The NPR Bill Of The Month series hit this one right on the head. I know I have poked fun at this series in the past, but that was mostly because Max OOP insists on a level of thoroughness that could border on the line of a psychological disorder. Take Midwife Crisis and $5,000 Nitrous as an example. You might need some serious nitrous just to get through it. In the end, just know I support this Bill Of The Month series and what it is trying to accomplish. Their most recent article is a great example and people will learn from it.

In this latest case (Bill Of The Month: Estimate For Cost Of Hernia Surgery Misses The Mark), we have what the Max Out of Pocket crew would consider the model healthcare consumer. This patient was planning to consume a non-emergent healthcare service to repair a hernia. The surgery was set to take place in a hospital. The coding world refers to this specific hernia repair as code 49650 (Laparoscopy, surgical; repair initial inguinal hernia).

From the beginning, the consumer did everything right. I mean with a name like Wolfgang I wouldn’t expect anything less. He waited to have the hernia repair until a year he had a baby knowing he had already met his deductible for the year. He did what I would do and asked what his max out-of-pocket would be for the service. He got a quote and verified that everyone providing services during the surgery would be in-network. He even paid a little of this out-of-pocket upfront before even having the hernia repaired. But all of this still wasn’t enough. The hospital botched the estimate by underestimating his out-of-pocket costs which resulted in a surprise medical bill. This ultimately cost the hospital a $1,600 write-off once reporters started poking around.

I happen to know the hospital still probably made money on the case. They probably even cleared much more cash on it than they would from Medicare for the same service.

Now, the Max Out of Pocket blog will dig even deeper here to make sure we are maximizing our benefit from this unfortunate situation.

On with the hernia repair!

Max Had A Hernia Repaired As A Child

Before we can get to this specific hernia repair, I wanted to mention Max OOP can personally relate to this article. I happened to have a hernia as a child and had it surgically repaired. I am actually fairly certain it was, like this case, an inguinal (groin) hernia repair. Unfortunately, only my mom would know the answer to that, and she is no longer with us. I am going to show the doctor my scar at my free preventive physical exam in October and see if he can verify it. I have no idea how much it would have cost back then or what my mom’s out-of-pocket cost was for the service. It was probably done in the late ’80s or early ’90s. She probably didn’t bother getting an estimate back then, and if she had, they definitely couldn’t provide it. If only she knew I would grow up to launch the Max Out of Pocket blog.  

The Hernia Repair Estimate

So how much should a hernia repair cost when done in a hospital and what are we looking at for our max out-of-pocket? Let me set the stage here a bit.

We have a hospital where the hernia repair will take place, an anesthesiologist to put the patient to sleep, and a surgeon to do the actual repair. All three will have a separate fee and bill.

I am going to do everyone a favor here and completely ignore the anesthesiologist. That service line deserves a post all to itself, and this NPR article doesn’t touch on it much. So for today, we are just going to talk about the hospital (a space to have the hernia repair) and the surgeon (the expert responsible for doing the actual hernia repair). But please, make sure your anesthesiologist is in your insurance network for any surgery.

As for everything else, I am going to refer to the ‘retail price’ (full price) for a hernia repair, the ‘T.J. Maxx price‘ (special insurance discounts) for a hernia repair, and the rock bottom ‘Walmart price‘ that represents what Medicare would pay for this service. All three prices represent the same exact service.

Max is very proud. The model healthcare consumer, in this case, was very proactive and got a cost estimate for the procedure ahead of time. This was huge in making a complaint that ultimately supported a $1,600 write-off for his remaining out-of-pocket at the end of this story. The only suggestion I would have for anyone else is to get a paper or electronic copy of the estimate before the service. That way we have it if we need it. It looks like this patient got the original quote over the phone and then tried to get the billing office to provide it after the fact, but they were unable to produce it for whatever reason.

In my experience, these quotes are a three-step process. The hospital starts by basing its total charge estimate on historical charge averages for other hernia repair cases done in their facility. Let’s peg that retail price average at $20,000. They then apply that charge estimate to the insurance contract to get the special price the insurance company negotiated (in this case Cigna) for said hernia repair. We can put that at $10,000 for example. After that, they try to estimate how much the patient will owe out of that “allowed amount”. This is based on the benefits package unique to the individual patient. In this case, his out-of-pocket would be a 20% coinsurance of the Cigna price for hernia repairs. So we can set that at $2,000 in this simple example. This is a relatively new process and the industry certainly hasn’t perfected it yet.  

The only commentary I have on this is I believe the insurance company should also have some obligation here. After all, they are the ones negotiating on the patient’s behalf to set this special hernia repair price, setting the patient’s benefits, and have the ultimate decision on how much the patient owes. They then leave the hospital and clinics to collect the very balance that they decided should come out of the patient’s pocket. Why doesn’t the insurance company have to collect this balance?

In this case, the retail charge estimate for the hospital was $10,333 and $1,675 for the surgeon.

Estimated Retail Charges For Hernia Repair = $12,008

Retail Charges For Hernia Repair

The actual retail charges for this case are below. It is almost not worth even looking at it since almost no one pays this rate. Even the uninsured are entitled to a discount on this price as mandated by the IRS.

It is almost questionable if the original hospital retail charge estimate only included the operating room time and failed to include the pharmacy items, medical supplies, recovery room, and anesthesia supplies. The line item for the operating room time on his invoice came out to $10,279 and the total estimate wasn’t that far off from that by coming in at $10,333. I can’t be sure with what we have, but if they are going to give this information out they really need to include the procedure and any other ancillary services that come with it. I would love to know what this hospital charges per minute in the OR, since $10,000 seems a little steep for this procedure.

It could also be that they quoted a unilateral hernia repair and since this was bilateral (both sides) the price came in higher. They came up short, regardless, and the actual charges for everything came in at almost $19,000.  

Actual Retail Charges For Hernia Repair = $18,827

Discounted Insurance Sale Price

Hospital charges are basically like the retail price you see at T.J. Maxx – no one ever pays that price. They pay a sale price. This particular patient gets the ‘T.J. Maxx’ discounted rate that was negotiated by his insurance company, Cigna. In this case, I must assume they are paying about 65% of the actual hospital retail charges and not a “per case” or “per hernia repair” rate.

His ‘T.J. Maxx’ sale price for the hernia repair is $10,552 for the hospital and $968 for the surgeon.

Cigna Special Sale Price For Hernia Repair = $11,520

The patient is then on the hook for 20% of this sale price, or $2,304, based on his agreement with his insurance. 

Cigna and other insurance companies don’t want their contracted prices for hernia repairs out there like this for the world to see. There are actually some proposed rules that might make this mandatory come 2020. Things will really get interesting if we can start shopping for hernia repairs and comparing these insurance prices, just like we can for most other products and services when browsing the aisles at T.J. Maxx. I have seen these hernia repairs done in my own market paid for by private insurance for much less than $11,000.

How Much Would Medicare Pay For A Hernia Repair?

With all this talk about Medicare For All, let’s take a quick look at what Medicare would pay for this same exact service for someone in the 65+ age group. Medicare is basically the Walmart of healthcare pricing.

Hospital

Medicare pays most non-rural hospitals an all-inclusive fixed ‘case rate’ amount for a hernia repair. In other words, they don’t care about the hospital retail price, they set the price. They have collected cost data for years and estimated what it should cost to provide a hernia repair. This amount is then adjusted depending on where in the country someone is having the surgery. It costs more to provide this service in a place like Connecticut than it does in North Carolina. Why? Well to start, nurses and employees make more money in a fancy place like Connecticut than they do in North Carolina. So, Medicare adjusts this payment to try and account for that fanciness. The unadjusted national hospital rate for this hernia repair is $4,595.85 in 2019. This will likely be adjusted up slightly as we move into 2020.

You can find these prices at this link at Medicare; just download Addendum B. I included a screenshot for your viewing pleasure. You need to make sure you understand how to read it though. That J1 means this is an all-inclusive rate. They aren’t always all-inclusive.

Unadjusted Medicare 2019 Payment for hernia repair = $4,596

Surgeon

The national Medicare payment rate for the surgeon to do a hernia repair would come to $447. Again, this is adjusted based on locality and we can see some pretty decent swings. If I request this service’s price from the Medicare website with Connecticut selected, it comes in slightly higher at $484. You can play with this fancy fee schedule lookup tool here, but I made a nice screenshot of the result for your viewing pleasure.

Unadjusted Medicare Surgeon Payment for hernia repair = $447

Total Out The Door Medicare Price

So since we need the hospital to provide a place to have the service in and a surgeon to do the actual hernia repair, we need to add these two figures together to get our total Medicare payment for a hernia repair.

Total Medicare Price For Hernia Repair = $447 + $4,596 = $5,084

As I mentioned, this is a national estimate and the Medicare payment would probably come in a little higher than this in a market like Connecticut. It would also likely be adjusted up about 150% for a bilateral scenario such as this one. So let’s call the Medicare price $7,500 just to be safe. About 20% of this would come out of a Medicare patient’s pocket, or about $1,500.

Total Medicare Price For Bilateral Hernia Repair = $5,084 X 1.5 = $7,627

Medicare vs. Private Insurance

As you can see, we have a serious gap between what Medicare pays for this hernia repair surgery compared to what this Bill Of The Month’s patient’s insurance would pay/allow for the same service. A gap of about $4,000. This is obviously a sample size of one, but we see gaps like this across a wide spectrum of services when comparing private insurance payments to Medicare payments and the gap is usually even more dramatic. This gap is a problem. A big problem. A problem that would need to be dealt with before moving to a Medicare For All model. Otherwise, hospitals and doctors will have serious financial problems.

$11,520 (Cigna Price) – $7,627 (Medicare Bilateral Price) = $3,893 (Problem Gap)

Here is a nice look at everything we learned today.

Final Thoughts

Hospitals are going to continue to struggle to bridge the estimate from the total charges to the contracted insurance rate, then to the patient’s actual benefit calculation (their out-of-pocket). Ultimately, when you have a third-party insurance company calculating how much the patient owes, things can get very complicated.

If I was CEO/CFO of a hospital in 2019, I would consider a contract where the insurance company is responsible for collecting their own balances that come out of the patient’s pocket. They get to turn off insurance payments when premiums aren’t paid but hospitals don’t get to turn off healthcare services when out-of-pocket responsibilities aren’t paid. Collecting these balances bog down healthcare providers from doing what they are good at, like same-day hernia repairs. We all know Max is a bit biased here.

I am not sure writing this off to $0.00 was appropriate. I think writing it down to the original estimate would be more reasonable since we don’t want to train the public to bully their way to a solution. But I am sure considering this was getting looked at by a reporter, the hospital probably decided to take the conservative and less controversial way out. I think we need to lean into these process break downs, acknowledge what actually broke in the process, and make a reasonable attempt to fix the issue. Customers like to see businesses take ownership of their mistakes. That said, I was really happy to see this resolved before the Bill Of The Month article was released.

I also think we should follow up and make sure the hospital corrected its process. If the reporter were to call the hospital today and request a new estimate for a hernia repair, would the result change? We could see how the estimate comes out and applaud the hospital for correcting the underlying issue versus just making a bill go away. We need to fix the system, not put patches on it.

The patient seemed to know he met his deductible, but I can’t tell from the article if the patient knew what his max out-of-pocket was. We should definitely take note of it before any surgery because, in the case of a complication, it wouldn’t take long to hit that max out-of-pocket and the hospital can’t always predict complications into their estimate.

As for a simple hernia repair, it seems to me the hospital should be able to get somewhere in the ballpark on an estimate for a patient’s costs.

Hernia Repair Factory?

Go ahead and laugh, I will just get Elon Musk to help me with this project.  

It appears the hospital’s agreement with the insurance company, in this case, is a percent of the total charges. These types of agreements make the charge estimate that much more important because if you get that wrong, everything else that follows is wrong. We talked about ‘case rates’ briefly when talking about baby deliveries a few months ago. If insurance companies negotiate a “per case” rate like Medicare does, that can really help simplify this process and make these procedures more “shoppable”.

I joked a few months back that perhaps we could create a baby delivery factory to help deal with the cost of having babies. Max proposes the same solution for hernia repairs. If you think about it, if we could get 5-6 regional hospitals across the country extremely efficient at repairing hernias to the point where we can dramatically reduce the cost to Walmart pricing, we could almost justify flying people there to get the service. Who knows, maybe we could even compete with the Medicare pricing above. I am obviously living in dreamland here, but I really do think the concept applies. These kinds of ideas will ultimately shake up the market.

Max Out of Pocket for hernia repair? Somewhere between $1,500 and $18,000 : ) It’s no wonder I am creating a medical office building empire to help me pay for these unpredictable costs.

The post Hernia Repairs For Sale, Reduced Price! appeared first on Max Out of Pocket.

An NPR article hit Max OOP’s radar this past weekend. Lauren Weber with Kaiser Health News reported on a medical bill a patient received from Hudson Hospital in Hudson, Wisconsin. In short, the article outlined the exorbitant bill that included a $4,836 line-item charge for nitrous oxide. The hospital ended up reducing the charge to $496, according to the invoice dated 1/9/2019. The article suggests this correction put the price within the normal market rate of $100-$500. In comparison, this is about $1,000 cheaper than Hudson Hospital’s communications area quoted for a normal epidural.

This case clearly has Max OOP written all over it.

Before we get Max OOP’s take, I want to make it clear I completely agree that a $4,836 charge for nitrous oxide during childbirth is outrageous and would normally need to be called out. There is work that needs to be done on hospital pricing across the country and now that consumers are taking on more and more of the bill through cost-sharing, they are taking a much closer look at those prices. But I also think this article missed a few opportunities to provide some additional education to healthcare consumers.

Bill Of The Month

Believe it or not, this is actually the first I have heard of this “Bill Of The Month” series and Max OOP really likes the idea. It will be a great way to hold healthcare providers accountable for some pricing issues we are seeing for healthcare services. It may even add some market pricing pressure to an industry that really isn’t a normal market.

Here is the goal of the series and a way to submit your own medical bill if interested.

This crowdsourced investigation by Kaiser Health News and NPR dissects and explains your medical bills every month in order to shed light on U.S. health care prices and to help patients learn how to be more active in managing costs. Do you have a medical bill that you’d like us to see and scrutinize? Submit it here and tell us the story behind it.

https://khn.org/news/tag/bill-of-the-month/

Let’s Finish The Case Study

Since this is a crowdsourced investigation, I am taking that as a green light to add to the conversation. First of all, nitrous oxide sounds like a great way to ease the pain of delivery while also avoiding a more invasive form of anesthesia such as an epidural. From the article, it sounds like we have seen exponential growth since 2011 (when only two hospitals offered it) in the use of this alternative way to manage pain. Leave it to the United States to let a TV show called “Call the Midwife” drive healthcare trends. But I do think that it’s great that a small 25-bed Critical Access Hospital (CAH) like Hudson is already offering such a helpful service. It is nice to hear that smaller communities have access to new methods of providing care and can provide those services at the request of the patient. After all, with a population less than 15,000 it can be hard to sustain specialized services like nitrous oxide and a bathtub delivery. I suppose Minneapolis would be too far to go for a service like this if Hudson didn’t have it available?

Setting The Stage

I think the fact that this particular patient was a healthcare professional herself (midwife) in the very specialty of service she was receiving set some authenticity to this scenario. I mean, seriously, if people who work in the field are getting ripped off, there’s no telling what hospitals are doing to your Average Jill Maxine.

I am actually really surprised someone in the field with a decent understanding of healthcare processes wasn’t able to get this issue resolved directly with the hospital before escalating it to a news correspondent. That said, administrative and support departments, particularly in Critical Access Hospitals, do struggle having adequate resources to address technical issues timely and correctly. So this particular patient very well could have had a difficult time getting an explanation.

When Kerrschneider saw she had been billed for anesthesia, she called the hospital repeatedly about the coding, wondering if the hospital had accidentally charged her for an epidural. She protested further when she discovered the high charge was simply for nitrous. She knew that the hospital where she works charges a flat fee of about $100 for the same thing.

Bill Of The Month: $4,836 Charge For Laughing Gas During Childbirth Is No Joke

I think there was an opportunity here to elaborate more on the specific path the patient took to resolve the issue. That could be a good thing to know if other patients are interested in learning how to be more active in managing costs.

For instance, if she was calling the “coding” department and not the “billing” department, perhaps she wasn’t talking to the right people? How many times did she call? Did she talk to the quality or compliance department? Did she attempt to escalate this to the hospital’s administration? Was the hospital really being unresponsive and not offering an explanation?

The invoice with the reduced charge (from $4,836 to $496) is dated 1/9/2019 and the actual services were provided between 12/19/2018 and 12/21/2018. Seems to me the hospital was able to correct the issue and bill the insurance company correctly and relatively quickly. I almost have to question if insurance was ever billed the incorrect amount for the $4,836 since they already showed payment on the 1/9/2019 invoice along with the corrected charge. There is even a handwritten note on the bill that said “billed insurance $7,550” which was the corrected total charge amount. So should the $4,896 charge really be the highlight of this article or should we be looking at the reduced charge of $496?

Kerrschneider eventually gave up and accepted the reduced nitrous charge since she didn’t want to further antagonize people in the region where she also works as a nurse midwife.

Bill Of The Month: $4,836 Charge For Laughing Gas During Childbirth Is No Joke

Okay, reporting the issue to the NPR/Kaiser Health News “Bill Of The Month” series might not be the best play if you don’t want to further antagonize people in the region. As I said, I have to poke fun where I can.

On To The Billing Issue

I think it is unfortunate that in addition to the itemized bill from the hospital, the patient didn’t provide the Explanation of Benefits (EOB) from her insurance. I think that the document would likely provide some additional clarity to the situation and also be a great tool to educate the readers. I will cover this document in depth later this year.

The author suggests the insurance company (Medica) “refused” to pay the $4,836 fee for anesthesia services citing “provider responsibility”. It is unclear to me if the correspondent actually spoke to someone at Medica or is making a reference to the Explanation of Benefits (EOB). In Max OOP’s experience, when something is flagged as “provider responsibility”, the provider (in this case the hospital) writes that amount off and the consumer is held harmless. Without the EOB, we really don’t know if the insurance company received the incorrect bill since the 1/9/2019 invoice clearly shows the charge correction down to $496. The author also references an agreed-upon rate between Medica (Insurance) and Hudson Hospital (Provider) for childbirth and total charges cannot exceed that amount. Max OOP will assume we are referring to a “per day” or “per case” rate here.

We haven’t touched on it here yet at Max Out of Pocket, but it is pretty common for your insurance to pay for your inpatient services (such as a normal vaginal delivery) on a set “per day” or “per case” rate. In other words, the payment is already set regardless of the charges on the bill. This is often referred to as the “allowed amount”. The concept is similar to how you might buy a car or a house in a ‘packaged’ deal. You don’t pay for the windshield wipers or faucets individually in those situations. It works the same way between the insurance company and the hospital. Unfortunately, the patient is stuck in the middle of this unusual “per widget” transaction. So in this case, even though there was clearly a charging mistake on the bill, it likely had absolutely no impact on this particular consumer since it was considered “provider responsibility”. Most patients aren’t aware of these contracts since they happen behind the scenes and there is certainly room for improvement here to make things more competitive.

In this case, total charges for the mother’s case came to $7,550 after the billing correction. The allowed (agreed-upon) amount between Medica and Hudson for the services is presumed to be the sum of the patient cost share (deductible + copayment) and insurance payment, or $5,616.89.

$1,500 Deductible + $823.38 Copayment + $3293.51 Insurance Payment

= $5,616.89 Allowed Amount Per Baby Delivery

So when Hudson Hospital acknowledged the error and decreased their fee to $496, the insurance still has a fixed pricing agreement with the hospital for baby deliveries ($5,616.89 per delivery) regardless of the charges. The price per delivery is the price we should be looking at here, not the nitrous. Are we comfortable with $5,616.89 for the delivery and mother’s stay? Could we create a cash-only baby delivery factory that might be able to compete with this?

Now, if the insurance company’s agreement with the hospital was a “percent of the total charge”, we would definitely have a problem here. Without the Explanation of Benefits, I can’t be 100% sure from the information we have. $5,616.89 seems like an odd global fee; I am surprised it isn’t an even dollar amount, but it could be an older contract.

Understanding Your Benefits

Altogether for the care she and her son received for his birth, she was on the hook for deductibles and copayments that totaled $3,635. She paid it.

Bill Of The Month: $4,836 Charge For Laughing Gas During Childbirth Is No Joke

If this particular consumer was surprised by the $3,635 in deductible and copayments for her piece of the service, she probably didn’t have a great understanding of her benefits from the start. That is really between her and her insurance since Hudson does not control who she signs up with. Maybe she should consider becoming a Max Out of Pocket reader since we are going to cover patient cost-share in depth later this year. All in good time. I noticed her ‘copayment’ is exactly 25% of what the insurance company paid. That sounds more like a coinsurance to Max OOP, but I can let it slide. It could be a regional thing.

$823.38 / $3,293.51 = 25% copayment

I would point readers to their Summary of Benefits and Coverage document provided by most insurance companies. Mine shows me an estimate of what it might actually cost to have a baby. So no surprises for Mr. and Mrs. Max OOP. Here it is!

We will reference this document in depth later this year as we continue Max OOP’s complete dissection of the healthcare system. I think insurance companies also have some work to do to make this document more useful to the patient.

Takeaway Clarification?

So, the author also offers this takeaway.

The takeaway: Nitrous oxide used during labor and delivery does not have a standardized charge or code, which is surprising considering that there are medical charge codes for just about everything — including being pecked by a chicken or getting sucked into a jet engine.

Bill Of The Month: $4,836 Charge For Laughing Gas During Childbirth Is No Joke

We all know Max OOP can be pretty nitpicky, but this statement is confusing two concepts and could potentially be confusing healthcare consumers. Charge codes and diagnosis codes are two very different things. Even though Max OOP will also poke fun at some of the interesting diagnosis codes out there, we really shouldn’t be confusing them with charge codes.

I also wanted to point out that since this is an inpatient case, it isn’t industry standard to assign CPT charge codes to the hospital claim line item charges that are submitted to insurance.

Title Clarification?

Not Funny: Midwife Slapped With $4,836 Bill For Laughing Gas During Her Labor

Bill Of The Month: $4,836 Charge For Laughing Gas During Childbirth Is No Joke

Seems like this title is a bit of a stretch. The “itemization” provided in the article showing the error specifically says “this is not a bill”. The bill dated 1/9/2019 showed the correct charge amount of $496 which was more than 4 months ago. Also, it seems unlikely the midwife was actually slapped with the bill. Paper cuts hurt and that seems like it would be a valid complaint. Don’t worry, we have an ICD-10 diagnosis code for that; “Paper entering through skin, initial encounter”. Ouch.

Final Thoughts

The nitrous oxide charge was clearly an error and needed to be corrected. I am not sure how many other patients received this service at this particular hospital, but it would be ideal to audit those cases and correct them if necessary. It is possible a simple clerical mistake may have caused the initial issue. My guess is one of the nurses or staff members inadvertently charged the facility rate for regular anesthesia (a timed charge every 15 minutes) or was using it as a placeholder if they didn’t know how to charge the nitrous oxide correctly. Max OOP is speculating here.

Hospital pricing should always be a function of cost. The article references the cost of the tank and refill cost, but fails to mention the resources needed to train staff, maintain equipment, and meet regulatory requirements. I have seen this service priced between $60 – $750 depending on the hospital. Is that fair? Not sure, but I am more concerned about the price per delivery. When we split items out of a large transaction like this, things can look weird and even flat out wrong. I think that is why insurance companies and hospitals try to set an average price for a normal baby delivery and then apply that price to everyone with that same insurance.

If there was truly a set price for inpatient delivery in this case then the charge error actually had no impact on this particular consumer and would just be considered “provider liability” and likely written off. If the pricing was set at “percent of total charge”, Max OOP may have a different take assuming the incorrect charge was actually sent to the insurance.

We need to continue to monitor hospital pricing across the country without being hypersensitive. We also need to dig deep into the details of those cases to make sure we are maximizing engagement from all parties. Getting everyone to the table (insurance, provider, patient, media, government) and working together to tackle healthcare costs would be the ideal situation. Heck, maybe Max OOP could be the moderator of the summit. But then again, I would probably quickly turn it into a beer summit and it wouldn’t be very productive. Putting a small hospital in Wisconsin in the spotlight who is providing access to a great service and appears to have corrected the issue timely may not be the best approach to fix pricing. Even though the patient spoke positively about the care received, I would just hate for this charge issue to overshadow some of the impressive accomplishments this birthing center has seen over the years. This would include a nursing staff that ranks in the top 90 percent nationwide according to Press Ganey patient survey data referenced on Hudson’s website. It is not easy to put up those kinds of numbers.

I suppose it will get patients to look at their bill, though, which is likely the intent of this series and needs to continue to happen. I am looking forward to more “Bill Of The Month” articles so we can continue to learn through this process.

Most of these concepts are more complex than I would normally cover in a single post. The intent is to slowly release these ideas in bite-sized chunks. But Max OOP just couldn’t resist this one.

*Max OOP has absolutely no affiliation with the hospital or insurance carrier referenced in this article. In fact, I live over 1,000 miles away and never have been to Hudson, Wisconsin. Therefore, the content in this article is the opinion of this blog and does not represent the views of any other party. I just happen to find this stuff interesting and this is an opportunity to educate others.

Any charging issues Max OOP can help you with?

The post Midwife Crisis and $5,000 Nitrous appeared first on Max Out of Pocket.