As soon as she fell, Deborah Buttgereit knew she couldn\u2019t avoid going to the hospital.<\/p>\n
\u201cI could hear the bones moving around in my elbow,\u201d said Buttgereit, who was 60 when she slipped on a patch of ice in December outside her apartment in Bozeman, Montana.<\/p>\n
Emergency room scans showed she had fractured her left arm near the joint. Doctors told her she needed surgery to repair it.<\/p>\n
At the time, Buttgereit didn\u2019t have health insurance \u2014 she had struggled to afford coverage after her husband\u2019s death. The local health system, Bozeman Health, estimated Buttgereit would have to pay $50,560 out-of-pocket for the outpatient surgery to have her elbow pieced back together.<\/p>\n
The estimate noted: \u201cYou could be charged more if complications or special circumstances occur.\u201d<\/p>\n
Four days after her fall, Buttgereit went in for surgery, which took about three hours. During a follow-up visit, she said, her doctor told her the procedure ended up being more complicated than expected.<\/p>\n
Then the bill came.<\/p>\n
The Medical Procedure<\/strong><\/p>\n Buttgereit broke her humerus, the upper-arm bone that meets two other bones and forms the elbow. The way the bone splintered is known as a distal humerus fracture. It\u2019s rare as far as breaks go, accounting for only about 2% of all fractures<\/a> among adults. But older people, as well as kids in high-contact sports, are more prone to the big falls that lead to such fractures. The injury is painful and can make it impossible to move the elbow.<\/p>\n Some of these types of fractures heal with time in a splint, but most often surgery is the only fix. The patient is put under anesthesia while a surgeon repositions fragmented bones with plates and screws.<\/p>\n The Final Bill<\/strong><\/p>\n $97,998. That includes at least $44,300 for the operating room and anesthesia administration, plus more than $50,000 for medical supplies and implants, such as screws and plates. After the hospital applied a self-pay discount, Buttgereit was on the hook for $78,398.40.<\/p>\n The Problem: Surprise Complications, Surprising Charges\u00a0<\/strong><\/p>\n The hospital said the price for Buttgereit\u2019s surgery increased because doctors encountered complications midprocedure.<\/p>\n In particular, the fall had shattered Buttgereit\u2019s bone into more pieces than her surgeon anticipated, according to operating notes. That meant it took more time, skill, and supplies to reconstruct her elbow. And, since she was uninsured, Buttgereit alone faced the burden to pay the higher costs.<\/p>\n \u201cI\u2019ll make payments the rest of my life to pay it all off,\u201d she said.<\/p>\n Buttgereit\u2019s husband died suddenly in 2023. About a year later, she left her job with the company that had employed them both. The memories of him in that space were too difficult, she said. That also meant leaving behind her health coverage. She moved to Bozeman to be closer to one of her daughters and found a health plan at healthcare.gov that the federal government subsidized because of her limited income.<\/p>\n But she also faced a higher cost of living in Bozeman than her Social Security benefits could cover, and she needed part-time work. While that new income helped pay her bills, Buttgereit said, she no longer qualified for the same level of subsidized coverage and couldn\u2019t afford her plan. So she dropped her health insurance.<\/p>\n About two months later, she fell.<\/p>\n After getting the surgery bill, Buttgereit began calling and emailing the hospital\u2019s customer service team, asking how the price had risen from the $50,560 estimate to nearly $98,000. The hospital had automatically applied the self-pay discount of $19,600 to Buttgereit\u2019s bill \u2014 20% of the total. But that still left her with a tab of more than $78,000.<\/p>\n After more time to think pain-free, she said, she also wanted to know why the initial estimate was much steeper than those she found online for similar procedures.<\/p>\n Specifically, Buttgereit asked how to dispute her bill. When she felt she wasn\u2019t making progress contesting the charges with the hospital, she asked about her options under the No Surprises Act, a federal consumer protection law.<\/p>\n According to emails reviewed by KFF Health News, a Bozeman Health billing employee incorrectly told Buttgereit the law applies only to ER services. The employee later said Buttgereit had the right to dispute the bill but gave her an incorrect deadline.<\/p>\n Hospital staffers recommended Buttgereit set up a payment plan and apply to the health system\u2019s financial aid program.<\/p>\n Erin Schaible, a spokesperson with Bozeman Health, told KFF Health News that online estimates don\u2019t reflect the specific details of a patient\u2019s care. In addition to the shattered bones noted in Buttgereit\u2019s surgery notes, Schaible said the physician identified nerve damage midsurgery that required additional work to fix.<\/p>\n \u201cThis situation highlights the importance of clear and compassionate communication,\u201d Schaible said. \u201cIn response, our team leaders are revising internal protocols for escalating patient concerns and are reeducating staff on best practices for communicating cost estimate changes.\u201d<\/p>\n The Resolution<\/strong><\/p>\n Buttgereit refused to apply for financial aid, opting instead to challenge what she sees as inflated pricing. Using Healthcare Bluebook, an online price comparison tool that draws on insurance claims data, Buttgereit found similar procedures ranged from $8,000 to $40,000. \u00a0<\/p>\n She said she believes that there are also errors on her bill and that the complications didn\u2019t justify the price.<\/p>\n \u201cI felt like going through financial assistance means that I\u2019m OK with the price of the bill,\u201d she said. \u201cI want to get the bill reduced on the front end and then, if I need financial assistance, go through it.\u201d<\/p>\n A billing employee emailed Buttgereit in May to offer an additional $7,000 discount if she set up a payment plan. If she later qualified for financial assistance, \u201cwe will adjust the amount accordingly,\u201d the email said.<\/p>\n In June, the employee told Buttgereit her account would be put on hold before a collection process was initiated, \u201cso that you have time to decide what to do.\u201d<\/p>\n Buttgereit agreed to a payment plan of $100 a month, though she continued to contest the total charges.<\/p>\n At that rate, it would take about 60 years to pay off the debt \u2014 or longer, if the health system were to charge interest.<\/p>\n Buttgereit made one more bid for help: She emailed the White House.<\/p>\n This month, in the same week she got a detailed letter from the hospital standing by its charges, Buttgereit said she received a call from an official with the Centers for Medicare & Medicaid Services, saying she could dispute the bill to federal health officials.<\/p>\n The Takeaway<\/strong><\/p>\n The best time to push back against a price is before surgery, upon receiving a hospital\u2019s best guess on costs, known as a \u201cgood faith estimate.\u201d Otherwise, undergoing surgery is considered tacit acceptance of that price as a baseline.<\/p>\n Patricia Kelmar, director of health care campaigns at the national consumer advocacy group U.S. PIRG, follows ways in which people get tangled financially in the health industry. She said patients should compare cost estimates by searching their hospital\u2019s online pricing tool<\/a> (as well as those of nearby hospitals) to see whether the estimates align. But not every procedure makes those lists, especially those for uncommon injuries, nor is every hospital\u2019s list easy to access and navigate.<\/p>\n Post-surgery, patients have few resources to fight big bills, but a little-known rule in the No Surprises Act could help, Kelmar said.<\/p>\n The law, which took effect in 2022, is best known for protecting patients from surprise bills for out-of-network, emergency care. But it also created a formal dispute process<\/a> for uninsured patients, or those paying completely out-of-pocket for nonemergency procedures, if their final tab is $400 or more than the initial estimate.<\/p>\n \u201cThis is a valid, important part of making sure that patients who are cash-pay have a watchdog,\u201d Kelmar said.<\/p>\n People can start the patient-provider dispute process<\/a> online, through the CMS website, by providing medical records and paying a $25 fee. Patients must initiate the process within 120 days of receiving the bill, and the bill may not be sent to a collection agency while under review.<\/p>\n An independent reviewer evaluates whether the final price is drastically different from what a health insurance company would have paid and whether the complication was predictable. If the review finds that the health provider erred on either front, federal health officials could require them to reduce the bill to match the original estimate or the median price insurers pay.<\/p>\n Buttgereit said she initially opted against pursuing that formal dispute process because, after such a review, the floor would be<\/a> the hospital\u2019s initial estimate, and she still had questions about how it would work. But after hearing from CMS, Buttgereit said it\u2019s the path she plans to take. \u00a0<\/p>\n \u201cYou\u2019ve got to fight for yourself,\u201d she said. \u201cI don\u2019t know where this is going to end up, but I feel a little bit more hopeful.\u201d<\/p>\n Bill of the Month is a crowdsourced investigation by <\/em>KFF Health News<\/em><\/a> and <\/em>The Washington Post\u2019s Well+Being<\/em><\/a> that dissects and explains medical bills.\u00a0Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? <\/em>Tell us about it<\/em><\/a>!<\/em><\/p>\n\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/p>\nUSE OUR CONTENT<\/h3>\n