ARI SHAPIRO, HOST:
We are watching a lot of Olympic dreams play out this week. Of course, many athletes' dreams ended in injury before the Tokyo Games, and one of those stories resulted in our Medical Bill Of The Month. Dr. Elisabeth Rosenthal from our partner Kaiser Health News is here to tell us about it. We want to warn listeners, it does include a vivid description of an injury. And Dr. Rosenthal, welcome. Who are we meeting today?
ELISABETH ROSENTHAL: We're meeting Phil Gaimon. He's a bicycle racer from Southern California, and he had a shot at being on Team U.S.A. for track racing events that start next week, but a really rough crash ended his Olympic journey and cost him a lot.
SHAPIRO: All right. Well, reporter Stephanie O'Neill caught up with Phil Gaimon. So let's listen to the story, and then we'll talk about it.
STEPHANIE O'NEILL, BYLINE: Former pro cyclist Phil Gaimon retired at age 30 into a comfortable career as host of his own YouTube channel. It features his passion for hill climbing, which is all about stamina and speed while cycling uphill. So it surprised him a couple years later when the U.S.A. cycling coach asked him to consider competing in the Tokyo Olympics. Gaimon was a road racer. They wanted a track racer. But he thought, why not try?
PHIL GAIMON: So just for a YouTube video, I went to the track in Los Angeles and, like, did a test. And what I didn't realize was, like, I've gotten a lot faster than I was last time I raced the track when I was 22.
(SOUNDBITE OF ARCHIVED RECORDING)
UNIDENTIFIED PERSON: Go. Go. Go. Go.
O'NEILL: He memorialized the moment in this video posted on his YouTube channel.
(SOUNDBITE OF ARCHIVED RECORDING)
UNIDENTIFIED PERSON: Woo (ph). Four-thirty, baby - 4:30, 4:30.
GAIMON: Yes.
O'NEILL: Gaimon's time was fast enough to have won a silver medal at the prior year's Nationals competition.
GAIMON: It was really exciting. It was just like, oh, look, like, the Olympics is on the radar all of a sudden, which is, of course, like, always a dream for every athlete.
O'NEILL: But then came the crash. It happened during a Pennsylvania competition, when another cyclist bumped into Gaimon as they raced around the steeply banked velodrome track.
GAIMON: The best I can figure out is they kind of hit my handlebars with their body or something and just turned my front wheel sideways, going full speed - so going probably close to 40 miles an hour.
O'NEILL: The crash left him with a partially collapsed lung, 11 broken bones, including a severe shoulder blade fracture. An ambulance rushed him to a nearby hospital, where doctors admitted him and surgically repaired his broken collarbone the next day. But his shoulder blade required a specialist.
GAIMON: So my shoulder blade was like a taco. And that was kind of the tricky part. So he wasn't able to operate on that.
O'NEILL: For three days, he says, he waited in severe pain for a qualified surgeon. On the fourth day, with a specialist still not available, he was discharged. Gaimon couldn't imagine flying home to LA in such pain to have the surgery, so with help from his mom and agent, he found a surgeon in nearby New York.
GAIMON: I was pretty mad because in my head I'm like, why am I better at your job of finding a surgeon than you are? You know, I shouldn't have been in that much pain for those days.
O'NEILL: But a far worse pain, he says, came later with the massive bills. Neither hospital was in his insurer's network. The first hospital billed more than $150,000. Health Net, his insurer, paid a small fraction of that bill, leaving Gaimon owing more than a hundred grand. The second hospital charged nearly 50,000, and Health Net refused all of that bill.
GAIMON: Someone at Health Net explained that, yeah, we're not covering this procedure because it was outpatient, it was voluntary. And I was like, what do you mean outpatient? I was there for a night. And what do you mean voluntary? Like, that was not an option to not have that surgery.
O'NEILL: He had backup insurance from U.S.A. Cycling, which paid the second hospital, but that coverage maxed out at $25,000. Phil Gaimon says after spending hundreds of hours on the phone and writing letters to no avail, he's now fielding about five phone calls a day from an assortment of debt collectors with no end in sight. For NPR News, I'm Stephanie O'Neill.
SHAPIRO: Wow. So not only was his Olympic dream dashed, but he ends up with this nightmare of medical debt - more than $200,000 dollars - even after his two insurance policies had already paid tens of thousands of dollars. Dr. Elisabeth Rosenthal, help us understand what's going on here.
ROSENTHAL: Yes, he owes that much after both plans paid. And he says he could sell his house and pay the bills, but he doesn't think he should have to. And I agree with him.
SHAPIRO: Yeah. Why is he facing this massive bill?
ROSENTHAL: Well, Phil hit a trifecta of billing landmines. He went to two hospitals that feature high charges. Both were out of network. And here's what's really important, in his case. He had insurance based in California, but his treatment was out of state. So some protections that would have applied at home just didn't apply in Pennsylvania and New York.
SHAPIRO: Why isn't this covered by those surprise billing laws that are supposed to protect patients from excess charges after their insurance pays?
ROSENTHAL: Yeah, you would think so, wouldn't you? More than 30 states have passed surprise billing laws, including California, in the last five years. And a federal law goes into effect next year - too late for Phil. But they vary a lot and are filled with booby traps, and he hit a really bad one. One state has no way to sanction or regulate doctors and hospitals in other states, so Phil's plan through California didn't protect him from providers' extra bills - so-called balanced billing - in either Pennsylvania or New York.
SHAPIRO: And what about the extreme cost? Those bills are just so high.
ROSENTHAL: Yeah, they're many multiples of what it actually costs the hospitals to perform the treatment, and much more than Medicare would pay. Hospitals in the U.S. can charge whatever they like, though. It's legal, but that doesn't make it fair.
SHAPIRO: So is there anything he can do?
ROSENTHAL: Yeah, I think he can and should try to argue that the surgery at the second hospital was part of the emergency, since the first hospital couldn't perform it. And it would be nice to see hospitals honoring the new law before 2022, when they have to. But that law has a gaping loophole too. It doesn't protect against those often thousands of dollars charged for the short, out-of-network emergency ambulance ride to the hospital.
SHAPIRO: That's Elisabeth Rosenthal of Kaiser Health News. Thanks as always.
ROSENTHAL: Thanks for having me. Unfortunately, bad billing makes for good stories.
SHAPIRO: And we'll look forward to another one next month. If you have a medical bill keeping you up at night, please go to NPR's Shots blog and send it to us.
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