Jean Louis-Charles couldn't afford spine surgery to ease nagging spinal pain following a motor vehicle accident. So he signed a document, promising to pay for the bill with money he hoped to obtain from a lawsuit against the driver who caused the collision.
That never happened.
Louis-Charles, 68, died hours after the operation at a Florida outpatient surgery center in March 2022. The surgery center had put him in an Uber together with his wife, Marie Julien, according to depositions. After a 60-mile ride home, he collapsed, court public records show.
Her husband's death left Julien to deal with a lot more than $100,000 in medical debt, as described in the “letter of protection,” or LOP, that Louis-Charles had signed.
In signing an LOP, people generally pledge to pay for the costs of their care even if it exceeds the things they win in a lawsuit or other settlement – as well as if the prices are far higher than most doctors would charge.
The agreements are legal and binding in lots of states, though Florida seems to be the epicenter of the use in personal injury claims. Advocates say the letters throw a lifeline to low-income people who need vital health care for injuries brought on by the negligence of others and don't have the money or insurance coverage to cover it. Doctors and surgery centers that accept LOPs say they frequently wait years for any lawsuit to stay before being paid, if.
A KHN investigation found that letters of protection can saddle patients with medical debt – and drive an accident care system that operates with little oversight despite widespread complaints of grossly inflated billings and other issues that are able to place patients at risk.
Marie Julien blamed Dr. Kingsley R. Chin – a controversial Hollywood, Florida, surgeon that has accepted LOP payments for more than a decade – on her husband's death after the spinal fusion procedure. This past year, she filed a malpractice suit against Chin alleging that Louis-Charles died after he “was discharged home while still in pain and with indications of post-operative complications.” In court papers, Chin denied any negligence.
“We felt the way the whole thing happened was very bizarre,” Julien, 71, a professional nursing assistant, recalled in a deposition drawn in the situation.
A 'Terrible Situation'
Just before 8 a.m. on New Year's Day 2022, Louis-Charles' car was stopped at a sore point near his home. Suddenly a white police vehicle, driven by a Palm Beach County Sheriff's Office detective, backed into his Toyota Corolla, hitting the passenger side door, based on a police report.
In her deposition, Julien said Chin operated on her husband's shoulder in 2022. But that didn't help much, and Chin recommended more extensive surgery, she said. “I wasn't happy at all with this idea,” she added.
Julien said she relented because Louis-Charles' pain was getting worse “day by day” and he had confidence in the surgeon. The Aventura Surgery Center in Hallandale, Florida, where Chin had served as medical director, sent an Uber to collect the couple the morning of March 12, 2022, Julien said.
During the two-hour spinal fusion, Chin replaced three disks with an implant he invented, according to his deposition. The patient spent one hour inside a recovery room before a nurse wheeled him out to a waiting Uber just after 3 p.m., according to Chin's testimony.
Louis-Charles couldn't speak, but signaled he was at pain and struggled to breathe throughout the hourlong ride home, according to Julien's deposition. She helped him walk through the front door of their Riviera Beach home. Once inside he collapsed, she testified.
A fire rescue crew rushed him to some hospital in Delray, where he died soon after 5:30 p.m., according to a Palm Beach County Medical Examiner's autopsy report. The medical examiner ruled the death any sort of accident brought on by “post-surgical bleeding with airway compression.”
In his deposition, Chin asserted Louis-Charles “looked great” heading out towards the car which traveling along the urban Interstate 95 corridor the motive force was “at any given time probably within Ten minutes or so” from the “major hospital or er.”
Chin known as the outcome a “terrible situation” and told Julien's lawyer during the deposition: “I just we do hope you can appreciate how much I regret what happened.”
Asked how her husband's death has affected her lifetime, Julien said: “How are you able to find words to explain this?” The couple wed in 1987 in Miami after moving using their native Haiti, where he worked as a house carpenter.
“It's been almost two years now. I have not been able to rest on [the] bed” she distributed to him, she said.
In late September, Julien and Chin settled the suit under confidential terms and also the bills were “written off,” based on Kevin Smith, an attorney who represented Julien. Chin has denied any liability.
'A Mixed Bag'
Though little-known towards the public, letters of protection are generally used to finance major health care in personal injury cases, including costly orthopedic surgery.
Attorneys who refer injured clients to willing doctors say the liens are their best tool for ensuring clients not only access care, but additionally are in a situation to win fair settlements from insurance providers that battle to minimize their liability and costs.
An LOP form used by some Florida medical providers says they agree to wait for payment as a “courtesy” towards the injured person, including boldface: “We understand insurance companies have unlimited resources, will hire defense lawyers and defense experts that will cause our payment to be delayed for months or years.”
The business community and insurers counter that LOP providers grossly inflate their medical fees to give juries a false picture of the costs of medical care.
“The sole reason for the LOP, why it exists, would be to increase verdicts and settlements,” Lauren McBride, a lawyer for Publix Super Markets, a series with more than 800 stores in Florida, testified in a condition legislative hearing in February 2022.
McBride said that nearly two-thirds of “slip-and-fall” injury claims in Publix stores involve letters of protection. In more than half those cases, the injured person had some form of insurance but declined to use it, she said. In some instances, injured people traveled long distances for costly care they might have obtained nearer to home at far less expense, she said. She also argued that LOPs give doctors a motivation to overtreat patients “to keep driving up medical bills” – and persuade juries to award big verdicts.
Kevin Leahy, an Austin, Texas, lawyer who has researched the practice there and represented clients on sides of the debate, said LOPs deserve more scrutiny. “It's an assorted bag,” he said. “There are certainly abuses going on. There are also hurt people getting care they need to improve.”
Leahy said LOPs have helped produce a “liability-based” health care network with few checks on its financial dealings or other standards. He named it “unregulated, opaque and not fully accurate about charges.”
Across the nation, LOPs happen to be tied to a range of alleged medical overcharges or other billing abuses, court public records show.
Nearly 200 women from 42 states, for instance, have joined a class-action suit that alleges doctors and lawyers talked them into signing LOPs promising to cover surgical removal of pelvic mesh – whether or not they needed it removed or otherwise.
The women allege that the doctors billed sky-high rates and said excitedly their insurance wouldn't cover the cost, so signing an LOP was the only method to safeguard their health. Private insurance would have paid about $8,000 of these services, far less than the $76,000-plus the ladies were charged underneath the LOP, based on the suit, filed in late August. The case is pending. Six doctors have filed motions to dismiss the situation.
In a 2022 federal civil case, evidence emerged that a Texas spine surgeon charged nearly $400,000 under an LOP for procedures that Medicare would reimburse below $20,000, court records state.
Reviewing court cases in Florida, KHN found dozens of examples in which patients who signed LOPs alleged these were later sued for payment of excessive fees or received substandard health care.
'Unnecessary and Dangerous'
On your day of his spinal surgery, Louis-Charles signed a letter of protection that read partly: “While I'm injured and want care, I am unable to financially afford to pay your bill at the time services are rendered, I therefore, grant tag heuer a lien on my small claim against any and all arises from any settlement, insurance benefits or judgment.”
The documents said he'd pay “what is usual and customary for the area.” But the fees were much higher than private medical health insurance would cover or what the Medicare fee schedule provides for.
The Aventura Surgery Center, co-owned by Miami personal injury lawyer Sagi Shaked, billed nearly $100,000 for that operation, court public records show. Two other Shaked-affiliated companies billed a lot more than $35,000 for surgical supplies and anesthesia, according to the court public records. Shaked did not respond to numerous requests for comment. In his deposition, Chin said he no more operates in the Aventura Surgery Center.
Mark Woodard, 54, who had been rear-ended in an April 2022 motor vehicle accident in Fort Lauderdale, had three spine operations at the Aventura Surgery Center performed by Chin within letter of protection.
His bills topped $430,000, including $179,500 for the surgery center, $177,972 billed by Chin's medical office and $39,327 for implants from SpineFrontier, a Massachusetts medical device company Chin owns, court public records show.
“These charges are way to avoid it of line,” said Michael Arrigo, a medical billing expert in California asked by KHN to review Woodard's bills. Arrigo said “usual and customary” charges could be under one-fourth of what was billed.
Woodard, that has worked as a painter and maintenance technician at beachfront hotels in Fort Lauderdale, argues in the lawsuit that his injuries from the crash were “nothing a lot more than cervical and lumbar sprains and strains – so that no reasonable physician might have performed surgery apart from for monetary purposes.”
According to Woodard's lawsuit, Chin persuaded him to have multiple operations and during one tore a 1-centimeter hole via a nerve root, leaving him in “extreme agony and excruciating pain.”
The suit, filed in March 2022, alleges the surgery center offered Chin a “safe haven to do his unnecessary and dangerous surgeries.” Additionally, it alleges that Chin “was not able to perform surgery at any hospital in the state of Florida and most if not all surgery centers where he'd applied had either denied him privileges or he had his privileges revoked at multiple hospitals.” In court filings, Shaked has denied the allegations and then any liability.
Chin also offers denied any negligence in court filings and in a deposition known as the fees he charged “reasonable inside the community.” Woodard's lawsuit is pending in Broward County Circuit Court.
Chin continues to be sued repeatedly for medical negligence, including several cases involving LOPs. He's been sanctioned by physician-licensing boards in three states, unrelated to his utilization of LOPs.
In early December, the Florida Department of Health, which licenses doctors, issued Chin a “letter of concern” and fined him $8,000. The action settled a state administrative complaint alleging that in August 2022 Chin sent home a 73-year-old man who suffered from complications of spinal surgery who should have been transferred “to a higher level of care in an inpatient setting (like a hospital).” Chin disputed the allegations.
Separately, federal agents arrested Chin in early September in Fort Lauderdale on kickback charges 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 guilty to the criminal charges.
In October, a federal judge ordered Chin to publish a $500,000 bond secured by his Florida home. He is free to travel inside the country “for business purposes only” and could travel once monthly to Jamaica “only for the purpose of practicing medicine there,” the order states. Chin has active medical licenses in Florida, Arizona, Nj, New York and in Jamaica, based on documents he filed to the court.
A 'Complete Shock'
By its very own account, the Broward Outpatient Surgical Center and its affiliates in Pompano Beach, Florida, have treated more than a thousand patients under letters of protection. But the billing practices Body lawsuit called its fees “astronomically unreasonable and inflated” – have been criticized in court filings for a long time. These cases often settle under confidential terms.
One patient argued inside a lawsuit that injured patients were “bounced around” a web of affiliated clinics for services that included maple grove chiropractic, pain injections, physical therapy and, finally, surgery, finished with no caps around the costs. The middle denied the allegations, and the case has since been settled.
Albert Frevola, a lawyer for the center, said that just before treatment patients are given a price list and sign an agreement to pay the bills from any settlement of the personal injury claims. He said the center serves many patients “who can not afford to obtain health care. It is a service that's valuable and needed.”
Some three dozen former patients have filed a recent mass tort lawsuit alleging medical negligence and billing fraud through the surgery center and its owners, chiropractors Brian and Craig Bauer, who are brothers. The suit also names spine surgeon Dr. Merrill Reuter, court records show. Neither Reuter nor his lawyer responded to requests for comment.
The patients allege they visited the middle after a car crash or any other accident and were persuaded to possess spinal surgery. In some cases, the operations either were billed weight loss complex compared to what they were, or otherwise done at all, based on the suit. Patients usually have run up bills of $100,000 or even more under LOPs, court public records show. “Due that personal injury patients rarely, if ever, use their private medical health insurance for such healthcare services, the Bauers and also the Bauer entities were able to pull off charging inflated amounts,” based on the suit.
Frevola, who represents the brothers, said they “flatly deny” the allegations and “are sad and distressed that these accusations are being made by exactly the same people they gave great care and medical treatment to.”
In another malpractice case, Terrell Harris, 37, alleged he was guided down a “treatment path” following a car crash in July 2022 that led to surgery at prices “far past the scope of reason, let alone custom.” The middle denied the allegations and filed a counterclaim accusing Harris of failing for his care underneath the LOP.
The suit is among eight pending in Broward County Circuit Court that make similar claims, including that of a woman who alleged she'd exactly the same pain after spinal surgery as she'd beforehand. Nearly five years later, to her “complete shock,” an MRI found no evidence the operation she was billed for have been done, according to the suit.
In a February 2022 court filing within the cases, the center and Brian Bauer denied the allegations and called them “frivolous and scandalous.” They filed a counterclaim demanding to become taken care of their professional services. The situation is pending.
Warring Creditors
When fees are inflated under an LOP, patients may take home more income under an insurance coverage settlement or jury verdict. But if an instance settles for under the sum of those bills, patients may be on the hook to pay the total amount.
Lawyers who typically co-sign the LOPs try to persuade medical providers to reduce their fees, which often happens. When that fails, however, lawyers file a court action called an interpleader, which asks the court to determine who gets what among warring creditors.
KHN reviewed a large number of Florida court cases in which medical creditors holding LOPs demanded payment entirely. While many of these cases settled under confidential terms, court records show some accident victims ended up mired indebted or saw their damage awards drastically reduced by outsize medical billings and attorney's fees. In some instances, lawyers took home more than their injured clients.
That happened to Jose Merced, who fell and hurt himself after entering into a hole outside his apartment within the Orlando area. He received a $75,000 settlement but incurred bills of more than $850,000 for operations and other medical costs, which he contested as “highly inflated,” court records show. The bills included more than $700,000 in orthopedic surgical and facility fees.
In August 2022, the court allowed just over $35,000 to pay for the surgeries. Merced was awarded $10,000, while his lawyer got nearly $27,000, approximately $18,000 of it for professional fees and the rest for expenses.
In some interpleader cases, lawyers asked judges for one-third of the total settlement for his or her fees, plus expenses, which could add hundreds, otherwise thousands, of dollars more to their share.
A law group founded by Florida personal injury attorney Robert Fenstersheib filed at least 50 interpleader cases in Broward County Circuit Court between January 2022 and October of the year. Fenstersheib, who had been a fixture of local television ads because the “lawyer who listens,” was shot to death by his son in a murder-suicide in September 2022, though his Fenstersheib Law Group still operates under his relatives.
Many of the LOP patients now suing the Broward Outpatient Surgery Center and its owners were clients of the Fenstersheib firm, court records show. The middle and the law firm did business for years, however the center sued what the law states firm in 2022 alleging the lawyers failed to pay it millions of dollars owed under LOPs. What the law states firm responded that it was a victim of a $6.5 million embezzlement by former employees who pocketed settlement money meant for the middle. The suit was settled under confidential terms this season.
Federal prosecutors filed criminal charges against two former Fenstersheib employees regarding the the theft. In late November, among the men, Michael Wihlborg, a 47-year-old senior high school dropout who had helped the law firm for nearly two decades, admitted receiving a lot more than $2.A million in stolen funds in the scheme; he pleaded guilty to 1 count of conspiracy to commit wire fraud and three counts of filing a false income tax return, court records show. He faces as much as 29 years in prison, according to court records. Co-defendant Matthew Matlock pleaded guilty to similar charges on Dec. 15, court records show. The law firm didn't have comment.
Ethics Question
Some lenders also accept LOPs as collateral for patients who take a loan to tide on them while their injury case winds through the courts, which generally takes years. Interest fees pile up fast.
A Miami man who was injured following a pile of wood fell on him at a home improvement center borrowed $51,400 from a loan provider backed by an LOP in September 2022. He owed the organization $140,322 3 years later because of an interest rate of 18% charged every six months, court public records show.
Doctors also can generate cash from letters of protection. When they argue they must wait years for payment, some spine surgeons sell the liens on the burgeoning medical debt market.
Court records in Florida show millions of dollars of those liens have altered when doctors sold them. Buyers paid 10% to 25% from the amount of the bill and gambled they would have the ability to collect a tidy profit when a patient's lawsuit was settled.
The ethics of doctors wheeling and in patient bills and having a financial stake in the outcome of litigation has been questioned. A united states Medical Association policy says such deals are unethical because “there may be the ever-present danger the physician may become less of a healer and much more of the advocate or partisan in the proceedings.”
Dr. Scott Lederhaus, a retired California neurosurgeon that has reviewed personal injury cases for that defense, said some patients argue in depositions that under an LOP they never saw bills, so that they had no idea of the extent of the medical costs they were incurring over time.
Lederhaus said there is little agreement on which is really a reasonable medical fee and, as a result, doctors “are in a position to charge anything they want” in personal injury claims.
And it remains unclear if the No Surprises Act, which Congress passed last year amid a national outcry over huge and unexpected medical bills, offers patients who signed LOPs any protection.
“A large amount of these doctors believe they are able to do anything they want and there's not really any oversight by anyone,” Lederhaus said.
Fred Schulte:
fschulte@kff.org,
@fredschulte
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