BlueCross BlueShield, a New York-based insurer.

Medical Services: A telehealth urgent care visit through Mount Sinai’s personal record app. Greenblatt was connected with an urgent care doctor through the luck of the draw. She was diagnosed with sinusitis, prescribed an antibiotic and Flonase, and told to come back if there was no improvement.

All this meant a big bill. The insurer said the telehealth visit was deemed an out-of-network service 鈥� a charge Greenblatt said the digital service didn’t do a great job of warning her about. It came as a surprise. “In my mind, if all my doctors are 鈥榠n-insurance,’ why would they pair me with someone who was 鈥榦ut-of-insurance’?” she asked. And the hospital system tried its best to make contesting the charge difficult, she said.

Service Provider: The doctor was affiliated with Mount Sinai’s health system, though where the bill came from was unclear: Was it from one of the system’s hospitals or another unit?

Total Bill: $660 for what was billed as a 45- to 59-minute visit. The insurer paid nothing, ruling it out of network.

What Gives: The bill was puzzling on multiple levels. Most notably: How could this be an out-of-network service? Generally, urgent care visits delivered via video are a competitive part of the health care economy, and they’re not typically terribly expensive.

Mount Sinai’s telehealth booking process is at pains to assure bookers they’re getting a low price. After receiving the bill, Greenblatt went back to the app to recreate her steps 鈥� and she took a screenshot of one particular part of the app: the details. She got an estimated wait time of 10 minutes, for a cost of $60. “Cost may be less based on insurance,” the app said; this information, Mount Sinai spokesperson Lucia Lee said, is “for the patient’s benefit,” and the “cost may differ depending on the patient’s insurance.”

A $60 fee would be in line with, if not a bit cheaper than, many other telehealth services. Doctor on Demand, for example, from a clinician for $79 for a 15-minute visit, assuming the customer’s insurance doesn’t cover it. Amazon’s new clinic service, offering telehealth care for a wide range of conditions, advertises that for a sinus infection.

The Health Care Cost Institute, an organization that analyzes health care claims data, told 麻豆女优 Health News its data shows an urgent care telehealth visit runs, on average, $120 in total costs 鈥� but only $14 in out-of-pocket charges.

So how did this visit end up costing astronomically so much more than the average? After all, one of the selling points of telemedicine is not only convenience but cost savings.

First, there was the length of the visit. The doctor’s bill described it as moderately lengthy. But Greenblatt recalled the visit as simple and straightforward; she described her symptoms and got an antibiotic prescription 鈥� not a moderately complex visit requiring the better part of an hour to resolve.

The choice of description is a somewhat wonky part of health care billing that plays a big part in how expensive care can get. The more complex the case, and the longer it takes to diagnose and treat, the more providers can charge patients and insurers.

Greenblatt’s doctor billed her at a moderate level of care 鈥� curious, given her memory of the visit as quick, almost perfunctory. “I think it was five minutes,” she recalled. “I said it was a sinus infection; she told me I was right. 鈥楾ake some meds, you’ll be fine.’”

Ishani Ganguli, a doctor at Brigham and Women’s Hospital in Boston who studies telehealth, said she didn’t know the exact circumstances of care but was “a bit surprised that it was not billed at a lower level” if it was indeed a quick visit.

That leaves the out-of-network aspect of the bill, allowing the insurer to pay nothing for the care. (Stephanie DuBois, a spokesperson for Empire BlueCross BlueShield, Greenblatt’s insurer, said the payer covers virtual visits through two services, or through in-network doctors. The Mount Sinai doctor fit neither criteria.) Still, why did Mount Sinai, Greenblatt’s usual health care system, assign her an out-of-network doctor?

“If one gets their care from the Mount Sinai system and the care is within network, I don’t think it is reasonable for the patients to expect or understand that one of the Mount Sinai clinicians is suddenly going to be out of network,” said Ateev Mehrotra, a hospitalist and telehealth researcher at Beth Israel Deaconess Medical Center.

It struck the doctors specializing in telehealth research whom 麻豆女优 Health News consulted as an unusual situation, especially since the doctor who provided the care was employed by the prestigious health system.

The doctor in question may have been in network for no insurers whatsoever: A review of the doctor’s Mount Sinai profile page 鈥� archived in November 2022 鈥� does not list any accepted insurance. (That’s in contrast to other doctors in the system.)

Lee, Mount Sinai’s spokesperson, said the doctor did take at least some insurance. When asked about the doctor’s webpage not showing any accepted plans, she responded the site “instructs patients to contact her office for the most up-to-date information.”

Attempting to solve this billing puzzle turned into a major league headache for Greenblatt. Deepening the mystery: After calling Mount Sinai’s billing department, she was told the case had been routed to disputes and marked as “urgent.”

But the doctor’s office would seemingly not respond. “In most other professions, you can’t just ignore a message for a year,” she observed.

The bill would disappear on her patient portal, then come back again. Another call revealed a new twist: She was told by a staffer that she’d signed a form consenting to the out-of-network charge. But “when I asked to get a copy of the form I signed, she asked if she could fax it,” Greenblatt said. Greenblatt said no. The billing department then asked whether they could put the form in her patient portal, for which Greenblatt gave permission. No form materialized.

When 麻豆女优 Health News asked Mount Sinai about the case in mid-October of this year, Lee, the system’s spokesperson, forwarded a copy of the three-page form 鈥� which Greenblatt didn’t remember signing. Lee said the forms are presented as part of the flow of the check-in process and “intended to be obvious to the patient as required by law.” Lee said on average, a patient signs two to four forms before checking into the visit.

But, according to the time stamp on the forms, Greenblatt’s visit concluded before she signed. Lee said it is “not standard” to sign forms after the visit has concluded, and said that once informed, patients “may contact the office and reschedule with an 鈥榠n-network provider.’”

“If it was provided after the service was rendered, that is an exception and situational,” she concluded.

The business with the forms 鈥� their timing and their obviousness 鈥� is potentially a vital distinction. In December 2020, Congress enacted the No Surprises Act, designed to crack down on so-called surprise medical bills that arise when patients think their care is covered by insurance but actually isn’t. Allie Shalom, a lawyer with Foley & Lardner, said the law requires notice to be given to patients, and consent obtained in advance.

More from Bill of the Month

• Out for Blood? For Routine Lab Work, the Hospital Billed Her $2,400 Nov 21, 2023
• When That Supposedly Free Annual Physical Generates a Bill Oct 30, 2023
• She Received Chemo in Two States. Why Did It Cost So Much More in Alaska? Sep 29, 2023

But the legislation provides an exception. It applies only to hospitals, hospital outpatient facilities, critical access hospitals, and ambulatory surgery centers. Greenblatt’s medical bill variously presents her visit as “Office/Outpatient” or “Episodic Telehealth,” making it hard to “tell the exact entity that provided the services,” Shalom said.

That, in turn, makes its status under the No Surprises Act unclear. The rules apply when an out-of-network provider charges a patient for care received at an in-network facility. But Shalom couldn’t be sure what entity charged Greenblatt, and, therefore, whether that entity was in network.

As for Mount Sinai, Lee said asking for consent post-visit does not comply with the No Surprises Act, though she said the system needed more time to research whether Greenblatt was billed by the hospital or another entity.

The Resolution: Greenblatt’s bill is unpaid and unresolved.

The Takeaway: Unfortunately, patients need to be on guard to protect their wallets.

If you want to be a smart shopper, consider timing the length of your visit. The “Bill of the Month” team regularly receives submissions from patients who were billed for a visit significantly longer than what took place. You shouldn’t, for example, be charged for time sitting in a virtual waiting room.

Most important, even when you seek care at an in-network hospital, whose doctors are typically in network, always ask if a particular physician you’ve not seen before is in your network. Many practices and hospitals offer providers in both categories (even if that logically feels unfair to patients). Providers are supposed to inform you that the care being rendered is out of network. But that “informed consent” is often buried in a pile of consent forms that you auto-sign, in rapid fire. And the language is often a blanket statement, such as “I understand that some of my care may be provided by caregivers not in my insurance network” or “I agree to pay for services not covered by my insurance.”

To a patient trying to quickly book care, that may not feel like “informed consent” at all.

“It’s problematic to expect patients to read the fine print, especially when they feel unwell,” Ganguli said.

Emily Siner reported the audio story.

Bill of the Month is a crowdsourced investigation by 麻豆女优 Health News and that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? !

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

That law has protected patients from some of the most outrageous out-of-network medical bills since it took effect in 2022 鈥� except when it comes to ground ambulances. Host Dan Weissmann and producer Emily Pisacreta unpack the story with Bram Sable-Smith of 麻豆女优 Health News and PIRG’s Patricia Kelmar and share what to do if you get hit with an out-of-network ambulance bill.

Credits

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there 鈥�

I have been following the world of medical bills for more than four years now 鈥� which makes me still a newbie, really. And here’s one thing that’s surprised me 鈥� beyond how much there is to know, and how deep the problems go.

It’s this: Sometimes, some things do actually change for the better.

Like, when I started, one of the most outrageous problems was something called “surprise bills”:

That’s when you go someplace, like a hospital, that takes your insurance, and then, SURPRISE! You get a bill from somebody there who says they DON’T take your insurance, and they feel free to charge you ANY ridiculous amount they want, and your insurance may cover a LITTLE of it, or none of it.

I was like, “I will be making episodes about this outrage for a long time.”

Except, at the end of 2020, about two years in for me, Congress actually did something about this outrage. They passed a law called the No Surprises Act.

It said, if you went somewhere in network 鈥� someplace your insurance covers 鈥� then any bill you get from anybody there? You should be covered as if they were in network. So, they don’t take your insurance? Not your problem. They’ve gotta work something out with your insurer. And if they can’t, an arbitrator steps in.

The law went into effect at the beginning of 2022. And: Surprise! In a lot of ways, it’s working. One study shows that it’s preventing a million of these surprise bills every month. A million. Every month.

Except, of course, nothing’s perfect. There are a lot of nuances we could look into, but one thing really stands out: There’s actually a hole written into the law that you could drive an ambulance through.

We’re gonna look at how that hole got there, what it means, and what MAYBE could get done about it.

This is “An Arm and a Leg,” a show about why health care costs so freaking much and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So our job on this show is to take one of the most enraging, terrifying, depressing parts of American life and bring you something entertaining, empowering and useful.

And today we’re talking about ambulances. With help from producer Emily Pisacreta.

Emily: Wee-oo-wee-oo

Dan: Haha! Emily you have spent the last few weeks looking at this whole deal

with ambulances. Why don’t you take it away?

Emily: Here’s a story that illustrates how weird ambulance bills can be. It’s a totally wild installment of “Bill of the Month,” the series from NPR and our co-producers 麻豆女优 Health News.

I talked to the 麻豆女优 reporter who did the story, Bram Sable-Smith, a Midwest correspondent there.

Bram Sable-Smith: I kind of focus on issues that face consumers, people who are living their lives.

Emily: One person who was just living her life was a woman named Peggy.

Bram Sable-Smith: She’s 55 years old. She works in a fine jewelry store in the Chicago suburbs. And her two siblings, Jim and Cynthia, were coming to visit her.

Emily: So Peggy and her siblings are in the car. They’re driving out into the country, going to see some horses. They’re out on this country road, they come up to an intersection, and all of sudden, bam, the car gets hit by a truck.

Bram Sable-Smith: It spun around and slammed into an electrical box right there on the side of the highway.

Emily: They survive, but they do get pretty banged up. Someone calls 911, and ambulances arrive. And here’s where the story goes from being scary to kinda weird. Peggy and her brother and sister need to go to the hospital.

But because an ambulance is not a bus, with seats for everyone, each sibling needs their own ambulance, and: Each of those ambulances is run by a different ambulance service. They end up at the same hospital, they get billed for the exact same services.

Bram: They were all charged for a life support fee and they were all charged a mileage fee.

Emily: However 鈥�

Bram: Months later when the bills came for the three of them, they got billed

three very different amounts for the exact same services.

Emily: And the bills were all out of network, and all pretty substantial. Especially Peggy’s. Cynthia’s bill was $1,250, Jim’s $1,415, and poor Peggy? Who invited her siblings on this ill-fated drive?

Bram Sable-Smith: Peggy’s bill was for $3,606.

Emily: That’s almost three times what her sister got charged. And these are all heavy-duty bills. Higher than what research shows is the average out-of-network ambulance bill.

But the fact that they’re out of network, like not billed to their insurance? That’s not an outlier. It’s estimated that 71% of ambulance bills are out of network on commercial plans. Which means 71% of the time 鈥�

Bram Sable-Smith: 鈥� ambulances are essentially able to charge whatever they want.

Emily: Result? These random ass charges.

Dan: Hold up. So this is exactly the kind of thing the No Surprises Act was supposed to prevent: out-of-network bills from someone you didn’t pick yourself. You know, like an ambulance. And you’re saying ambulances are especially unlikely to be covered by your insurance. But they’re not governed by the No Surprises Act.听

Emily: That’s right.

Dan: OK, so why did Congress leave ambulances out of the No Surprises Act?

Emily: I mean, I had the same question. It’s like 鈥� Congress was able to juggle all the demands of the insurance lobby and health care providers including, I should mention, AIR ambulance companies

Dan: Wait, that’s helicopter rides?

Emily: Yep. Helicopters, air ambulances, that were charging tens of thousands of dollars a ride. Congress dealt with them here, but, like 鈥� not regular degular ambulances? So yeah, why not?

And the answer has to do with who actually runs ambulances in the U.S. And how they get their funding.

That story starts decades ago. You ready for this?

Dan: What, a ride in the Wayback Machine? Yeah, I mean have you met me? I was born ready for this.

Emily: OK, sea tbelts on. Once upon a time, about 60 years ago 鈥�

Patricia Kelmar: We really didn’t have an emergency transportation system for

medical care in the U.S.

Emily: That’s Patricia Kelmar. She runs health care campaigns at a consumer-advocacy organization called the Public Interest Research Group. She lobbied for the No Surprises Act. And when we talked, we got into the history of ambulances, because everything has an origin story. She says a national ambulance system started with a big federal report in 1966. And here’s what it said:

Patricia Kelmar: We were losing a lot of people who were having medical emergencies at home or out in the community and didn’t get to the hospital fast enough.

Emily: The report identified accidental injuries as the leading cause of death for Americans in the first half of their life span. It said more Americans died from motor vehicle accidents in 1965 than American troops in the Korean War.

Patricia Kelmar: So this report really opened the eyes of public health officials, and there was a movement in the early Seventies to create a national emergency transportation system.

Dan: Wait! This reminds me of a show that was on when I was a kid called Emergency! with an exclamation point.

Emily: Yeah totally!

[Emergency! theme]

[Clip from Emergency! plays]

Dispatcher: Rampart Emergency?听

Paramedic 1: Rampart, this is Squad 51.

Dan: Yeah! Kids I knew had Emergency! lunchboxes

Emily: Yeah, it was a whole cultural moment. It seems like this apparently had American audiences on the edge of their seats.

[Clip from Emergency! plays]

Dispatcher: Go ahead, 51.

Paramedic 1: Rampart, we have a male patient here, age 17. He has, uh, acute abdominal pain.

Emily: That first aired in 1972.

[Clip from Emergency! plays]

Paramedic 1: Patient’s, uh, ingested two loaves of raw dough. Ambulance has just arrived.

[Emergency! Sound]

Emily: Lawmakers had a vision to match. In 1973, Congress passed the Emergency Medical Services Systems Act, to bring high-quality emergency care to every part of the country.

Patricia Kelmar: It was developed thinking about regions so that we didn’t have too many ambulances, but we had enough ambulances to serve different populations, and the best part was there was federal funding to make this happen.

Emily: But then in the ’80s 鈥� the structure of that funding changed. Now states would get block grants, big chunks of federal health care dollars that they would decide for themselves how to use.

Patricia Kelmar: And so every community then, throughout our country, responded to this change in the funding system by 鈥� understanding that we still need ambulances, but funding it in different ways.

Emily: Which is why in some places you’d never get a bill for an ambulance. The local city or county governments owns and operates it, and a mix of funding streams, including local taxes just cover it.

And in other places, you certainly would get a bill. And it wouldn’t be from the county, but it’d be from a hospital, or a for-profit EMS company. Because they run about 40% of this landscape too, and some of those companies are even owned by private equity.

And still in other places, you get volunteer ambulance companies running bake sales or even raising money on GoFundMe.

In the case of Peggy and her siblings, just by virtue of where they got into the accident, they ended up in publicly run ambulances from three different jurisdictions, each with their own funky funding, each with their own unique pricing scheme.

Dan: Huh. So that’s where things stood with ambulances when Congress was cooking up the No Surprises Act. Coming right up: Why did that lead Congress to punt? And what might come next?

[midroll]

Dan: This episode of “An Arm and a Leg” is produced in partnership with 麻豆女优 Health News. That’s a nonprofit newsroom covering health care in America. Their work is absolutely terrific; I love partnering with them. We’ll have a little more information about 麻豆女优 Health News at the end of this episode.

[midroll music fades out]

Dan: OK 鈥� So, since the 1960s, we’ve got ambulance care around the country that meets certain standards 鈥� great. But how the ambulances get funded, who owns them, and how much you get billed after it drops you off, all these things depend on location 鈥� not so great.

But, you know: hospital funding, hospital bills 鈥� that’s not standard across the country, either. Why did Congress apply the No Surprises Act to hospitals, but not ambulance rides? Emily, looking at you here.

Emily: Hey, look, even experts have a tough time with that one. Here’s an economist named Loren Adler from the Brookings Institution. He researches health insurance and he watched the whole No Surprises Act take shape.

I asked him: So, no ambulances. Why’s that?

Loren Adler: So, I’m not sure I can give you a super satisfactory answer. I don’t really think there’s a great reason. Uh, I can give the sort 鈥�

Emily: You don’t have to 鈥� you certainly don’t have to defend 鈥�

Loren Adler: Yeah, um, that’s true.

Emily: Actually he did have a couple of reasons. He started with: who actually runs ambulance services most of the time.

Loren Adler: About 60% of emergency ground ambulance transport is actually billed by local governments or fire departments.

Dan: So “Big Ambulance Incorporated” didn’t steamroll Congress?听

Emily: Not according to Loren.

Loren Adler: As much as observers might think that lobbyists and sort of stakeholder industry have a lot of say over Congress, I’m not objecting to that characterization. Uh, you know, calls from local lawmakers and mayors and fire department chiefs have even more weight.

Dan: So, OK. We’re talking local public servants. Like, Leslie Knope from Parks and Rec, if she were a fire chief.

Emily: Yeah, and as Loren might say: A high ambulance bill looks like an outrage to you, but to her it looks like something else.

Loren Adler: It is effectively a source of local government revenue.

Dan: So Congress was hearing from Leslie Knope, “Are you trying to bankrupt

my little town of Pawnee?” And they were like, “OK. So, no ambulances then.”

Emily: Right. Loren also sees a much nerdier factor at play.

Dan: Hit me.

Emily: Remember, whether it’s Leslie Knope or “Big Ambulance Inc.” running them, local ambulance services are overwhelmingly out of network.

And so according to Loren, the mechanisms that make the No Surprises Act work would be hard to apply.

Loren Adler: The sort of structure of the No Surprises Act is all kind of based around this median in-network price,

Emily: Did you catch that? Median in-network price.

That is, Congress had to decide: If we’re gonna make a law where an out-of-network provider can’t just charge Whatever They Want anymore in these situations, then 鈥� what are they supposed to get paid? Congress said 鈥�

Loren: We’re gonna tell insurers you have to pay whatever your sort of average in-network price was for the service.

Emily: But with so few in-network providers, there is no reliable, average in-network price.

Dan: OK. That was super-nerdy. And I’m gonna note that even if Leslie Knope and a bunch of nerds led the charge here, Big Ambulance Inc. got the benefit too. So what now?

Emily: Well, Congress did recognize that they were leaving this giant sign up at the door that said “Welcome Surprise Ambulance Bills.” And they said, OK, we can’t figure this shit out now. But let’s have a bunch of experts get together and let’s have them write us some recommendations for later. They told the Department of Health and Human Services: Go form a committee.

And now Loren is on that committee. So is Patricia Kelmar 鈥� the consumer advocate we heard from earlier.

Patricia Kelmar: The advisory committee is called the Ground Ambulance and Patient Billing Advisory Committee. If that’s not a mouthful, I don’t know 鈥�

Emily: Yeah. Yep.听

Patricia Kelmar: But it’s, it’s probably indicative of how complicated finding solutions to surprise billing can be.

Emily: Patricia and the panel, they first met in early May, and the law says they have 180 days after that to come up with some policy recommendations for lawmakers to take under advisement. After that, it’ll be up to Congress to take action again.

Dan: And, I mean, not to be a cynic, but it took years to get the No Surprises Act passed. What if I decide not to hold my breath until Congress does something about ambulances?

Emily: You’ll be forgiven, my dude.

Dan: So, where does that leave us? Scrounging for in-the-meantime advice, right?听

Emily: Yep. Patricia has some tips.

Patricia Kelmar: The first thing we recommend is that you talk to both your insurer and the ambulance company and try to negotiate better coverage or lowering of the bill.

Emily: If you get your insurance through work, your HR department may be able to help. Let them know what happened and see whether they can get insurance to pay it off.

If that’s not an option, try to negotiate with the ambulance provider.

Patricia Kelmar: Always explain your financial situation. Try to work out something. I have. Patients who called me about their ambulance bills, and when they call and explain, sometimes they get a discount.

Emily: And finally, there might actually be state local laws in your area that pertain to balance bills, that include ambulances.

Dan: Ooh, I’ve got one more tip!

Emily: Mmmhm?

Dan: This one is from our pal Jared Walker. He runs a group called Dollar For. Their whole thing is helping people get financial assistance, or charity care. 鈥楥ause, you know, nonprofit hospitals are required to give price breaks to at least SOME people with low incomes.

And Jared says: Ambulance companies aren’t required to have those kinds of policies, but A LOT OF THEM DO.

He also says: You should look them up. Like, the specific policy for whatever company you are dealing with. Because these policies can have funny names 鈥� like “Compassionate Care Policy.” And if you don’t ask for them by name, the person you call may pretend they don’t know what you’re talking about. That’s what Jared says. So, Jared, if you’re listening, big thanks to you for those crucial details.

Emily: Cool cool cool. But none of these solutions work for everyone.

Peggy, the woman who got into an accident with her siblings? Her bill went to collections, and she had a hell of a time fighting back. The bill disappeared only after her story aired on national radio.

Dan: That one’s definitely not gonna work for everybody.

Emily: No. Which reminds me of another thing Patricia told me.

Patricia: For the ambulance committee, there’s a public portion. People can log in, they can listen, people can share their stories, tell us something about what they want us to do, and if they don’t get called on that time, they can just write a note, and let us know.

Dan: Wherever you’re listening to this, we’ll post information about how you can chime in.

Also, I found a list of 10 states that have surprise-billing protections for ambulances 鈥� including Illinois, Ohio, New York, Colorado. We’ll have a link to the list of all 10 states as well.

Emily, thank you so much for telling us all about ambulances.

Emily: My pleasure.

Dan: And I’ve got a request here. Something I could use everybody’s help with:

We are planning an upcoming episode about AI. 鈥楥ause we’re wondering: Can we train ChatGPT to make it easier to appeal stupid insurance denials?

And we’re gonna need 鈥� some raw material. Some stupid insurance denials.

If you’ve gotten one recently, and you’d like some help from a chatbot 鈥� and an actual human expert that we will recruit 鈥� can you please get in touch? Go to

Let us know the story. Please include the relevant documents. We won’t share your personal information without your OK, but if we use your story, we will want to talk with you, maybe put your voice on the show.

Are you game? Or: Do you know somebody who might be? Let’s get our new robot overlords working for us, you know, while we can.

And besides: I’m pretty sure the folks at the insurance companies are already trying to do the same. Let’s start catching up.

Again: The place to share is: . Thank you so much. This should be fun.

We’ll have another episode for you in a few weeks.

Till then, take care of yourself.

This episode of “An Arm and a Leg” was produced by Emily Pisacreta 鈥� with help from Lucy Little, Bella Cjazkowski, and me, Dan Weissmann 鈥� and edited by Ellen Weiss.

Daisy Rosario is our consulting managing producer. Adam Raymonda is our audio wizard. Our music is by Dave Winer and Blue Dot Sessions.

Gabrielle Healy is our managing editor for audience. She edits the First Aid Kit Newsletter.

Bea Bosco is our consulting director of operations. Sarah Ballema is our operations manager.

“An Arm and a Leg” is produced in partnership with 麻豆女优 Health News 鈥� formerly known as Kaiser Health News.

That’s a national newsroom producing in-depth journalism about health care in America, and a core program at 麻豆女优 鈥� an independent source of health policy research, polling, and journalism.

And yes, you did hear the name Kaiser in there, and no: 麻豆女优 isn’t affiliated with the health care giant Kaiser Permanente. You can learn more about 麻豆女优 Health News at armandalegshow.com/麻豆女优.

Zach Dyer is senior audio producer at 麻豆女优 Health News. He is editorial liaison to this show.

Thanks to Public Narrative 鈥� that’s a Chicago-based group that helps journalists and nonprofits tell better stories 鈥� for serving as our fiscal sponsor, allowing us to accept tax-exempt donations. You can learn more about Public Narrative at

And thanks to everybody who supports this show financially.

If you haven’t yet, we’d love for you to join us. The place for that is

Thank you!

“An Arm and a Leg” is a co-production of 麻豆女优 Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,”听. You can also听follow the show on听听and听. And if you’ve got stories to tell about the health care system, the producers听.

To hear all 麻豆女优 Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on , , , or wherever you listen to podcasts.

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).