Scorpion Peppers Caused Him ‘Crippling’ Pain. Two Years Later, the ER Bill Stung Him Again.

Maxwell Kruzic said he suffered stomach pain so “crippling” on Oct. 5, 2023, that he had to drive off the road twice while driving to the emergency room at Mercy Regional Medical Center in Durango, Colorado. “It was the worst pain of my life,” he said.

Kruzic was seen immediately because hospital staff were almost sure he had appendicitis. They inserted an IV, called a surgeon and sent him for a CT scan to confirm the diagnosis.

But the scan showed a perfectly normal appendix and no problems in the abdomen. Doctors racked their brains to find other possible diagnoses. Could it be a kidney stone? Gallstones? Here is a 37 year old man who was in pain, but nothing was really working for him.

Then someone asked what Kruzic ate ​​the day before. He said he ate tacos with hot sauce he made from a type of scorpion pepper, grown from seeds he ordered from a chili pepper research institute.

Peppers measure more than 2 million Scoville heat units on the spiciness scale, he noted, compared to a jalapeño at up to 8,000 or a habanero at 100,000 to 350,000.

Chili peppers are among “the hottest in the world, incredibly hot,” Kruzic said. “Delicious.” He loves spicy food and has never had a problem with it, but apparently it was just too hot for his digestive system.

Kruzic spent much of the night on a stretcher in the emergency room. After about four hours, the pain subsided and he was sent home with medication to treat nausea and vomiting.

Then the bill came – about two years later.

The medical procedure

Kruzic underwent blood tests and a CT scan of his abdomen during his visit to the emergency room for acute abdominal pain.

Eating very spicy foods can cause painful inflammation and irritation of the digestive system. The discomfort usually goes away on its own.

The final bill

$8,127.41, including $5,820 for the scanner. Kruzic paid $97.02 during his visit to the hospital, which was in-network under his insurance. After insurance payments and discounts, he owed $2,460.46 – the remainder of the $1,585.26 he owed for his plan’s deductible and $972.22 he owed in coinsurance.

The problem: phantom invoices from past visits

Last September, Kruzic received a bill for his pepper-induced emergency room visit in 2023.

Unfortunately for patients, there are no uniform rules for timely billing.

Anticipating a bill, Kruzic repeatedly visited the hospital’s online portal, as well as that of its insurer, UnitedHealthcare. He pointed out that the insurer said the claim was processed shortly after it was processed. For about eight months, he continued to check the billing section of the hospital portal, which indicated he owed “$0.” He called UnitedHealthcare, and Kruzic said a representative assured him that if the hospital said he owed nothing, that was the case.

It’s unclear what exactly caused the nearly two-year delay. At least part of the problem appears to be due to prolonged disagreements between the insurer and the hospital over the cost of her visit.

Lindsay Radford Foster, a spokesperson for CommonSpirit Health, the hospital system, said in a statement to KFF Health News: “United Healthcare, the insurer responsible for the medical claim, underpaid the account based on the care provided. As a result, CommonSpirit contacted UnitedHealthcare’s Payer Relations department to rectify the underpayments.”

When asked why it took two years, she cited a reorganization at UnitedHealthcare and a change in the insurer’s representative assigned to the case.

But UnitedHealthcare disputed that view. “It was paid accurately,” said Caroline Landree, a spokeswoman for the insurer.

But those explanations don’t satisfy Kruzic, a consulting geologist: “Receiving an invoice two years after service wouldn’t be a good idea in any other industry. We could never contact a client two years after completing a project and say, ‘By the way, we missed that charge.’

“How could this be considered anything other than surprise billing? » he added.

The federal No Surprises Act does not protect against all types of medical bills that patients find surprising. It primarily protects patients from out-of-network charges when they go to an in-network hospital or in case of an emergency.

But when it comes to medical billing, what’s legal and what’s reasonable are two very different questions.

“The bill certainly seems outrageous,” said Maxwell Mehlmen, co-director of the Law-Medicine Center at Case Western Reserve University School of Law. “The question is whether it’s legal.”

That, he said, “is a matter of state law and the terms of the insurance policy and the agreement between the hospital and the insurer.”

In Colorado, there are numerous regulations regarding the amount of time healthcare providers have to file a claim and bill a patient. For example, Medicaid patient claims must be filed within 120 days of the date of service. For patients with private insurance, conditions may be specified in their insurers’ contracts with individual providers.

If a hospital submitted a proper claim and the provider and insurer made payment in good faith, then a patient may be billed for their share of the costs years later.

The resolution

Hours after KFF Health News contacted the hospital’s media relations department for this story, Kruzic received a call from a hospital manager telling him his bill had been adjusted to zero.

Blaming administrative changes at the insurer, Radford Foster of CommonSpirit said UnitedHealthcare took so long to properly pay the bill that the hospital could not collect from the patient. She said Kruzic’s statement balance “was supposed to be adjusted to zero, but due to a clerical error, a statement was mistakenly sent to the patient.”

UnitedHealthcare’s Landree said that “given the significant delay, we are addressing this issue directly with the doctor’s office.”

“Mr. Kruzic will not be responsible for any additional costs related to this bill,” she said.

Takeaways

KFF Health News’ “Bill of the Month” series receives complaints every year about phantom bills – bills that arrive long after a service is rendered.

Sometimes it’s because the insurer and hospital are arguing over payment and the patient’s liability — usually a percentage of that amount — can’t be calculated until the dispute is resolved. Other times, insurers check old bills and, determining they were overpaid, attempt to recoup the money, resulting in the patient (or even their surviving spouse) being billed the difference.

For now, the legality of billing long after treatment depends primarily on the fine print of insurance contracts.

The fact that an insurer states that a claim has been “processed” does not mean that the insurer has agreed to pay and the bill has been settled. It could also mean that the insurer balked at paying the bill or refused to pay altogether.

As for Kruzic and his affinity for hot peppers? He said he still likes spicy food, but that in his cooking, “I won’t use scorpion peppers anymore.”

Bill of the Month is a participatory survey conducted by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers reduce their medical bills, and it has been cited in states, at the U.S. Capitol, and at the White House. Do you have a confusing or scandalous medical bill you want to share? Tell us about it!