Filling out paperwork is par for the course when visiting the doctor. But there may be some forms patients aren’t expected to read too closely. 

Chet Waldman, a partner at the law firm Wolf Popper, experienced this firsthand when he went in for an epidural shot for chronic pain at ProHealth Ambulatory Surgery Center in New Hyde Park last month. Staff at the outpatient facility told him he couldn’t go through with the procedure unless he agreed to sign ProHealth Care’s patient financial liability form as written. Waldman, who has represented patients in surprise medical bill lawsuits, refused and was turned away.

ProHealth insists its financial liability form is reasonable, but Waldman says he was being asked to write a “blank check.”

(Full disclosure: Waldman is a cousin of Brian Lehrer, who works for WNYC; Gothamist, WNYC, and ClearHealthCosts are partners in #PriceCheckNYC, our series on making health care costs more transparent.)

The form essentially said he agreed to pay whatever costs were incurred that day that were not covered by his insurance, Waldman says. (ProHealth declined to provide a copy of the form to Gothamist.) He was concerned that by signing it, he would be undermining his rights under New York’s surprise billing law, which says that patients will not be financially liable when they unexpectedly receive out-of-network care. Waldman knew his doctor at ProHealth was in-network for his insurance plan. But he says no one at the office could tell him at the time whether the anesthesiologist was also in-network.

Given his uncertainty about what he would ultimately be charged, Waldman inserted the word “reasonable” at several points in the form to qualify the amount he was willing to pay before signing it. This apparently “horrified” the ProHealth staff member at the front desk, who told him he could not modify the agreement,  he said. 

When he told another staff member that he is an attorney familiar with the surprise billing law, “she offered me the ability to have my medical procedure as long as I agreed not to have anesthesia,” he wrote in a letter about the experience. He declined. Then the staff told him that if he didn’t sign, he couldn’t have his procedure, so he left with assurances that a ProHealth lawyer would call to discuss the issue.

He said he has similarly edited other financial liability forms in other medical encounters, to ensure that he is signing a form acknowledging he will pay “reasonable” charges. 

Waldman sent a scathing letter about the incident to various news outlets, as well as the Health Care Bureau of the New York Attorney General’s Office, the state Departments of Health and Financial Services, and the Nassau County District Attorney and Department of Health. He also billed ProHealth for $1,780 for “professional time wasted” on going to the center and not receiving treatment.

Kimberley Lazar, ProHealth’s general counsel, maintains that Waldman’s concerns about the financial liability form are unfounded.

“I don’t think it implicates the surprise billing law,” Lazar said in a phone call with Gothamist. “It just states that the patient is responsible for their portion of the financial obligations. I’ve explained to [Waldman] how the surprise billing act is not implicated here.”

Lazar finally confirmed last week that the surgery center’s anesthesia provider, Mobile Medical Services, is, in fact, in-network for Waldman’s Oxford insurance plan. This took a surprising amount of digging on ProHealth’s part to find out. When Waldman first called his insurer after the failed visit, he says he was told that the anesthesia company was not in-network.

The uncertainty about whether the anesthesia company was in-network is particularly puzzling given that Waldman’s health plan, along with the surgery center and anesthesia company, are all apparently part of UnitedHealth Group. Lazar confirmed that the anesthesia provider, Mobile Medical Services, is affiliated with ProHealth. ProHealth, one of the New York region's largest medical groups, was acquired in 2014 by OptumCare, a unit of UnitedHealth Group. UnitedHealth has owned Oxford since 2004. Dr. Zeyad Baker, the CEO of ProHealth, has been adamant that there’s a “firewall” between Optum and United.

Firewall notwithstanding, though, this would not be the first time a UnitedHealth Group subsidiary was set up to seemingly shift health costs onto patients. The company agreed in January 2009 to settle a lawsuit brought by Andrew Cuomo, then New York's Attorney General, accusing United's Ingenix medical billing database of setting faulty rates for medical procedures that may have led millions of patients across the country to overpay for out-of-network care, while benefiting insurers. United did not acknowledge wrongdoing in the settlement, although one UnitedHealth Group lawyer admitted that "conflicts of interest were inherent" in the Ingenix database. United agreed at the time to shut down Ingenix and make a $50 million payment to set up an independent database to replace it.

In any case, now that the anesthesia question has been resolved, ProHealth has worked with Waldman to reschedule his epidural appointment for February 3rd. “I believe we’ve resolved all of his concerns here,” Lazar said.

Waldman disagrees:  “I said, ‘OK, yeah, this is all great, you helped me, but I’m still not signing your form.” He says he offered to make edits to the form ahead of his next appointment, but Lazar has yet to okay the idea. She has not responded to a query from Gothamist about whether Waldman will be able to move forward with his procedure if he continues to refuse to sign the form as written. Waldman contends Lazar implied that she would let him amend the form if he agreed to stop cooperating for this article.

“Blank check” financial liability forms are common and have become a growing concern for patients, according to Elisabeth Benjamin, vice president of health initiatives at the nonprofit Community Service Society of New York. Her organization has amassed a collection of the forms from a range of health care providers in New York, showing that the language used—and how broad it is—can vary widely:

“We’ve been seeing a lot of patients getting these forms that say, ‘I promise to pay whatever my insurance company doesn’t pay and I’m on the hook, regardless of what you do or don’t do,’” Benjamin says. “That drives people really crazy.”

Even if patients are told whether their care will be in-network, they typically are not told exactly how much they’re agreeing to pay, Benjamin notes. Demanding patients to automatically pay any bill they receive is even more problematic in light of the fact that advocacy groups that review medical bills on patients’ behalf estimate that 75 to 80 percent of the bills contain errors.

The Patient Medical Debt Protection Act, introduced in the state legislature in the fall, would put in place a range of measures to increase consumer protections in health care, including standardizing the language in financial liability forms. The bill already has 32 sponsors in the Assembly and 12 in the Senate.

In the meantime, most patients will probably sign whatever medical forms they’re handed.

Matthew Insley-Pruitt, another Wolf Popper partner, had a similar experience to Waldman’s when he went in for a colonoscopy at Carnegie Hill Endoscopy in Manhattan last Monday. He signed all the paperwork given to him at the front desk, he said, then went toward the endoscopy suite. "They make you disrobe, take vitals, and insert an IV," he said. At that point, he said, as he was on the gurney, the anesthesiologist entered the room and said, 'Hi, I will be your anesthesiologist, and I'd like you to sign these forms.'" 

The forms confirmed that he would be financially liable for any uncovered expenses, he said. He asked the anesthesiologist if she took the same insurance as the other providers there, and she said, "I don't know that, but I'm sure that out front they would have told you if there’s a problem." 

He said he took that as an "oral representation" that there would not be a problem, so he signed. He has not yet received any bills.

Update, February 18th: 

The standstill between patient Chet Waldman and ProHealth has ended. Waldman says after this story came out, ProHealth caved and allowed him to edit the financial liability form he was originally turned away for refusing to sign as written when he went in for an epidural for chronic pain in December. He finally received the procedure on February 3rd. The lawyer said this time he edited the form more extensively than he did the first time around.

“In addition to adding the word ‘reasonable’ any time the form asked that you pay their balance bills, I also crossed out several sentences where I would have had to agree to pay their undisclosed rates,” Waldman tells Gothamist.

A spokesperson for ProHealth said of the incident, “Our priority is to deliver the very best care. We’re happy that we could address his concerns and that he’s chosen us for that care.”

But Waldman says he still worries other patients will end up having to sign the same “blank check” financial liability form.

“While ProHealth ultimately accommodated me after sending me home because I was a lawyer who made waves and whose leverage was bolstered by the Gothamist article,” Waldman said, “the episode will not be of any help to future patients who have to sign ProHealth’s forms unless it causes ProHealth to go back and modify the forms.”

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Support for this work was provided by the New York State Health Foundation (NYSHealth). The mission of NYSHealth is to expand health insurance coverage, increase access to high-quality health care services, and improve public and community health. The views presented here are those of the authors and not necessarily those of the New York State Health Foundation or its directors, officers, and staff.