Get on the chopper, or else!
June 18, 2010 9:22 AM   Subscribe

My friend was strongarmed into an unnecessary medevac flight, and is now stuck with a $17,000 bill. Is this common, and does he have any recourse?

My friend (I'll call him Q) crashed his motorcycle a few weeks ago. As he puts it, “ I had too much speed and not enough talent.” Q went off the road and splatted into the hillside. He immediately got up and started removing his helmet and jacket; he knew he'd broken some ribs and didn't want the paramedics to cut his kit off.

Eventually, an ambulance arrived. Q doesn't have health insurance, and informed the paramedics of this. They asked him where he wanted to go, and that Podunk Regional Hospital was closest. Q said, “Podunk it is, then.”

The ER at Podunk examined him and determined that he'd broken six ribs and bruised a lung. There's no treatment for broken ribs except painkillers, as broken ribs are very painful (DON'T SNEEZE!) but you can't cast them. They asked Q if he had someone who could come pick him up. Q said sure and called his best friend. Best Friend was 10 minutes away from Podunk Hospital (after an hour's drive) when the staff at Podunk ER told Q that he needed to be flown via helicopter to University Hospital's Trauma Unit for evaluation for a punctured lung. Q reminded the ER staff that he didn't have insurance and that moments ago they had been willing to shake him loose into Best Friend's Mini Cooper. They insisted he go by chopper and threatened to withhold any prescriptions for painkillers if he refused the airlift.

Q took the chopper ride. He arrived at University Hospital and waited twelve hours to be examined by a doctor. (University Hospital is in a small city where a 12-hour wait for walk-in ER services would be shocking.) When he finally was examined, the docs confirmed that he had six broken ribs and a bruised lung.

Yesterday Q received a bill for his helicopter ride: $17,000 and change. Given that the necessity of this service is highly questionable, does Q have any recourse? Threatening to withhold palliative care seems unethical – is it, or is this SOP when a doc wants you to do something you don't want to do? Short of hiring a lawyer, is there anything Q can do?

This lengthy drama is playing out in Tennessee, USA, and I swear on my copy of Infinite Jest that I am not Q. Also, it would not be helpful to chastise Q for riding a motorcycle without health insurance. Like I said, this ain't me and that was not my choice to make.
posted by workerant to Grab Bag (25 answers total) 4 users marked this as a favorite
who would he be suing if in fact there was a punctured lung? Its not like the doctor is trying to screw him.
posted by H. Roark at 9:26 AM on June 18, 2010 [2 favorites]

I can only thing of four flavors of recourse: (a) call the hospital billing department and try to argue your way out of the bill; (b) call consumer protection-type agencies, such as your state attorney general's office and/or perhaps the department that handles hospital and try to get some help; (c) sue!; (d) just not pay and make collection difficult. I think you would want to start with (a) and (b).
posted by Mid at 9:35 AM on June 18, 2010

By the way, sorta in defense of the hospital, I am sure there is some policy or protocol that says vehicle crash + possible lung puncture = fast ride to trauma unit. When they don't do that and someone dies as a result, it's a malpractice suit.
posted by Mid at 9:37 AM on June 18, 2010 [4 favorites]

I don't think he will get out of the bill.

However, I do think you can work with the company to get the bill reduced. Just call the company directly and explain that you do not have insurance. They handle this all the time. The $17K price is for insurance companies to pay; he will not be expected to pay that amount. (my insurance company paid that amount, flat, when I needed a chopper-- it was the only part of my health care bills that had a no questions asked about it.)

Your friend needed medical help. His doctors gave him the best advice they could. He listened. Tell your friend to advocate for health insurance reform as he begins to repay his bills, and to thank his lucky stars that he didn't need anything more expensive. I wish him best of luck with this struggle; I understand it will be difficult.
posted by samthemander at 9:41 AM on June 18, 2010 [2 favorites]

I would recommend contacting an attorney for a free consultation. The threat to withhold treatment if he didn't submit to the helicopter ride raises all kinds of questions for me. There may be some legal issues here.

I also wonder if the doctor who foisted the helicopter ride doesn't take a cut from the helicopter company, which may raise other legal issues. There are lots of fairly sketchy medevac companies, and there's not a whole lot of evidence that using them actually improves outcomes, especially in cases where a regular ambulance is available and the origin and destination are connected by a reasonable road. I would not be surprised if they resorted to a kickback mechanism for doctors.
posted by jedicus at 9:53 AM on June 18, 2010 [3 favorites]

Second the recommendation for a free consultation.

I also doubt either the "best advice" or "some policy or protocol" will ever include threatening to withhold treatment. That seems the core of the issue. Even if it were the best advice -- the best advice often being coercive -- given the spacing of events, it seems more that they were coercing him primarily in an attempt to cover their ass, and only secondarily in an attempt to act in his best interest.
posted by astrochimp at 9:56 AM on June 18, 2010

Threat: "Get in the chopper or I'm going to stop treating you and let you die."

Responsible practice of medicine: "You need to get in the chopper. As a medical professional, I can't just write you a prescription for painkillers and let you leave without first knowing how bad your lung is damaged. Not only is it bad medicine, but my license and property is on the line if your lung damage ends up killing you in three days. I can't trust that you'll come back if you experience further symptoms or these symptoms don't go away with time because you've already exercised the poor judgment of riding a motorcycle without health insurance and then trying to leave when you could be seriously injured."
posted by lockestockbarrel at 10:03 AM on June 18, 2010 [21 favorites]

I also doubt if he will get out of the bill--I would think that making a serious effort to negotiate in good faith with the air ambulance company is his best strategy. He consented to the trip and that is pretty much it. If he felt under duress because of the apparent threat of withholding pain medication he could have simply declined the pain medication and got it asap in his local community. They may have declined giving pain medication, without a thorough exam by a specialist, as some pain medications suppress respiration or could mask dangerous turns in his condition, e.g. a spontaneous pneumothorax or other life threatening conditions.

I am sure he is chastising himself for not having health insurance, assuming it is available for him, so I will not do it. But riding beyond his capabilities is inexcusable as it not only threatens his well being but others.
posted by rmhsinc at 10:04 AM on June 18, 2010

Having pinned questionable intent on the doctors in previous advice, how do we exempt Q from the same? Perhaps he is generating this quote to try to get out of the $17,000 bill?
posted by leafwoman at 10:05 AM on June 18, 2010

They insisted he go by chopper and threatened to withhold any prescriptions for painkillers if he refused the airlift.

If true, your friend has a lovely malpractice suit on his hands.

Responsible practice of medicine: "You need to get in the chopper. As a medical professional, I can't just write you a prescription ... "

This is responsible, yes, but the situation you're describing is why you have "discharge against medical advice" standards and policies to limit liability.

It really all comes down to what was actually said, which none of us really know. Consultation with a lawyer is advised here.
posted by Cool Papa Bell at 10:18 AM on June 18, 2010 [2 favorites]

lockestockbarrel: I'd agree on the "responsible" part, but sometimes there's a clear line between what is responsible and what is legal. Put otherwise: free and informed consent is a pretty good thing to have in medicine -- so good, in fact, that we'd do well not to toss it out the window any time the possibility of serious consequences arises.
posted by astrochimp at 10:18 AM on June 18, 2010

I have a friend who is an ER doc. He said that they charge so much because so many people don't pay. He gets a fee for every day someone he admitted is hospitalized, even if he never sees them again. An ex-girlfriend still gets bills here for an ambulance ride more than a decade ago.

Since they do have trouble collecting, they may negotiate down.
posted by StickyCarpet at 10:20 AM on June 18, 2010 [1 favorite]

I'd be surprised if the medevac charge is negotiated down right away. It will probably need to go to collections and hang out there first for a while.

Has Q looked into filing a claim against his auto insurance for this accident? I would start there.
posted by FergieBelle at 10:23 AM on June 18, 2010

Is there no health coverage on his vehicle insurance? Just checking...
posted by galadriel at 10:25 AM on June 18, 2010

I think he's stuck with this bill. I was in a motorcycle accident once without health insurance, and was later sued by the ambulance company for nonpayment. Finally had to pay it off when I went to buy a house -- there was nothing I could do.
posted by M.C. Lo-Carb! at 10:35 AM on June 18, 2010

the threat of withholding treatment sounds really fishy to me and I would question this really happened. but that's for a lawyer to dissect. do consult one.

as far as the punctured lung goes: wasn't the original hospital able to diagnose that? how come he was flown to another joint and then had to wait twelve hours for treatment? usually helicopter patients are an absolute priority, so what did those guys already know that your friend did not?
posted by krautland at 10:44 AM on June 18, 2010

To answer a few questions: I posted this because I'm curious about his situation. Q is fully resigned to negotiating down and then paying all the bills associated with this incident, so I think we can give him a pass on specious motives.

Very few (or no?) motorcycle insurance policies cover medical expenses.

I guess that's the crux of my question: is it kosher to withhold palliative care to a person who checks himself out against medical advice?
posted by workerant at 10:49 AM on June 18, 2010

One more followup: the threat to withhold treatment really happened. Best Friend witnessed it.
posted by workerant at 10:50 AM on June 18, 2010

I am totally NAD, but don't most painkillers have the possibility of depressing respiration? Which could be pretty bad if there were lung damage?
posted by Addlepated at 10:51 AM on June 18, 2010

I have two stories for you of my own examples with this kind of thing.

1.)When my daughter was barely a year old she got really sick with the flu. We took her to the hospital because I was worried that she might get dehydrated when the puking was joined by very loose bowels.

When we got to the hospital we were told that yes, she was getting dehydrated and that it was dangerous for someone her size and age because her blood sugar could get messed up and lead to seizures. The hospital told us that they didn't have the proper resources to treat her since there is a world renowned children's hospital less than a half an hour away (10 minutes by ambulance, much less by helicopter.) We were told that the fluid they gave her would stabilize her but that she should go to the other hospital by ambulance. We asked if we could just take her in our car since it was so close and it was the middle of the night so we were not going to be dealing with any traffic. The doctor was reluctant, but since she was stable he allowed it. He drilled it into our heads that we should go straight to the other hospital and that it was literally a matter of life and death. He also called the other ER and told them we were coming. When we got there they took us right in and got her hooked up to the I.V. (the other ER left the catheter in her arm so it was a very simple matter.) The trip took less than 20 minutes.

2.) When I was pregnant with my second child I went into very early labor. I went to the hospital and after being examined they determined that it was very likely that the baby was going to be born that night. The pregnancy was far enough that they would try to save him but he would be severely premature. I was told that I needed to be sent to the University hospital attached to the same children's hospital so that he would be able to get the best care.

They told me I would have to be sent in the helicopter and I pitched a fit. I did not want to go in the helicopter when we'd already driven ourselves with my daughter.

When the helicopter crew got there I told them that I would agree to an ambulance, but not the chopper. The nurse explained to me that there was only one crew to deal with my situation. A nurse to deal with preterm labor, and a nurse that specialized in very premature babies. She told me that the reason I had to go in the helicopter was that they needed to get me to the hospital quickly in case there was another woman who needed them. They needed to be ready for the next patient. I don't know if this is just something they told me to shut me up, but it made sense at the time so I went along with it.

The reason I'm telling you these long stories is to illustrate 1.) they could have let him go with his friend if he really was stable and 2.) maybe there were other reasons why he needed to go by helicopter that he didn't know about. I agree that it seems fishy that the doctor would withhold the prescription, but maybe they really felt he needed more care and that was the bargaining chip that they used. Personally I prefer to get the straight answer, but maybe they felt that your friend wouldn't cooperate without drastic measures.

I think he can try a consultation with a lawyer and he can try to negotiate with the company, but I don't' think he's going to get out of paying the bill.
posted by TooFewShoes at 10:52 AM on June 18, 2010

I think it's also worth pointing out that hospitals tend to lose money on helicopters. Survival flight is a prestige thing, though, so everyone wants 'em. Some hospitals may be inclined to use them more often than strictly necessary in order to up their utilization.

Just saying.
posted by pjaust at 11:12 AM on June 18, 2010

You've had some good advice above and also some bad advice. As a flight physician (I staff a medical helicopter), here is what I can add:

- 6 broken ribs and a bruised lung is a SERIOUS injury. Discharging your friend from Podunk would have been malpractice. It was the most responsible thing to do to transfer him to University Trauma for further care. Podunk did the right thing. Whether he needed helicopter transport or not, I can't judge. You didn't say how long it would take to get to University by ground transport, which is a crucial part of the story. You imply that since friend was a few minutes away in the car, friend could have picked him up and brought him - that would have been very inappropriate. The only appropriate options are transfer by ground with a paramedic crew or transfer by air. If a ground paramedic crew is not available in a timely fashion, the patient should be transferred by air.

- Yes, there is no treatment for broken ribs like a cast or splint, but when there are multiple broken ribs and/or lung bruising, that raises the risk for respiratory failure and other complications. Also, when you have many broken ribs, it becomes so painful to breathe that people take smaller breaths and do not fully inflate their lung, which puts them at risk for pneumonias. I've asked my trauma surgeon whether a patient with even two broken ribs should be able to be discharged (that is without lung bruising) and he said "technically, they should ALL be admitted to the hospital overnight." (you'll also see this in the eMedicine link I posted) Your post implies that you and your friend do not realize the severity of his injury and that is why I stress the point.

- Your friend may feel frustrated now, that he turned out to be OK and has a big medical bill. However, he should thank his lucky stars that he did not decompensate and start to die at Podunk Hospital. With such a serious injury, this could have happened, and a place like that does not have the staff or the resources to deal with major trauma victims. It could have been a lot worse!

- In case people are curious, a standard 15 minute roundtrip flight on the helicopter costs about $7000-$10,000 at my facility. I see the bills on every patient. Longer flights up to 1 hour can be twice as much (most of the cost is built in as soon as you lift off the ground). So the bill that Q received is not unusual to my eyes.

- I doubt that your friend waited 12 hours to be seen by a doctor. I cannot speak for random hospitals, but every trauma center that I've been to has a trauma team waiting for the helicopter (or ambulance) when they arrive. As the patient gets unloaded, the trauma team receives a report from the helicopter team, and does things like cut the patient's clothing off, examine them head to toe, and start ordering x-rays. Like I said, I deliver patients to about 3 or 4 different trauma centers, and I have never dropped a patient off without giving a signout directly to a team that is evaluating the patient while I drop them off. Your friend probably didn't realize that certain people were doctors. I get confused for a nurse or a tech or some other staff member all the time because we all just tend to wear regular scrubs in the ER. Even when we introduce ourselves as 'doctor', people are usually under a lot of stress and it is hard for them to process the info.

- Final note, yes, it is inappropriate to threaten to withhold medication if the patient doesn't follow your treatment plan. Your friend can write a note to Podunk and reprimand the staff there, but seeing as the actual outcome of having pain medications purposefully withheld did not take place, it doesn't sound like there'd be any sort of lawsuit there. I do know of a bunch of instances of doctors using pain medications as a sort of bribe to get patients to do the right thing for themselves. Honestly I've been tempted to do it myself, because people care about their pain but they don't always care about their health in general and whether they are about to do something to put their own life in danger. Anyway, even if a patient is about to make a stupid decision about their health, like refusing treatment for a life-threatening condition and walking out of the hospital, it is most appropriate for the physician involved to give the patient the best follow-up, discharge instructions, and outpatient treatment that they can arrange, partly because it's the best thing for the patient, and partly because when that person drops dead the next day, in court they will be able to show that they still cared and tried to do their best for the person despite the person's refusal of treatment.
posted by treehorn+bunny at 11:13 AM on June 18, 2010 [38 favorites]

He should try to negotiate the bill. Insurance companies do it all the time. I am lucky enough to have insurance, but here is an example of the negotiations between a hospital and insurance company.

Lower abdominal pain with fever, went to ER, was admitted after CT scan showed ruptured diverticulitis.Was in the hospital for a total of 5 days.

Hospital bill $36,164.07
Insurance "discount" $29,816.07
Insurance paid $5,448.00
I paid $900

So, they will reduce the bill. Don't just ignore the bill, call them and plead your case. They would rather get something rather than nothing.
posted by JujuB at 11:55 AM on June 18, 2010

Lesson: ALL motorcyclists should have MedPay on their motorcycle insurance. Even if you have medical insurance (but especially if you don't), MedPay will go a long way to limiting out-of-pocket expenses.

Your friend needs to talk to a lawyer, stat.
posted by coolguymichael at 11:57 AM on June 18, 2010

Building on what coolguymichael said, I have no idea whether Tennessee is a no-fault insurance state, but there may be benefits available to Q through his insurance on his motorcycle. He should check his policy or talk to a personal injury lawyer.*

*even though it doesn't seem like there's anyone to sue on an at-fault (tort) claim, a personal injury lawyer would have the familiarity with the insurance regime and they usually give free consultations.
posted by AV at 1:26 PM on June 18, 2010

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