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Patients describe being hospitalized, with a bill collector at their side

Christopher Snowbeck, Pioneer Press, St. Paul, Minn. –

One woman says she was asked to pay hundreds of dollars while hooked to a morphine drip in the emergency room.

Another patient who arrived at the ER by ambulance with chest pains says a hospital worker approached her for money before doctors had run a test to make sure she wasn’t suffering from a heart attack.

In a third case, a woman who paid $984 at the time her son underwent a scheduled surgery later found she needed to pay only $200 and struggled to get a prompt refund.

Those are just three of the patient stories that have emerged in the wake of a critical report in April from Minnesota Attorney General Lori Swanson about billing and collection practices in the Fairview health system.

Swanson’s report took aim at the health system and Chicago-based Accretive Health, which was Fairview’s consultant on billing and collection issues for a two-year period beginning in 2010. After the report was issued in late April, Fairview broke ties with the company and apologized to patients.

Accretive Health, meanwhile, has defended itself by repeatedly attacking Swanson’s report and enlisting high-profile help, including public comments from Chicago Mayor Rahm Emanuel, former chief of staff in the Obama administration.

As the back-and-forth continues, more patients are coming forward to tell their stories.

“After they put me on a morphine drip, they came into the emergency room with a credit card machine,” wrote Mary Kahl, 50, of Hastings, in an email. “Because

I had an IV in my arm and had limited mobility, they handed me my purse so I could pay them on the spot!”

“It was just so out-of-line,” said Judy Rotach, a licensed clinical counselor in Arden Hills who was asked for money in the ER despite her chest pains. In a letter to Fairview, Rotach wrote that she “cannot imagine requesting or even requiring immediate payment for a client who enters my office in an emergency situation.”

Marcia Newton of Corcoran, whose son underwent ear surgery last year, summed up her feelings this way: “I’ve lost a lot of trust and respect for Fairview’s management and board of directors.”

Fairview spokesman Ryan Davenport said the health system would not address specific patient cases, but he said Fairview is taking such concerns seriously.

“We know based on the attorney general’s report that interactions with some of our patients regarding their financial obligations fell short of our professional expectations and organization values,” Davenport said in a statement. “We’re sorry for that, and we are now working to restore faith and trust among those impacted.”


Swanson’s report covered a broad range of topics.

One section alleged that Accretive Health broke debt-collection laws. Another looked at whether Accretive Health and Fairview violated a 2007 agreement between the attorney general and the health system about how to handle billing matters and charity care.

As a charitable hospital, Swanson said: “They don’t pay property taxes, income taxes, sales taxes, and they can benefit from the sale of tax-exempt bonds. In exchange for all that … they have certain obligations.”

A third section of her report alleged violations of privacy laws. In a section about what Swanson described as a culture clash between Fairview and Accretive Health, she questioned whether federal law had been violated when it comes to Fairview providing emergency room care for patients regardless of their ability to pay.

The questions about ER care, it turns out, prompted the federal government this month to send investigators to the University of Minnesota Medical Center, Fairview in Minneapolis.

Accretive has maintained that Swanson’s allegations obscure the fact that it follows industry standards for talking with patients about the money they owe for health services. Accretive employees were instructed never to insist that patients pay old or current bills in order to receive care, the company contends, adding that bedside conversations about bills were voluntary.

Emergency room treatment, in particular, was never conditioned on patients paying bills, the company has said. Plus, Accretive said there were policies that barred workers from

talking about payments with ER patients suffering from heart conditions, life-threatening injuries and relatively serious conditions.

“It is clear that the attorney general’s report is highly misleading and was not informed by even a single meeting with any current Accretive Health employee,” the company said in a prepared response this month to questions posed by Sen. Al Franken, D-Minn.

Accretive declined comment for this story.


For five patients who shared their stories with the Pioneer Press, the central issue involved whether Fairview was overly aggressive in trying to collect money as care was being delivered.

“They made it seem like I didn’t have a choice,” said a woman treated in July 2010 at the Fairview Ridges Hospital emergency room in Burnsville. Another woman in the same ER was so taken aback by a request for about $950 that she described it in an interview as a “shakedown.”

Both women have told their stories to the attorney general’s office, although they asked that their names not be printed to maintain the privacy of their health concerns.

Swanson said she’d never before heard of such collection efforts in emergency rooms.

“These are patients that have insurance,” Swanson said in an interview. “But rather than (Fairview) waiting for the claim to be processed and go through the insurance pipeline, patients are being asked to pay right there on the spot.

“There’s a time and a place to collect money,” she added, “but I don’t think a bedside collection visit for a medically distressed patient in the emergency room is the place.”

In the case of scheduled procedures like that for Marcia Newton’s son, Swanson said she was not trying to draw boundaries around when so-called “point-of-service” collections might be appropriate or inappropriate. But if hospitals are going to ask for such sums, they should use restraint.

“This notion of asking people to pay high amounts that turn out to have no correlation to reality — that’s concerning,” Swanson said. “And then to put the burden on the consumer to fight to get it back, that’s something I don’t like to see.”

Swanson’s report includes an internal Fairview email written in February that noted several self-pay credit balances needed to be refunded because they were significantly overdue. One hadn’t been paid for more than eight years.

“One of the accounts was indeed 3,000 days old,” said Davenport, the Fairview spokesman, in an email. All the long-overdue refunds have now been resolved, he said.


Self-pay payments cover what health plan officials call the “patient responsibility,” which often means the deductible that individuals must pay before insurance benefits kick in. Patient financial responsibilities have been growing significantly in recent years as more employers and individuals opt for health plans with high deductibles.

With these health plans, insurance companies offer lower premiums upfront in exchange for greater out-of-pocket costs when patients seek care. The trend, in turn, has put hospitals and clinics in the position of needing to collect more money directly from patients.

Hospitals are having more trouble with “bad debt,” cases in which they can’t collect from patients who have the ability to pay, said Nancy Kane, a hospital finance expert at Harvard University.

At Fairview, one factor in the growing bad debt tally was “increasing difficulty in collecting insured patient liable balances,” the health system said in a 2011 financial statement.

“Through our partnership with Accretive,” the document added, “we have launched collection initiatives intended to promote process efficiencies around patient-liable accounts as well as co-payment and deductible amounts owed to us by patients with insurance.”


Marcia Newton doesn’t know exactly how Accretive might have been involved with her experience at Fairview. She just knows it was frustrating.

Newton took her son Maxx to the University of Minnesota Medical Center, Fairview in November for surgery to put in ear tubes. A registration employee said the hospital charge for the surgery would be about $9,000, so Newton would need to pay $876 as her share under her insurance policy.

Newton paid with a credit card. But when she received a statement in December about the care costs from her health plan, she saw that the actual cost of the procedure was about $4,200. Her responsibility was just $200.

It wasn’t until early February that Newton received her refund. And it didn’t come without some unpleasant conversations with Fairview workers, she said, recalling one instance where a Fairview worker “told me I didn’t understand billing.”

“I felt that was a tactic where she was trying to intimidate me … in hopes that I would just go away,” said Newton, who is the only patient representative identified by name in Swanson’s report.

After hearing about the report, Judy Rotach, 50, who lives in the Forest Lake area, said she contacted Fairview Lakes Medical Center in Wyoming directly about her experience.

Following her ambulance ride with chest pains, Rotach was waiting to be taken into the CT scanning area when a hospital employee approached with a portable payment cart. Rotach said that she had given her wallet to her husband and that he was not in the room at that moment.

“It was clear that this was not okay,” Rotach wrote in an April 28 letter to Fairview Lakes Medical Center that she shared with the Pioneer Press. “The whole scene was extremely disconcerting to me and increased anxiety in an already anxiety-producing situation.”

Later, as Rotach was undergoing a CT scan of her heart, a hospital worker hit up her husband for money. He paid $475 with a credit card “because clearly that was the immediate requirement,” Rotach wrote.

In the wake of Swanson’s report, Rotach said she received a $400 refund check from Fairview. She owed $75 as a standard co-payment, but a letter from the health system explained that the hospital had been using an “estimating tool” for co-insurance payments that was inaccurate, Rotach said.

“I had really good care there,” she said in an interview. “It’s just really unfortunate.”

Mary Kahl of Hastings said she received good care at Fairview Southdale Hospital, too. She was referred to the emergency room from an urgent-care center where workers felt they couldn’t treat Kahl’s severe abdominal pains.

Kahl was diagnosed with a digestive tract disorder and given painkillers in the ER prior to being transferred to a hospital bed, she said. That’s when the hospital worker approached asking for money.

“I said: ‘Are you serious? Right now?’ ” Kahl said in an interview. “She said ‘Yes,’ and I could pay with either cash, check or credit.”


Fairview has already made changes in the emergency room, said Davenport, the health system’s spokesman. Fairview no longer collects co-insurance payments such as deductibles in the ER. The health system also has stopped trying to collect on past-due balances when patients come to the emergency room for care, Davenport said.

Neither practice is allowed at the Allina and HealthEast systems, according to officials at both groups.

Fairview also is putting more resources toward quickly getting refunds to patients, Davenport said.

The Minneapolis-based Allina health system also asks patients to pay deductibles at the time of a scheduled procedure, said Chris Hughes, vice president of revenue-cycle management. But the Minneapolis-based health system promises to refund overpayments within 30 days, he said.

HealthEast has been thinking about implementing some point-of-service collections at the time of scheduled procedures, said Mike Nass, the system’s chief financial officer. But if it does so, the St. Paul-based system would do so in a way that’s mindful of patients’ vulnerable position, Nass said, as well as debt-collection standards set by the attorney general.

Point-of-service collections are attractive to health care providers, Nass said, because “collectability decreases dramatically after a service has been provided.” But Swanson’s report has given health systems “a little bit of pause for what they might have been thinking about rolling out,” he said.

That was one goal of the Fairview report, Swanson said.

“These reports highlight issues and behavior that may not be consistent with the mission, values and duties of a charitable hospital,” she said.

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