As soon as she fell, Deborah Buttgereit knew she couldn’t avoid going to the hospital.

“I could hear the bones moving around in my elbow,” said Buttgereit, who was 60 when she slipped on a patch of ice in December outside her apartment in Bozeman, Montana.

Emergency room scans showed she had fractured her left arm near the joint. Doctors told her she needed surgery to repair it.

At the time, Buttgereit didn’t have health insurance — she had struggled to afford coverage after her husband’s death. The local health system, Bozeman Health, estimated Buttgereit would have to pay $50,560 out-of-pocket for the outpatient surgery to have her elbow pieced back together.

The estimate noted: “You could be charged more if complications or special circumstances occur.”

Four days after her fall, Buttgereit went in for surgery, which took about three hours. During a follow-up visit, she said, her doctor told her the procedure ended up being more complicated than expected.

Then the bill came.

The Medical Procedure

Buttgereit broke her humerus, the upper-arm bone that meets two other bones and forms the elbow. The way the bone splintered is known as a distal humerus fracture. It’s rare as far as breaks go, accounting for only about 2% of all fractures among adults. But older people, as well as kids in high-contact sports, are more prone to the big falls that lead to such fractures. The injury is painful and can make it impossible to move the elbow.

Some of these types of fractures heal with time in a splint, but most often surgery is the only fix. The patient is put under anesthesia while a surgeon repositions fragmented bones with plates and screws.

The Final Bill

$97,998. That includes at least $44,300 for the operating room and anesthesia administration, plus more than $50,000 for medical supplies and implants, such as screws and plates. After the hospital applied a self-pay discount, Buttgereit was on the hook for $78,398.40.

The Problem: Surprise Complications, Surprising Charges

The hospital said the price for Buttgereit’s surgery increased because doctors encountered complications midprocedure.

In particular, the fall had shattered Buttgereit’s bone into more pieces than her surgeon anticipated, according to operating notes. That meant it took more time, skill, and supplies to reconstruct her elbow. And, since she was uninsured, Buttgereit alone faced the burden to pay the higher costs.

“I’ll make payments the rest of my life to pay it all off,” she said.

Buttgereit’s husband died suddenly in 2023. About a year later, she left her job with the company that had employed them both. The memories of him in that space were too difficult, she said. That also meant leaving behind her health coverage. She moved to Bozeman to be closer to one of her daughters and found a health plan at healthcare.gov that the federal government subsidized because of her limited income.

But she also faced a higher cost of living in Bozeman than her Social Security benefits could cover, and she needed part-time work. While that new income helped pay her bills, Buttgereit said, she no longer qualified for the same level of subsidized coverage and couldn’t afford her plan. So she dropped her health insurance.

About two months later, she fell.

After getting the surgery bill, Buttgereit began calling and emailing the hospital’s customer service team, asking how the price had risen from the $50,560 estimate to nearly $98,000. The hospital had automatically applied the self-pay discount of $19,600 to Buttgereit’s bill — 20% of the total. But that still left her with a tab of more than $78,000.

After more time to think pain-free, she said, she also wanted to know why the initial estimate was much steeper than those she found online for similar procedures.

Specifically, Buttgereit asked how to dispute her bill. When she felt she wasn’t making progress contesting the charges with the hospital, she asked about her options under the No Surprises Act, a federal consumer protection law.

According to emails reviewed by KFF Health News, a Bozeman Health billing employee incorrectly told Buttgereit the law applies only to ER services. The employee later said Buttgereit had the right to dispute the bill but gave her an incorrect deadline.

Hospital staffers recommended Buttgereit set up a payment plan and apply to the health system’s financial aid program.

Erin Schaible, a spokesperson with Bozeman Health, told KFF Health News that online estimates don’t reflect the specific details of a patient’s care. In addition to the shattered bones noted in Buttgereit’s surgery notes, Schaible said the physician identified nerve damage midsurgery that required additional work to fix.

“This situation highlights the importance of clear and compassionate communication,” Schaible said. “In response, our team leaders are revising internal protocols for escalating patient concerns and are reeducating staff on best practices for communicating cost estimate changes.”

The Resolution

Buttgereit refused to apply for financial aid, opting instead to challenge what she sees as inflated pricing. Using Healthcare Bluebook, an online price comparison tool that draws on insurance claims data, Buttgereit found similar procedures ranged from $8,000 to $40,000.

She said she believes that there are also errors on her bill and that the complications didn’t justify the price.

“I felt like going through financial assistance means that I’m OK with the price of the bill,” she said. “I want to get the bill reduced on the front end and then, if I need financial assistance, go through it.”

A billing employee emailed Buttgereit in May to offer an additional $7,000 discount if she set up a payment plan. If she later qualified for financial assistance, “we will adjust the amount accordingly,” the email said.

In June, the employee told Buttgereit her account would be put on hold before a collection process was initiated, “so that you have time to decide what to do.”

Buttgereit agreed to a payment plan of $100 a month, though she continued to contest the total charges.

At that rate, it would take about 60 years to pay off the debt — or longer, if the health system were to charge interest.

Buttgereit made one more bid for help: She emailed the White House.

This month, in the same week she got a detailed letter from the hospital standing by its charges, Buttgereit said she received a call from an official with the Centers for Medicare & Medicaid Services, saying she could dispute the bill to federal health officials.

The Takeaway

The best time to push back against a price is before surgery, upon receiving a hospital’s best guess on costs, known as a “good faith estimate.” Otherwise, undergoing surgery is considered tacit acceptance of that price as a baseline.

Patricia Kelmar, director of health care campaigns at the national consumer advocacy group U.S. PIRG, follows ways in which people get tangled financially in the health industry. She said patients should compare cost estimates by searching their hospital’s online pricing tool (as well as those of nearby hospitals) to see whether the estimates align. But not every procedure makes those lists, especially those for uncommon injuries, nor is every hospital’s list easy to access and navigate.

Post-surgery, patients have few resources to fight big bills, but a little-known rule in the No Surprises Act could help, Kelmar said.

The law, which took effect in 2022, is best known for protecting patients from surprise bills for out-of-network, emergency care. But it also created a formal dispute process for uninsured patients, or those paying completely out-of-pocket for nonemergency procedures, if their final tab is $400 or more than the initial estimate.

“This is a valid, important part of making sure that patients who are cash-pay have a watchdog,” Kelmar said.

People can start the patient-provider dispute process online, through the CMS website, by providing medical records and paying a $25 fee. Patients must initiate the process within 120 days of receiving the bill, and the bill may not be sent to a collection agency while under review.

An independent reviewer evaluates whether the final price is drastically different from what a health insurance company would have paid and whether the complication was predictable. If the review finds that the health provider erred on either front, federal health officials could require them to reduce the bill to match the original estimate or the median price insurers pay.

Buttgereit said she initially opted against pursuing that formal dispute process because, after such a review, the floor would be the hospital’s initial estimate, and she still had questions about how it would work. But after hearing from CMS, Buttgereit said it’s the path she plans to take.

“You’ve got to fight for yourself,” she said. “I don’t know where this is going to end up, but I feel a little bit more hopeful.”

Tescha Hawley learned that hospital bills from her son’s birth had been sent to debt collectors only when she checked her credit score while attending a home-buying class. The new mom’s plans to buy a house stalled.

Hawley said she didn’t owe those thousands of dollars in debts. The federal government did.Hawley, a citizen of the Gros Ventre Tribe, lives on the Fort Belknap Indian Reservation in Montana. The Indian Health Service is a federal agency that provides free health care to Native Americans, but its services are limited by a chronic shortage of funding and staff.

Hawley’s local Indian Health Service hospital wasn’t equipped to deliver babies. But she said staff there agreed that the agency would pay for her care at a privately owned hospital more than an hour away.

That arrangement came through the Purchased/Referred Care program, which pays for services Native Americans can’t get through an agency-funded clinic or hospital. Federal law stresses that patients approved for the program aren’t responsible for any of the costs.

But tribal leaders, health officials, and a new federal report say patients are routinely billed anyway as a result of backlogs or mistakes from the Indian Health Service, financial middlemen, hospitals, and clinics.

The financial consequences for patients can last years. Those sent to collections can face damaged credit scores, which can prevent them from securing loans or require them to pay higher interest rates.

The December report, by the federal Consumer Financial Protection Bureau, found these long-standing problems contribute to people in Native American-majority communities being nearly twice as likely to have medical debt in collections compared with the national average. And their amount of medical debt is significantly higher.

The report found the program is often late to pay bills. In some cases, hospitals or collection agencies hound tribal citizens for more money after bills are paid.

Hawley’s son was born in 2003. She had to wait another year to buy a home, as she struggled to pay off the debt. It took seven years for it to drop from her credit report.

“I don’t think a person ever recovers from debt,” Hawley said.

Hawley, a cancer survivor, still must navigate the referral program. In 2024 alone, she received two notices from clinics about overdue bills.

Frank White Clay, chairman of the Crow Tribe in Montana, testified about the impact of wrongful billing during a U.S. House committee hearing in April. He shared stories of veterans rejected for home loans, elders whose Social Security benefits were reduced, and students denied college loans and federal aid.

“Some of the most vulnerable people are being harassed daily by debt collectors,” White Clay said.

No one is immune from the risk. A high-ranking Indian Health Service official learned during her job’s background check that her credit report contained referred-care debt, the federal report found.

Native Americans face disproportionately high rates of poverty and disease, which researchers link to limited access to health care and the ongoing impact of racist federal policies.

White Clay is among many who say problems with the referred-care program are an example of the U.S. government violating treaties that promised to provide for the health and welfare of tribes in return for their land.

The chairman’s testimony came during a hearing on the Purchased and Referred Care Improvement Act, which would require the Indian Health Service to create a reimbursement process for patients who were wrongfully billed. Committee members approved the bill in November and sent it for consideration by the full House.

A second federal bill, the Protecting Native Americans’ Credit Act, would prevent debt like Hawley’s from affecting patients’ credit scores. The bipartisan bill hadn’t had a hearing by mid-December.

The exact number of people wrongfully billed isn’t clear, but the Indian Health Service has acknowledged it has work to do.

The agency is developing a dashboard to help workers track referrals and to speed up bill processing, spokesperson Brendan White said. It’s also trying to hire more referred-care staff, to address vacancy rates of more than 30%.

Officials say problems with the program also stem from outside health providers that don’t follow the rules.

Melanie Egorin, an assistant secretary at the U.S. Department of Health and Human Services, said at the hearing that the proposed legislation doesn’t include consequences for “bad actors” — health facilities that repeatedly bill patients when they shouldn’t.

“The lack of enforcement is definitely a challenge,” she said.

But tribal leaders warned that penalties could backfire.

White Clay told lawmakers that some clinics already refuse to see patients if the Indian Health Service hasn’t paid for their previous appointments. He’s worried the threat of penalties would lead to more refusals.

If that happens, White Clay said, Crow tribal members who already travel hours to access specialty treatment would have to go even farther.

The Consumer Financial Protection Bureau report found clinics are already refusing to see any referred-care patients due to the program’s payment problems.

The bureau and the Indian Health Service also recently published a letter urging health care providers and debt collectors not to hold patients accountable for program-approved care.

White, the Indian Health Service spokesperson, said the agency recently updated the referred-care forms sent to outside hospitals and clinics to include billing instructions and to stress that patients aren’t liable for any out-of-pocket costs. And he said the staff can help patients get reimbursed if they have already paid for services that were supposed to be covered.

Joe Bryant, an Indian Health Service official who oversees efforts to improve the referral program, said patients can ask credit bureaus to remove debt from their reports if the agency should have covered their bills.

Leaders with the Confederated Tribes of the Colville Reservation in Washington state helped shape the proposed legislation after their citizens were repeatedly harmed by wrongful billing.

Tribal Chairman Jarred-Michael Erickson said problems began in 2017, when a regional Indian Health Service office took over the referred-care program from local staff.

It “created a domino effect of negative outcomes,” Erickson wrote in a letter to Congress.

He said some tribal members whose finances were damaged stopped using the Indian Health Service. Others avoided health care altogether.

Responsibility for the Colville Reservation program transferred back to local staff in 2022. Staffers found the billing process hadn’t been completed for thousands of cases, worth an estimated $24 million in medical care, Erickson told lawmakers.

Workers are making progress on the backlog and they have explained the rules to outside hospitals and clinics, Erickson said. But he said there are still cases of wrongful billing, such as a tribal member who was sent to collections after receiving a $17,000 bill for chemotherapy that the agency was supposed to pay for.

Erickson said the tribe is in the process of taking over its health care facilities instead of having the Indian Health Service run them. He and others who work in Native American health said tribally managed units — which are still funded by the federal agency — tend to have fewer problems with their referred-care programs.

For example, they have more oversight over staff and flexibility to create their own payment tracking systems.

But some Native Americans oppose tribal management because they feel it releases the federal government from its obligations.

Beyond wrongful billing, access to the referred-care program is limited because of underfunding from Congress. The $1 billion budget this year is $9 billion short of the need, according to a committee report by tribal health and government leaders.

Donald Warne, a physician and member of the Oglala Sioux Tribe in South Dakota, called the proposed legislation a “band-aid.” He said the ultimate solution is for Congress to fully fund the Indian Health Service, which would reduce the need for the referred-care program.

Back in Montana, Hawley said she braces for a fight each time she gets a bill that the referral program was supposed to cover.

“I’ve learned not to trust the process,” Hawley said.

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This article first appeared on KFF Health News and is republished here under a Creative Commons license.