When 50-year-old Sovereign Valentine of Montana began to feel progressively run down, he made some changes to his diet and workout routine. As a personal trainer, he knew subtle diet changes can make a world of difference to his health. However, when he felt progressively worse, he made the drive to the local hospital unaware he was in kidney failure. (1)

Kidney disease is often called the “silent disease” as it commonly only presents symptoms when it is advanced. The hospital told Sovereign he needed dialysis immediately. They transferred him to a nearby hospital for his first dialysis session. He needed outpatient dialysis three times a week. There were two local facilities offering dialysis. He chose a Fresenius Kidney Care clinic in Missoula. This is when his insurance nightmare began. (1, 2)

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Out-Of-Network Facility

Fresenius Kidney Care was “out-of-network.” As a result, Sovereign would be personally billed for whatever wasn’t covered by his insurer. To make matters worse, he was told there were no in-network dialysis clinics in Montana. (1)

Sovereign’s wife Dr. Jessica Valentine, a doctor at a rural hospital, tried to find out the costs from the facility and the insurer without luck. (1)

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59 Times The Medicare Fees

It turned out that the dialysis for his end-stage renal disease would cost him $13,867.74 per session. This was about 59 times the $235 Medicare fees. Sovereign’s treatment came to a staggering $540,841.90 for 14 weeks of dialysis care. His insurer paid $16,241.73, leaving him with a bill of $524,600.17 to pay from his own pocket. “It was far worse than what I had imagined would be the worst-case scenario,” says Dr. Valentine. Sovereign, on the other hand, found it so outrageous he just had to laugh. (1)

Fresenius: The Dominant Providers

Fresenius and DaVita are the most dominant providers of dialysis care in the U.S. They form a duopoly according to health economists. Because their treatments are life-saving, they charge exorbitant prices. They are out-of-network, which makes things even worse for patients. The bill handed to Sovereign was more than the average cost of an actual kidney transplant. (2, 3)

Medicare Coverage

According to 1973 law, patients under 65 with end-stage renal disease can join Medicare. However, they must wait 90-days for coverage. As a result, patients are vulnerable to their illness and the financial burdens their medical care will present. (1)

Companies like Fresenius have incentive to charge as much as possible for dialysis treatment during the 90-day period before Medicare kicks in. Patients desperate for treatment often don’t understand the costs.  A recent study found that commercial payers usually pay about four times the Medicare rate. (1, 4)

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Staying Out-of-network

According to Sabrina Corlette, professor at Georgetown University’s Health Policy Institute, dialysis companies can get more from health plans by staying out-of-network. This allows them to charge what they want because they aren’t subject to Medicare dictated fees. “They have the health plans over a barrel,” she says. (1)

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Cancel Medical Bills

Once the story made the news, Fresenius said they would waive the couple’s unpaid bill and treat Sovereign as an in-network patient. To avoid out-of-network issues Kaiser Health News advises patients to:

  • Do thorough checks for treatment in your area to find in-network services
  • Look under “facilities” as opposed to “providers” when searching
  • Speak to your benefits department if your insurance is through your work
  • Check your medical bills to look for excessive charges

You could be protected under state laws based on a “surprise bill” that could mean you are “held harmless” for charges. This could help cancel hospital bills. (1, 5) Be vigilant with your health care and your rights. Not everyone’s story ends with a positive outcome like Sovereign’s.

*Article originally appeared at Healthy Holistic Living. Reprinted with permission.