She expected to pay $150. She ultimately owed $641.60

VIRGINIA BEACH

Mary Ann Dockter was sure it had to be a typo.

She had an epidural done for back pain in April 2006. A couple of weeks later, she got a bill from Sentara Healthcare for $753.95. She figured that once it was processed by Cigna, her health insurance carrier, she’d be on the hook for 20 percent of that and expected to pay $150 or so.

A while later, Dockter learned that Cigna had paid $2,166.40 to Sentara for the $754 charge but that she, somehow, still owed $641.60.

“I said, 'Something’s wrong. This is just kind of screwy,’” Dockter said.

After repeated calls to Sentara and Cigna, she said, she was assured that, no, everything was as it should be.

Except for Sentara and Cigna, “everyone we’ve talked to said it doesn’t make sense,” said Gerry Wardzinski, Dockter’s husband. “How can you get more money than what you billed and expect us to pay on top of it?”

So Dockter and Wardzinski refused to pay the bill. It wasn’t the money – the comfortably retired couple could afford it – it was the principle of the thing, they said.

Eventually, Sentara sued Dockter for nonpayment, and on Thursday, she was in Virginia Beach General District Court.

“I thought there was a mistake, and I tried to solve that mistake … for two years,” Dockter told the judge. “I just assumed there’s a mistake because this was way out of line for a $700 procedure.”

In court, Sentara’s lawyer Robert Bray explained how it worked out that Dockter owed what she owed.

Health systems have contracts with insurers about what the insurer will pay for a given procedure. While the specifics are confidential, Cigna’s contract with Sentara allowed for a “case rate” to be applied. In Dockter’s case, that meant the epidural injection she received was part of a group of outpatient surgeries that were all covered at the case rate of $2,808.

Presumably, while the $753 charge for Dockter’s epidural was only a fraction of the case rate, there are other, more involved procedures that Sentara would bill significantly more for. Regardless, Cigna would pay $2,808 and, in theory, it all comes out in the wash in the long run.

In Dockter’s explanation of benefits from Cigna, it shows that a $100 deductible was subtracted from the $2,808. Then Cigna paid 80 percent of the remaining $2,708, or $2,166.40.

Dockter’s policy with Cigna included a coinsurance payment, so what she owed to Sentara was then 20 percent of $2,708 – or $541.60 – plus the $100 deductible. That totals $641.60.

Back in 2006, Dockter was expecting to pay 20 percent of Sentara’s $753.95 bill, but instead, she was responsible for paying 20 percent of the contracted amount between Sentara and Cigna.

Dockter and Wardzinski said they understood Sentara’s argument but thought it was wrong and ought to be fought.

“Gerry says not to use the word 'moral,’ but it’s a moral issue to me,” Dockter said.

On Thursday, the judge ruled for Sentara and directed Dockter to pay the bill. After the judgment, Dockter, Wardzinski and Bray – who is Sentara’s chief collection counsel – worked out what was owed for the original epidural and others she’s had since then. Dockter wrote a check to Sentara. Bray then arranged to have the judgment against her vacated so that it wouldn’t show up on her credit history.

Bray said he understood how Dockter and Wardzinski felt.

“It would be frustrating for me if I were in their shoes,” Bray said.

Occasionally, once everything is sorted out between the provider and the insurer, it can have “unexpected consequences for a patient,” he said. “It’s difficult to get a good grasp on what it’s going to cost.”

Bray said he thought he had an ethical obligation to collect what was owed to Sentara from people who are able to pay – in part to help pay for charity or discounted care for patients who are unable to pay the full price.

Dockter’s situation is unusual in that, normally, insurers don’t pay more than the billed charges and often pay less, said Emma Inman, a spokeswoman for Sentara. She added that patients can call the health system to find out what their expected out-of-pocket costs would be for a given treatment. But, she said, the best source for insured patients is to call their insurance carrier, which should be able to give a better estimate and also compare costs among providers.

Cigna did not return two phone calls Friday.

Dockter turned 65 recently and will now be covered by Medicare, which she presumes will not pay so much for an epidural. Court decision aside, she’s happy to be done with the matter.

“This has been an annoyance.”

Nancy Young, (757) 446-2947, nancy.young@pilotonline.com