It was the primary day of her family’s vacation within the San Juan Islands last June when Danielle Laskey, who was 26 weeks pregnant, thought she was leaking amniotic fluid.

A registered nurse, Laskey called her OB-GYN back home in Seattle, who said to hunt immediate care. Staff members at a close-by emergency department found no leakage. But her OB-GYN still desired to see her as soon as possible.

Laskey and her husband, Jacob, made the three-hour trip to the Swedish Maternal & Fetal Specialty Center-First Hill. Laskey had sought the clinic’s specialized look after this pregnancy, her second, after a dangerous complication along with her first: The placenta had develop into embedded within the uterine muscles.

Back in Seattle, doctors on the clinic found Laskey’s water had broken early, posing a serious risk to her and the fetus, and ordered her immediate admission to Swedish Medical Center/First Hill. She delivered her son after seven weeks within the hospital. Though she was treated for multiple postpartum complications, she was well enough to be discharged the subsequent day. Her son, who’s healthy, went home a month later.

Laskey soon developed a fever and body aches, and she or he was told by her OB-GYN to go to Swedish’s emergency department. She said doctors there desired to admit her when she arrived Aug. 20 and scheduled a procedure for Aug. 26 to remove a fraction of placenta that her body had not eliminated by itself.

Laskey, who had already spent weeks away from her 3-year-old daughter, selected to go home. She returned for the procedure, which went well, and she or he was home the identical day.

Then the bills got here.

The Patient: Danielle Laskey, 31, was covered by a state-sponsored plan offered by her employer, a neighborhood school district, and administered by Regence BlueShield.

Medical Service: In-patient hospital services for 51 days, plus a one-day stay that included a second placenta removal procedure.

Service Provider: Swedish Medical Center/First Hill, a part of Windfall Health & Services, a big, nonprofit, Catholic health system.

Total Bill: Swedish, through Regence, billed about $120,000 in cost sharing for Laskey’s initial hospitalization and about $15,000 for her second visit and procedure.

What Gives: The specialized clinic caring for Laskey before her hospital admission was in her insurance plan’s network. The clinic’s doctors admit patients only to Swedish Medical Center, one in every of the Seattle area’s only specialized providers for Laskey’s condition — which, on condition that connection, she assumed was also within the network.

So after being urgently admitted to Swedish, Laskey believed her bills can be largely covered, with the couple expected to pay $2,000 at most for his or her portion of in-network care due to her plan’s out-of-pocket cost limit.

It turned out Swedish was out of network for Laskey’s plan and, at first, Regence determined that Laskey’s hospitalizations weren’t emergencies. In November, a Regence case manager initially told Jacob that Laskey’s lengthy hospitalization was an emergency admission and out-of-network charges wouldn’t apply. But then she called back and said the costs would apply in any case, because Laskey had not are available through the emergency department.

Each Washington state and federal laws prohibit insurers and providers from billing patients for out-of-network charges in emergency situations. The couple said neither Swedish nor Regence told them before or throughout the two hospitalizations that Swedish was out of network, and that they never knowingly signed anything agreeing to just accept out-of-network charges.

Jacob, who works as a psychiatrist at a unique hospital, said he mentioned the surprise-billing laws to the case manager, but she replied that the laws didn’t apply to his family’s situation.

It was only after Regence was contacted by KHN that the insurer explained its reasoning to the reporter: Regence said the Swedish hospital, while out of network for Danielle, had a broader contract with the insurer as a “participating provider” and so the insurer was not in violation of surprise-billing laws by approving Swedish’s out-of-network coinsurance charges.

The broader contract allowed Swedish to bill members of any Regence plan who receive out-of-network services there 50% coinsurance — the patient’s portion of the general cost the insurer allows the provider to charge — with no out-of-pocket maximum for the patient.

What is the difference between a hospital that is “in network” and one which’s a “participating provider”? On this case, by contracting with Regence as an out-of-network but in addition participating provider, Swedish straddled the road between being out and in of network — designations that traditionally indicate whether a provider has a contract with an insurer or not.

Setting the terms with an insurer for providing its members emergency or other care appears to permit hospitals to sidestep recent surprise-billing laws that prevent out-of-network providers from charging high, unpredictable rates in emergencies, based on government and private-sector medical billing experts.

Experts said they’d not heard of out-of-network providers evading surprise-billing laws by being contracted as “participating providers” until KHN asked about Laskey’s case.

Ellen Montz, director of the Center for Consumer Information and Insurance Oversight on the Centers for Medicare & Medicaid Services, said that under the federal No Surprises Act the definition of a “participating” emergency facility that’s subject to the law’s surprise billing protections will depend on whether the ability has a contract with the insurer specifying the terms and conditions under which an emergency service is provided to a plan member.

Matthew Fiedler, a senior fellow on the University of Southern California-Brookings Schaeffer Initiative for Health Policy who studies out-of-network billing, said Laskey’s case seems to fall right into a “weird” gray area of the state and federal laws protecting patients from out-of-network charges in emergency situations.

If there had been no contract between Regence and Swedish, the laws clearly would have prohibited those charges. But since there was a contract specifying a 50% coinsurance rate when Swedish was out of network for a selected Regence plan, those laws legally may not apply, Fiedler said.

After he declined to use for the hospital’s financial assistance program, Jacob said Swedish also notified the couple in November that they’d two months to pay or be sent to collections.

Natalie Kozimor, a spokesperson for Windfall Swedish, said the hospital disagreed with “a number of the details and characterizations of events” presented by the Laskeys, though she didn’t specify what those were. She said Swedish assisted Danielle along with her appeal to Regence.

“We had no luck with Swedish taking any role or responsibility with regard to our billing or advocating on our behalf,” Jacob said. “They mainly just referred us to their financial department to place us on a payment plan.”

The Resolution: In December, the couple appealed Regence’s approval of Swedish’s out-of-network charges for the 51-day hospitalization, claiming it was an emergency and that there was no in-network hospital with the expertise to treat her condition. Additionally they filed a grievance with the state insurance commissioner’s office.

The office told KHN that the “participating provider” contract doesn’t override the laws barring out-of-network charges in emergency situations. “Danielle had an emergency and Regence acknowledges it was an emergency, so she can’t be balance-billed,” said Stephanie Marquis, public affairs director for the Washington state Office of the Insurance Commissioner.

On Jan. 13, Regence said it could grant the Laskeys’ appeal to cover the primary hospitalization as an in-network service, erasing the largest a part of Swedish’s bill but still leaving the family on the hook for the $15,000 bill for Danielle’s second visit and procedure.

On Jan. 27, two days after KHN contacted Regence and Swedish about Danielle Laskey’s case, a Regence representative called and informed her that her second hospitalization also can be reclassified as an in-network service.

Ashley Bach, a Regence spokesperson, confirmed to KHN that each stays now will likely be covered as emergency, in-network services, eliminating Swedish’s coinsurance charges. But in what appears to be contrary to the insurance commissioner’s stance, he said the bills had not violated state or federal laws prohibiting out-of-network charges in emergency situations due to the contract with Swedish covering all its plans.

“Under the Washington state and federal balance-billing laws, the definitions of whether a provider is taken into account in network hinges on whether there may be a contract with a selected provider,” Bach said.

The Takeaway: Greater than a 12 months after the federal surprise-billing law took effect, patients can still get hammered by surprise bills resulting from health plans’ limited provider networks and ambiguities about what is taken into account emergency medical care. The loopholes are on the market, and patients like Laskey are only discovering them.

Washington state Rep. Marcus Riccelli, chair of the House Health Care and Wellness Committee, said he’ll ask the state’s private and non-private insurers what steps they might take to avoid provider network gaps and out-of-network billing surprises like this. He said he may also review whether there may be a loophole in state law that should be closed by the legislature.

Fiedler said policymakers need to think about addressing what looks like a serious gap in the brand new laws protecting consumers from surprise bills, because it’s possible that other insurers across the country have similar contracts with hospitals. “Potentially this can be a significant loophole, and it isn’t what lawmakers were aiming for,” he said.

Congress may need to repair the issue, for the reason that federal agencies that administer the No Surprises Act may not have authority to do anything about it, he added.

Bruce Alexander, a CMS spokesperson, said the Departments of Health & Human Services, Labor, and Treasury are looking into this issue. While the agencies cannot predict whether a recent rule or guidance will likely be needed to handle it, he said, “they continue to be committed to protecting consumers from surprise medical bills.”

Within the meantime, patients, even in emergencies, should ask their doctors before a hospital admission whether the hospital is of their plan network, out of network, or (look ahead to these words) a “participating provider.”

Because the Laskeys discovered, hospital billing departments may offer little assist in resolving surprise billing. So, while it’s price contesting questionable charges to the provider, it’s also often an choice to quickly appeal to your state insurance department or commissioner.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you may have an interesting medical bill you ought to share with us? Tell us about it!

This text was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.