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Pay upfront or no surgery, cancer patient is told
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Pay upfront or no surgery, cancer patient is told

The night before scheduled surgery to remove a mass in her uterus, Jacqueline Bouchard got a call from the hospital saying she’d need to pay $1,000 before she could have the procedure.

The 59-year-old Green Valley resident, who was diagnosed with advanced, aggressive breast cancer in 2013, didn’t have the money to pay in full. Alone and upset, she tried reasoning with Banner-University Medical Center Tucson, she said, but to no avail.

So she didn’t have the surgery.

As health-care co-payments, co-insurance payments and deductibles rise, more hospitals are asking for payment upfront as a way of guarding against bad debt.

Industry experts say it’s a new era in hospital billing and that collecting at the hospital yields a much lower default rate than billing patients after they’ve gone home.

Still, there are steps hospitals can take to soften their collection methods and improve patient relations.

Officials with Banner Health have apologized to Bouchard and say they are retraining the staff. The company, which entered the Tucson market in March, says its aim is to notify patients about their financial obligation five days before surgery — not the night before.

“Clearly it is bad practice to call the day or night before the surgery and say, ‘pay up,’ ” said David E. Williams, president of the Health Business Group in Boston, a health-care strategy consulting company. “Obviously if someone is in a life-threatening situation, any surgery is frightening. They might not be in the best frame of mind to handle a call of this nature.

“The hospital needs to get paid to stay in business, but there are better ways.”

Hospitals need
out-of-pocket revenue

More Americans have health insurance than in the past. But more consumers, looking to get the best value for their dollar, are buying high-deductible plans.

Those plans keep health costs at a minimum — unless you get sick.

Co-payments and co-insurance payments have risen along with health-care costs, and the result is that out-of-pocket payments have become a larger source of hospital revenue.

“It could be $2,000 to $3,000, and that is an amount a hospital can’t afford to pass up on,” Williams said.

The practice of upfront collection took Bouchard by surprise. Since her diagnosis, she’s had several procedures at Banner-University Medical Center Tucson, including radiation, chemotherapy and a radical double mastectomy, with no “pay-before-procedure” requests.

A retired psychologist who worked in the Vermont prison system, Bouchard was collecting disability because of illnesses at the time of her cancer diagnosis.

During the summer of 2014, she enrolled in Medicare disability for her health coverage. While the government health insurance program primarily covers people over age 65, it also covers disabled people like Bouchard. Her monthly Social Security income was too much for her to qualify for both Medicaid — a government insurance program for low-income people — and Medicare.

Bouchard looked into supplementing her coverage with a Medigap plan to pay expenses Medicare doesn’t cover. But no Arizona insurers sell Medigap plans to people under 65. So she relies on original Medicare, which requires her to pay 20 percent of the Medicare-approved cost for outpatient surgeries.

As a result, some of her medical expenses since last summer have been substantial — upward of $10,000 when medications are included, she said. She always pays her bills and doesn’t dispute how much the hospital said she owed for her procedures. She just can’t pay all at once.

Problems began
after Banner deal

Bouchard said the “pay upfront” demands coincided with Phoenix-based Banner Health’s recent acquisition of the hospital, which was previously locally owned by University Medical Center Corp. She’s had two scheduled surgeries since Banner assumed control March 1 — and both times said she got calls the night before telling her that she had to pay upfront.

In the first instance, she was scheduled to have a blockage removed from her bile duct on May 7. She was at home with friends the evening of May 6 when the hospital called, telling her she owed $902 before her surgery.

“I cried on the phone,” Bouchard said. “I told them, ‘I don’t know how you could do this to me. I am a cancer patient. I am not talking plastic surgery or a hangnail.’ ”

A neighbor who was at Bouchard’s home when the call came in offered a $450 loan. Bouchard said she asked whether that would be enough and says the financial representative agreed she could pay half, but made it clear this was not the usual practice. She had the surgery the next day after paying the $450, and plans to pay off the remainder in increments.

Two weeks later, Bouchard was scheduled for the uterine mass surgery. At about 8 p.m. the night before, she was home alone when the hospital called, alerting her of her financial responsibility. This time it was $1,000 and Bouchard said the hospital would not bend when she said she couldn’t pay it all at once.

“I got really angry,” she said. “My doctor made it clear this is medically necessary.”

She already had a ride set up to take her to the surgery, so she called the hospital in the morning to ask whether there was any way she could negotiate a payment plan and have the surgery anyway.

“I didn’t know whether I had rights or not,” she said. “How on earth would I know that?”

Surgery canceled

A patient’s rights in such a situation depend on whether surgery is considered an emergency, and that is up to the doctor.

Public health-care facilities that accept federal funds can’t deny medically necessary care to an uninsured patient, but a privately owned hospital can refuse care in a non-emergency situation, said Pat Palmer, founder and CEO of the Virginia-based Medical Billing Advocates of America.

Palmer advises patients to work out payment arrangements ahead of time when possible.

“The practice of calling a patient the night before a surgery regarding payment seems to be occurring more frequently,” she said.

Still, it’s not ideal, said Maria Persons, director of revenue cycle at Tucson Medical Center.

“The last thing we want them to worry about on the day before a procedure is how they are going to make their payment,” she said.

Persons said TMC makes every effort to work with the patient seven to 10 days ahead of their procedure, and asks for an upfront 50 percent deposit of what they owe.

“Obviously, if we get a patient that was scheduled two days ago, we’re scrambling to try to get information to that patient,” she said.

“If a patient said to me, ‘I can pay 25 percent,’ then we would work to make payment arrangements for the remaining balance. We would do that upfront so that after the patient has had services, it’s not a big surprise. We’re not really working with them afterwards to try to identify this liability.”

Bouchard said Banner-University Medical Center Tucson would not negotiate a payment plan, so she didn’t have the scheduled May 22 surgery to remove the uterine mass. Her emotions went from frustrated to despondent. At one point she thought about quitting treatment altogether.

Her 26-year-old son, Dominic Delabruere, who lives in Vermont, thought there must be a mistake and called the hospital himself. In a three-way call with his mother and the hospital, he said he, too, tried to negotiate the payment.

“It was a few days after they sent her away, and I asked if maybe there was a loophole,” Delabruere said. “They told us to talk to her doctors. We tried that. It seemed like it was a cold dead end.”

Determined to help his mother, Delabruere set up a GoFundMe campaign online to raise the money.

Hospital apologizes

When the Arizona Daily Star contacted Banner Health about Bouchard’s case on June 4, officials were apologetic.

Jeni Erikson, Banner’s senior director of admitting, called Bouchard to see what went wrong and how to help, a hospital spokeswoman said.

“Banner’s practice is to explain to each patient their financial responsibility based on their insurance requirements prior to scheduled procedures and to collect co-payments upfront if possible,” hospital spokeswoman Katie Riley wrote in an email.

“Exceptions can certainly be made and should have been offered. We apologize that this patient did not receive the service she deserved or that Banner aspires to. I know that Jeni apologized to the patient, and I did, too. Staff will continue to receive training to ensure this does not happen again.”

Bouchard had the surgery June 9 and is now paying off her bill. She is starting a breast cancer survivor group, which will have its first meeting Thursday morning at Green Valley’s Our Lady of the Valley Catholic Church. She expects some conversations will focus on medical bills.

Banner Health, which is the largest private employer in Arizona, wants patients to pay their share upfront, says Jeff Buehrle, chief financial officer of Banner-University Medicine.

Buehrle said that last year, Banner Health wrote off $140 million in bad debt, which is debt incurred by patients who did not pay what they owed, including unpaid co-payments and co-insurance. That’s why upfront payment is important, he said.

“But if it’s not possible, we will work with the patient to make financial arrangements rather than canceling the procedure,” he said. “We didn’t follow our own policy in this case.”

Banner’s goal is to notify patients of their financial obligation five days before a procedure if it’s scheduled far enough in advance. But there has been a transition period as Banner implements its policies in Tucson, Buehrle said.

“It started the night before and then we moved to two nights, then three nights. But our goal is five and we’ll probably be there in a month,” he said. “We are highly centralized and we try to have a standardized approach of training and education at all Banner facilities.”

A better answer

Michael Trilli, a Phoenix-based health-care analyst with Aite Group, says the hospital industry is generally flexible in offering payment plans. But hospitals operate on very thin margins and patients’ financial responsibility has increased. That can be a difficult balance for the hospital.

“If I am going to buy a TV, I may not pay for that TV all in one shot. There are different financing options for me to pay it down,” Trilli said.

“That is where hospitals are trying to get, but it is a big mind shift … health care is different from a TV. There are human emotions involved. There will probably never be a right answer, but there will probably be a better answer.”

Persons, of TMC, stressed that the vast majority of patients want to pay, even if they can’t always afford to do it right away.

“We have very few patients who really do not want to pay. We have more patients who, if we sit down and explain it to them and work with them, we come to a good resolution for the patient and a good resolution for the hospital.”

Contact Stephanie Innes at or 573-4134.

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