January 23, 2022

The Sneaky Means Docs and Attorneys Go away Sufferers with Debt

15 min read


By Fred Schulte | KHN

Jean Louis-Charles couldn’t afford backbone surgical procedure to ease nagging neck and again ache after a automobile crash. So he signed a doc, promising to pay the invoice with cash he hoped to get from a lawsuit in opposition to the motive force who brought about the collision.

That by no means occurred.

Louis-Charles, 68, died hours after the operation at a South Florida outpatient surgical procedure heart in March 2019. The surgical procedure heart had put him in an Uber along with his spouse, Marie Julien, in keeping with depositions. After a 60-mile experience dwelling, he collapsed, court docket data present.

Her husband’s dying left Julien to cope with greater than $100,000 in medical debt, as described within the “letter of safety,” or LOP, that Louis-Charles had signed.

In signing an LOP, individuals typically pledge to cowl the prices of their care even when it exceeds what they win in a lawsuit or different settlement — and even when the costs are far larger than most medical doctors would cost.

The agreements are authorized and binding in lots of states, although Florida seems to be the epicenter of their use in private harm instances. Advocates say the letters throw a lifeline to low-income individuals who want important medical look after accidents brought on by the negligence of others and don’t have the cash or insurance coverage protection to pay for it. Docs and surgical procedure facilities that settle for LOPs say they typically wait years for a lawsuit to settle earlier than being paid, if in any respect.

A KHN investigation discovered that letters of safety can saddle sufferers with medical debt — and drive a private harm care system that operates with little oversight regardless of widespread complaints of grossly inflated billings and different issues that may place sufferers in danger.

Marie Julien blamed Dr. Kingsley R. Chin — a controversial Hollywood, Florida, surgeon who has accepted LOP funds for greater than a decade — for her husband’s dying after the spinal fusion process. Final yr, she filed a malpractice go well with in opposition to Chin alleging that Louis-Charles died after he “was discharged dwelling whereas nonetheless in ache and with indicators and signs of post-operative issues.” In court docket papers, Chin denied any negligence.

“We felt that the best way the entire thing occurred was very weird,” Julien, 71, an authorized nursing assistant, recalled in a deposition taken within the case.

A ‘Horrible Scenario’

Simply earlier than 8 a.m. on New 12 months’s Day 2018, Louis-Charles’ automobile was stopped at a pink mild close to his dwelling. All of a sudden a white police automobile, pushed by a Palm Seashore County Sheriff’s Workplace detective, backed into his Toyota Corolla, hitting the passenger aspect door, in keeping with a police report.

In her deposition, Julien stated Chin operated on her husband’s shoulder in 2018. However that didn’t assist a lot, and Chin really useful extra in depth surgical procedure, she stated. “I wasn’t blissful in any respect with that concept,” she added.

Julien stated she relented as a result of Louis-Charles’ ache was getting worse “day-to-day” and he had confidence within the surgeon. The Aventura Surgical procedure Middle in Hallandale, Florida, the place Chin had served as medical director, despatched an Uber to gather the couple the morning of March 12, 2019, Julien stated.

Throughout the two-hour spinal fusion, Chin changed three disks with an implant he invented, in keeping with his deposition. The affected person spent an hour or so in a restoration room earlier than a nurse wheeled him out to a ready Uber simply after 3 p.m., in keeping with Chin’s testimony.

Louis-Charles couldn’t converse, however signaled he was in ache and struggled to breathe in the course of the hourlong experience dwelling, in keeping with Julien’s deposition. She helped him stroll via the entrance door of their Riviera Seashore dwelling. As soon as inside he collapsed, she testified.

A fireplace rescue crew rushed him to a hospital in West Palm Seashore, the place he died simply after 5:30 p.m., in keeping with a Palm Seashore County Medical Examiner’s post-mortem report. The health worker dominated the dying an accident brought on by “post-surgical bleeding with airway compression.”

In his deposition, Chin stated that Louis-Charles “seemed nice” heading out to the automobile and that touring alongside the city Interstate 95 hall the motive force was “at any given time most likely inside 10 minutes or so” from a “main hospital or emergency room.”

Chin known as the end result a “horrible scenario” and informed Julien’s lawyer in the course of the deposition: “I simply hope you may admire how a lot I remorse what occurred.”

Requested how her husband’s dying has affected her life, Julien stated: “How are you going to discover phrases to clarify such a factor?” The couple wed in 1987 in Miami after shifting from their native Haiti, the place he labored as a home carpenter.

“It’s been virtually two years now. I’ve not been capable of sleep on [the] mattress” she shared with him, she stated.

In late September, Julien and Chin settled the go well with beneath confidential phrases and the payments have been “written off,” in keeping with Kevin Smith, an lawyer who represented Julien. Chin has denied any legal responsibility.

‘A Blended Bag’

Although little-known to the general public, letters of safety are generally used to finance main medical care in private harm instances, together with pricey orthopedic surgical procedure.

Attorneys who refer injured shoppers to keen medical doctors say the liens are their greatest software for making certain shoppers not solely achieve entry to care, but additionally are ready to win truthful settlements from insurance coverage firms that struggle to attenuate their legal responsibility and prices.

An LOP type utilized by some Florida medical suppliers says they comply with look ahead to fee as a “courtesy” to the injured particular person, including in boldface: “We perceive insurance coverage firms have limitless sources, will rent protection attorneys and protection consultants that can trigger our fee to be delayed for months or years.”

The enterprise neighborhood and insurers counter that LOP suppliers grossly inflate their medical charges to provide juries a false image of the prices of medical care.

“The only function of the LOP, why it exists, is to drive up verdicts and settlements,” Lauren McBride, a lawyer for Publix Tremendous Markets, a series with greater than 800 shops in Florida, testified in a state legislative listening to in February 2019.

McBride stated that just about two-thirds of “slip-and-fall” harm claims in Publix shops contain letters of safety. In additional than half these instances, the injured particular person had some type of insurance coverage however declined to make use of it, she stated. In some instances, injured individuals traveled lengthy distances for pricey care they might have obtained nearer to dwelling at far much less expense, she stated. She additionally argued that LOPs give medical doctors an incentive to overtreat sufferers “to maintain driving up medical payments” — and persuade juries to award large verdicts.

Kevin Leahy, an Austin, Texas, lawyer who has researched the apply there and represented shoppers on each side of the controversy, stated LOPs deserve extra scrutiny. “It’s a combined bag,” he stated. “There are positively abuses occurring. There are additionally harm individuals getting care they should get higher.”

Leahy stated LOPs have helped create a “liability-based” well being care community with few checks on its monetary dealings or different requirements. He known as it “unregulated, opaque and never totally correct about expenses.”

Throughout the nation, LOPs have been tied to a spread of alleged medical overcharges or different billing abuses, court docket data present.

Practically 200 ladies from 42 states, for instance, have joined a class-action go well with that alleges medical doctors and attorneys talked them into signing LOPs promising to pay for surgical elimination of pelvic mesh — whether or not they wanted it eliminated or not.

The ladies allege that the medical doctors billed sky-high charges and informed them their insurance coverage wouldn’t cowl the price, so signing an LOP was the one solution to safeguard their well being. Personal insurance coverage would have paid about $8,000 for these companies, far lower than the $76,000-plus the ladies have been charged beneath the LOP, in keeping with the go well with, filed in late August. The case is pending. Six medical doctors have filed motions to dismiss the case.

In a 2020 federal civil case, proof emerged {that a} Texas backbone surgeon charged practically $400,000 beneath an LOP for procedures that Medicare would reimburse at lower than $20,000, court docket data state.

Reviewing court docket instances in Florida, KHN discovered dozens of examples wherein sufferers who signed LOPs alleged they have been later sued for fee of extreme charges or obtained substandard medical care.

‘Pointless and Harmful’

On the day of his spinal surgical procedure, Louis-Charles signed a letter of safety that learn partially: “Whereas I’m injured and wish care, I can’t financially afford to pay your invoice on the time companies are rendered, I due to this fact, grant this supplier a lien on my declare in opposition to any and all proceeds from any settlement, insurance coverage advantages or judgment.”

The paperwork stated he could be charged “what is common and customary for our space.” However the charges have been a lot larger than personal medical insurance would cowl or what the Medicare price schedule supplies for.

The Aventura Surgical procedure Middle, co-owned by Miami private harm lawyer Sagi Shaked, billed practically $100,000 for the operation, court docket data present. Two different Shaked-affiliated firms billed greater than $35,000 for surgical provides and anesthesia, in keeping with the court docket data. Shaked didn’t reply to quite a few requests for remark. In his deposition, Chin stated he not operates on the Aventura Surgical procedure Middle.

Mark Woodard, 54, who was rear-ended in an April 2017 automobile crash in Fort Lauderdale, had three backbone operations on the Aventura Surgical procedure Middle carried out by Chin beneath a letter of safety.

His payments topped $430,000, together with $179,500 for the surgical procedure heart, $177,972 billed by Chin’s medical workplace and $39,327 for implants from SpineFrontier, a Massachusetts medical system firm Chin owns, court docket data present.

“These expenses are method out of line,” stated Michael Arrigo, a medical billing skilled in California requested by KHN to evaluation Woodard’s payments. Arrigo stated “ordinary and customary” expenses could be lower than one-fourth of what was billed.

Woodard, who has labored as a painter and upkeep technician at beachfront lodges in Fort Lauderdale, argues in his lawsuit that his accidents from the crash have been “nothing greater than cervical and lumbar sprains and strains … such that no cheap doctor would have carried out surgical procedure apart from for financial functions.”

In keeping with Woodard’s lawsuit, Chin persuaded him to have a number of operations and through one tore a 1-centimeter gap via a nerve root, leaving him in “excessive agony and excruciating ache.”

The go well with, filed in March 2021, alleges the surgical procedure heart provided Chin a “protected haven to carry out his pointless and harmful surgical procedures.” The go well with alleges that Chin “was unable to carry out surgical procedure at any hospital within the state of Florida and most if not all surgical procedure facilities the place he had utilized had both denied him privileges or he had his privileges revoked at a number of hospitals.” In court docket filings, Shaked has denied the allegations and any legal responsibility.

Chin additionally has denied any negligence in court docket filings and in a deposition known as the charges he charged “cheap throughout the neighborhood.” Woodard’s lawsuit is pending in Broward County Circuit Court docket.

Chin has been sued repeatedly for medical negligence, together with a number of instances involving LOPs. He has been sanctioned by physician-licensing boards in three states, unrelated to his use of LOPs.

In early December, the Florida Division of Well being, which licenses medical doctors, issued Chin a “letter of concern” and fined him $8,000. The motion settled a state administrative criticism alleging that in August 2019 Chin despatched dwelling a 73-year-old man who suffered from issues of spinal surgical procedure who ought to have been transferred “to the next stage of care in an inpatient setting (equivalent to a hospital).” Chin disputed the allegations.

Individually, federal brokers arrested Chin in early September in Fort Lauderdale on kickback expenses as CEO at SpineFrontier, which sells spinal implants he invented and utilized in operations on Louis-Charles and Woodard. Chin has denied the civil allegations and has pleaded not responsible to the felony expenses.

In October, a federal choose ordered Chin to publish a $500,000 bond secured by his Florida dwelling. He’s free to journey throughout the nation “for enterprise functions solely” and should journey one time per thirty days to Jamaica “just for the aim of training drugs there,” the order states. Chin has energetic medical licenses in Florida, Arizona, New Jersey, New York and in Jamaica, in keeping with paperwork he filed with the court docket.

A ‘Full Shock’

By its personal account, the Broward Outpatient Surgical Middle and its associates in Pompano Seashore, Florida, have handled greater than a thousand sufferers beneath letters of safety. However the billing practices — one lawsuit known as its charges “astronomically unreasonable and inflated” — have been criticized in court docket filings for years. These instances typically settle beneath confidential phrases.

One affected person argued in a lawsuit that injured sufferers have been “bounced round” an online of affiliated clinics for companies that included chiropractic care, ache injections, bodily remedy and, lastly, surgical procedure, all executed with no caps on the prices. The middle denied the allegations, and the case has since been settled.

Albert Frevola, an lawyer for the middle, stated that previous to therapy sufferers are given a value listing and signal an settlement to pay the payments out of any settlement of their private harm claims. He stated the middle serves many sufferers “who can’t afford to get medical care. It’s a service that’s helpful and wanted.”

Some three dozen former sufferers have filed a current mass tort lawsuit alleging medical malpractice and billing fraud by the surgical procedure heart and its homeowners, chiropractors Brian and Craig Bauer, who’re brothers. The go well with additionally names backbone surgeon Dr. Merrill Reuter, court docket data present. Neither Reuter nor his lawyer responded to requests for remark.

The sufferers allege they visited the middle after a automobile crash or different accident and have been persuaded to have spinal surgical procedure. In some instances, the operations both have been billed as extra advanced than they have been, or not executed in any respect, in keeping with the go well with. Sufferers typically have run up payments of $100,000 or extra beneath LOPs, court docket data present. “Because of the truth that private harm sufferers hardly ever, if ever, use their personal medical insurance for such well being care companies, the Bauers and the Bauer entities have been capable of get away with charging inflated quantities,” in keeping with the go well with.

Frevola, who represents the brothers, stated they “flatly deny” the allegations and “are unhappy and distressed that these accusations are being made by the identical individuals they gave nice care and medical therapy to.”

In a separate malpractice case, Terrell Harris, 37, alleged he was guided down a “therapy path” after a automobile crash in July 2017 that led to surgical procedure at costs “far past the scope of motive, not to mention customized.” The middle denied the allegations and filed a counterclaim accusing Harris of failing to pay for his care beneath the LOP.

The go well with is certainly one of eight pending in Broward County Circuit Court docket that make comparable claims, together with that of a girl who alleged she had the identical ache after spinal surgical procedure as she had beforehand. Practically 5 years later, to her “full shock,” an MRI discovered no proof the operation she was billed for had been executed, in keeping with the go well with.

In a February 2020 court docket submitting in one of many instances, the middle and Brian Bauer denied the allegations and known as them “frivolous and scandalous.” They filed a counterclaim demanding to be paid for his or her companies. The case is pending.

Warring Collectors

When charges are inflated beneath an LOP, sufferers can take dwelling extra money beneath an insurance coverage settlement or jury verdict. But when a case settles for lower than the sum of these payments, sufferers could also be on the hook to pay the steadiness.

Attorneys who usually co-sign the LOPs attempt to persuade medical suppliers to cut back their charges, which regularly occurs. When that fails, nonetheless, attorneys file a court docket motion known as an interpleader, which asks a choose to determine who will get what amongst warring collectors.

KHN reviewed dozens of Florida court docket instances wherein medical collectors holding LOPs demanded fee in full. Whereas many of those instances settled beneath confidential phrases, court docket data present some accident victims ended up mired in debt or noticed their harm awards drastically lowered by outsize medical billings and authorized charges. In some instances, attorneys took dwelling greater than their injured shoppers.

That occurred to Jose Merced, who fell and harm himself after stepping right into a gap exterior his condominium within the Orlando space. He obtained a $75,000 settlement however incurred payments of greater than $850,000 for operations and different medical prices, which he contested as “extremely inflated,” court docket data present. The payments included greater than $700,000 in orthopedic surgical and facility charges.

In August 2020, a choose allowed simply over $35,000 to pay for the surgical procedures. Merced was awarded $10,000, whereas his lawyer obtained practically $27,000, simply over $18,000 of it for skilled charges and the remaining for bills.

In some interpleader instances, attorneys requested judges for one-third of the full settlement for his or her charges, plus bills, which may add a whole lot, if not hundreds, of {dollars} extra to their share.

A legislation group based by South Florida private harm lawyer Robert Fenstersheib filed at the very least 50 interpleader instances in Broward County Circuit Court docket between January 2019 and October of this yr. Fenstersheib, who was a fixture of native tv adverts because the “lawyer who listens,” was shot to dying by his son in a murder-suicide in September 2020, although his Fenstersheib Regulation Group nonetheless operates beneath his kinfolk.

Lots of the LOP sufferers now suing the Broward Outpatient Surgical procedure Middle and its homeowners have been shoppers of the Fenstersheib agency, court docket data present. The middle and the legislation agency did enterprise for years, however the heart sued the legislation agency in 2019 alleging the attorneys did not pay it thousands and thousands of {dollars} owed beneath LOPs. The legislation agency responded that it was a sufferer of a $6.5 million embezzlement by former workers who pocketed settlement cash meant for the middle. The go well with was settled beneath confidential phrases this yr.

Federal prosecutors filed felony expenses in opposition to two former Fenstersheib workers in reference to the theft. In late November, one of many males, Michael Wihlborg, a 47-year-old highschool dropout who had labored for the legislation agency for practically twenty years, admitted receiving greater than $2.1 million in stolen funds from the scheme; he pleaded responsible to at least one rely of conspiracy to commit wire fraud and three counts of submitting a false revenue tax return, court docket data present. He faces as much as 29 years in jail, in keeping with court docket data. Co-defendant Matthew Matlock pleaded responsible to comparable expenses on Dec. 15, court docket data present. The legislation agency had no remark.

Ethics Query

Some lenders additionally settle for LOPs as collateral for sufferers who borrow cash to tide them over whereas their private harm case winds via the courts, which generally takes years. Curiosity expenses pile up quick.

A Miami man who was injured after a pile of wooden fell on him at a house enchancment retailer borrowed $51,400 from a finance firm backed by an LOP in September 2014. He owed the corporate $140,322 three years later due to an rate of interest of 18% charged each six months, court docket data present.

Docs can also generate money from letters of safety. Whereas they argue they have to wait years for fee, some backbone surgeons promote the liens on a burgeoning medical debt market.

Court docket data in Florida present thousands and thousands of {dollars} of those liens have modified arms when medical doctors bought them. Consumers paid 10% to 25% of the full quantity of the invoice and gambled they might be capable of acquire a tidy revenue as soon as a affected person’s lawsuit was settled.

The ethics of medical doctors wheeling and dealing in affected person payments and having a monetary stake within the final result of litigation has been questioned. An American Medical Affiliation policy says such offers are unethical as a result of “there may be the ever-present hazard that the doctor could develop into much less of a healer and extra of an advocate or partisan within the proceedings.”

Dr. Scott Lederhaus, a retired California neurosurgeon who has reviewed private harm instances for the protection, stated some sufferers argue in depositions that beneath an LOP they by no means noticed payments, so they’d no concept of the extent of the medical prices they have been incurring over time.

Lederhaus stated there may be little settlement on what’s an affordable medical price and, because of this, medical doctors “are capable of cost no matter they need” in private harm instances.

And it stays unclear whether or not the No Surprises Act, which Congress handed final yr amid a nationwide outcry over big and surprising medical payments, gives sufferers who signed LOPs any safety.

“A variety of these medical doctors are beneath the impression they’ll do no matter they need and there’s not going to be any oversight by anybody,” Lederhaus stated.

KHN (Kaiser Well being Information) is a nationwide newsroom that produces in-depth journalism about well being points. Along with Coverage Evaluation and Polling, KHN is likely one of the three main working packages at KFF (Kaiser Household Basis). KFF is an endowed nonprofit group offering info on well being points to the nation.



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