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The email arrived in Elliot Malin’s inbox from his cousin’s mom.
“Scott needs a kidney,” the subject line read.
The message matter-of-factly described Scott’s situation: At 28 years old, Scott Kline was in end-stage renal failure. He wasn’t on dialysis yet. But he probably should have been.
His mom was reaching out to as many people as she could, asking them to be screened as a potential donation match.
“Thank you for considering it, but please don’t feel any pressure to do it,” she wrote. “Sorry I have to share this burden, but the best potential match is family.”
Malin didn’t need to be pressured. For him, the decision was easy.
“There was no other thought besides trying to help Scott,” Malin later said.
He clicked on a link in the email to begin the screening process.
If he turned out to be a match, Malin knew the surgery could put his health at risk. The recovery would be physically painful. What he didn’t anticipate was that it would put his finances in jeopardy. That just as he would have to trust the skilled hands of the surgeon to make sure the operation went well, he’d have to trust in the expertise of billing coders and financial coordinators to navigate the increasingly complex system that covers the costs of transplant surgeries.
Living organ donors are never supposed to receive a bill for care related to a transplant surgery. The recipient’s insurance covers all of those costs. This rule is key to a system built on encouraging such a selfless act. And for most uninsured patients in end-stage kidney failure, Medicare would pick up the tab. But in Malin’s case, he would end up facing a $13,000 billing mistake and the threat of having his bill sent to collections.
A bill from NorthStar Anesthesia to Malin for $13,064 (Andri Tambunan, special to ProPublica)Donors like Malin play a critical role in the nation’s transplant system. According to data from the United Network for Organ Sharing, in the last three years more than 30% of kidney donations came from living donors. Neither UNOS nor other national advocacy organizations track how often billing problems like those encountered by Malin occur. But advocates say they do happen and can deter donors from coming forward.
“Living donors should not be receiving any bills at all whatsoever regarding any part of the living donation process,” said Morgan Reid, director of transplant policy and strategy for the National Kidney Foundation.
Malin and Kline describe themselves as cousins, but their blood relationship is distant. Their great-grandfathers were brothers, making them third cousins. Still, they’re the same age and grew up as friends, sometimes traveling and spending holidays together. Kline attended Malin’s wedding in 2019.
Exactly what went wrong with Kline’s kidneys is a mystery. In the summer of 2020 he had just moved to Fort Worth, Texas, for work. He went in for routine blood work to monitor a medication he was taking. When the results came in, the doctor called to ask if he was on dialysis.
“You’re in end-stage renal failure,” the doctor told him.
“Oh, no I’m not,” Kline responded.
The bloodwork wasn’t wrong. He had just 17% kidney function. Thus began his search for a new organ. Kline was told his wait for a kidney could be three to five years if a friend or family member didn’t step forward. In February 2021, Kline and his family began reaching out to everyone they knew. Volunteers signed up for medical screening, but insurance would only pay to test one at a time. Waiting for one potential donor to be ruled out before testing another drew out an already lengthy process.
Four months after Malin signed up to be screened, he got final confirmation he was a match.
By June, the two cousins were deep in the byzantine organ transplant bureaucracy: screeners, financial counselors, doctors, specialists, laboratories and, the most difficult, insurance companies.
“The amount of hoops you have to jump through to do this is pretty extraordinary,” Malin said, describing rounds of medical tests, mountains of paperwork and preauthorizations for procedures. A multidisciplinary team of professionals assembled to assist the two patients through the process.
“The hospital was amazing on trying to make everything as easy as possible,” he said of the team.
Malin said they gave him one assurance: He wouldn’t have to contend with any bills or be responsible for a dime of the surgery’s estimated $160,000 cost. The team had received preauthorization from Kline’s insurance plan, which would pick up all of Malin’s medical costs.
That assurance, however well-intentioned, fell flat.
Malin, right, and his cousin Scott Kline in the hospital for the transplant surgery (Courtesy of Elliot Malin)In July, Malin traveled from his home in Reno, Nevada, to Fort Worth, where the cousins underwent the transplant surgery at Baylor Scott & White All Saints Medical Center. The surgery was successful.
Malin spent three days in the hospital recovering, Kline a day or two longer — a painful experience made bearable by their companionship.
“We would do our little walks around the hospital floor,” Kline said. “We would be suffering together. It was really nice to have that. Usually you’re there alone, especially during COVID.”
By early August, Malin was back in Reno to finish recuperating. The next week, he started law school. Life was getting back to normal.
When the first bill arrived, it was more annoying than stressful. It totaled just $19.15 for blood work done before the surgery. The hospital said it would take care of it, Malin said. Then he got a notice that an old insurance plan he was no longer a member of had been billed $934 for lab work. Again, he notified the hospital.
In late September, Malin got a bill for a stomach-dropping amount: $13,064. While he was startled by the cost, it didn’t worry him too much. He knew Kline’s insurance was responsible for paying it. He notified the hospital and forgot about it.
A month later, a second notice arrived. Then, on Dec. 6, Malin received a document that scared him.
“Final Notice! Your account is now considered delinquent,” the notice read. If he didn’t take action, the billing company warned, it would attempt “further collection activity.”
The bill was from NorthStar Anesthesia, a firm that provides anesthesia services to hospitals across the country, including Baylor Scott & White All Saints.
NorthStar Anesthesia warns Malin that his bill could be sent to collections. (Courtesy of Malin, highlight added by ProPublica)Now, Malin wasn’t only irritated that the bills just kept coming, he was worried about his credit.
“I did call them and kind of chewed them out a little bit,” Malin said. “I walked through what this was for, that it was a kidney donation and I’m not the responsible party.”
Malin complained on Twitter about the aggressive billing practice, eliciting an array of responses, from jokes about asking for his kidney back to outrage that he’d be in this position after such a gift.
After he called the billing company and the hospital, there was nothing else he could do.
“I’m just waiting to see if I go to collections or not,” Malin told ProPublica two weeks later.
He did his best to leave Kline out of it entirely.
“He’s had a lot on his plate,” Malin said of his cousin. “His recovery has been harder than mine. He’s the one accepting the organ, so he’ll be on immunosuppressants the rest of his life. Because of COVID, he’s largely stuck indoors. I don’t tell him a lot of it. I don’t want to stress him out.”
Still, it troubled Kline that Malin was facing such problems.
“At the end of the day, I want everything to go as smoothly as possible for Elliot,” Kline said. “He was doing me an unbelievable kindness. I owe my life to him.”
A stack of bills for Malin's transplant surgery (Andri Tambunan, special to ProPublica)Malin heard nothing until Jan. 19, one day after ProPublica reached out to NorthStar for comment.
“The CFO of NorthStar just called me and told me she’s taken care of the bill,” Malin texted a reporter.
The next day, the company emailed Malin, confirming he would not be responsible for the bill, that he was never sent to collections and that his credit wouldn’t be affected.
“On behalf of NorthStar, I apologize for causing any confusion or concern for you regarding this matter and assure you that it has been resolved,” wrote Kate Stets, the company’s chief financial officer.
She said that after his call on Dec. 7, the bill had been rerouted to “the correct parties,” but that the company had failed to communicate that to him. The letter explained that NorthStar had received incorrect insurance information at the time of the surgery. (A spokesperson later said NorthStar received no insurance information at the time of the surgery.) In such cases, bills are automatically sent to the patient.
The company has since adjusted its policy to prevent that from happening in future transplant cases, Stets wrote.
“To be clear, it is not NorthStar’s policy to bill transplant donors for bills related to their donation surgeries,” Stets wrote. “We recognize the well-established public policy standard and practice that transplant donors should not be billed for such services — that we and the nation’s health care system have a responsibility to foster and encourage such acts of selflessness and generosity.”
In a statement, a NorthStar spokesperson said no other organ donors owe “out of pocket payments.”
“NorthStar did not hear from Baylor on this matter previously and was first notified of the billing error on December 7, 2021 after insurance information was not provided to NorthStar by the transplant center at the point of care,” a spokesperson said. “NorthStar resolved the error immediately and closed the account that same day, prior to any inquiry from ProPublica.”
Both Malin and Kline commended the team at Baylor Scott & White All Saints that guided them through the process. The hospital, however, declined to grant an interview to ProPublica about what went wrong with the billing.
A spokesperson provided a short statement: “We are pleased this has been resolved for our patient by NorthStar. Although billing can be complicated, these occurrences are rare. We have also been in touch with the patient and we don’t have anything further to report.”
Financing such surgeries is so complex that transplant centers employ coordinators to help both patients with the process.
“I tell donors, I can’t guarantee you won’t get a bill, but if you do, call me,” said Deidra Simano, president of the Transplant Financial Coordinators Association.
In one case, after trying everything to get a provider to bill the proper insurance, Simano resorted to paying a patient’s $200 bill with the transplant center’s credit card.
“That’s what we had to do to make it go away,” she said.
Malin said he feels fortunate to be equipped to fight the billing issues. He worries about others with fewer means facing a similar situation, recognizing it could be a barrier to those selfless enough to donate an organ.
“It sucks but I wouldn’t have changed any of it,” he said. “I like my cousin. I want him to be healthy.”
Malin with a kidney-shaped pillow given to him at the hospital for his recovery (Andri Tambunan, special to ProPublica)The city of Minneapolis, Minnesota is temporarily ending the use of no-knock warrants following the killing of 22-year-old Amir Locke by Minneapolis police officers. The city's mayor, Jacob Frey, has placed a moratorium on these warrants until the policy can be reviewed by Professor Pete Kraska of Eastern Kentucky University and anti-police violence activist DeRay McKesson.
This comes as too little too late for Locke and his surviving family. The entire raid was caught on body cam and it shows Amir Locke picking up a gun (but not pointing it at officers) after he was awakened by police officers swarming into the residence.
Locke, who was not a target of the investigation, was sleeping in the downtown Minneapolis apartment of a relative when members of a Minneapolis police SWAT team burst in shortly before 7 a.m. Wednesday. Footage from one of the officers' body cameras showed police quietly unlocking the apartment door with a key before barging inside, yelling "Search warrant!" as Locke lay under a blanket on the couch. An officer kicked the couch, Locke stirred and was shot by officer Mark Hanneman within seconds as Locke held a firearm in his right hand.
Locke was shot once in the wrist and twice in the chest. He died thirteen minutes after the shooting. As you may have noticed from the preceding paragraph, Locke was not a suspected criminal. And for those who may argue simply being within reach of a firearm is justification for shooting, Locke's handgun was legal and he had a concealed carry permit. His justifiable reaction to people barging into an apartment unannounced is somehow considered less justifiable than the officers' decision to kill him.
In most cases, that's just the way it goes, which -- assuming the warrant dotted all i's and crossed all t's -- means the Second Amendment is subservient to other constitutional amendments, like the Fourth. Here's how Scott Greenfield explains this omnipresent friction in a nation where the right to bear arms is respected… but only up to a point:
The Second Amendment issue is clear. Locke had a legal gun and, upon being awoken in the night, grabbed it. He didn’t point it at anyone or put his finger on the trigger, but it was in his hand. A cop might explain that it would only take a fraction of a second for that to change, if he was inclined to point it at an officer, put his finger on the trigger and shoot. But he didn’t.
This conundrum has been noted and argued before, that if there is a fundamental personal right to keep and bear arms, and that’s what the Supreme Court informs us is our right, then the exercise of that constitutional right cannot automatically give right to police to execute you for it. The Reasonably Scared Cop Rule cannot co-exist with the Right to Keep and Bear Arms.
"Cannot co-exist." This means that, in most cases, the citizen bearing arms generally ceases to exist (along with this right) when confronted by a law enforcement officer who believes they are reasonably afraid.
There's another point to Greenfield's post that's worth reading, but one we won't discuss further in this post: the NRA's utter unwillingness to express outrage when the right to bear arms is converted to the right to remain permanently silent by police officers who have deliberately put themselves in a situation that maximizes their fears, no matter how unreasonable those fears might ultimately turn out to be.
But this is a situation that could have been avoided. A knock-and-announce warrant would have informed Locke (who was sleeping at a relative's house) that law enforcement was outside. As the owner of a legal gun and conceal/carry permit, it's highly unlikely this announcement would have resulted in Locke opening fire on officers.
It didn't have to be this way, but the Minneapolis Police Department insisted this couldn't be handled any other way.
A law enforcement source, who spoke on the condition of anonymity because of the sensitive nature of the case, said that St. Paul police filed standard applications for search warrant affidavits for three separate apartments at the Bolero Flats Apartment Homes, at 1117 S. Marquette Av., earlier this week.
But Minneapolis police demanded that, if their officers were to execute the search within its jurisdiction, St. Paul police first secure "no-knock" warrants instead. MPD would not have agreed to execute the search otherwise, according to the law enforcement source.
If it had been handled the St. Paul way, Locke might still be alive. There's no evidence here indicating deployment of a knock-and-announce warrant would have made things more dangerous for the officers. If this sort of heightened risk presented itself frequently, the St. Paul PD would respond accordingly when seeking warrants.
St. Paul police very rarely execute no-knock warrants because they are considered high-risk. St. Paul police have not served such a warrant since 2016, said department spokesman Steve Linders.
Contrast that with the Minneapolis PD, which appears to feel a majority of warrant service should be performed without niceties like knocking or announcing their presence.
A Star Tribune review of available court records found that MPD personnel have filed for, and obtained, at least 13 applications for no-knock or nighttime warrants since the start of the year — more than the 12 standard search warrants sought in that same span.
This is likely an undercount, the Star Tribune notes. Many warrants are filed under seal and are still inaccessible. But it does track with the MPD's deployment stats. According to records, the MPD carries out an average of 139 no-knock warrants a year.
This happens despite Minnesota PD policy specifically stating officers are supposed to identify themselves as police and announce their purpose (i.e., "search warrant") before entering. That rule applies even if officers have secured a no-knock warrant. If officers wish to bypass this policy that applies to no-knock warrants, they need more than a judge's permission. They also need direct permission from the Chief of Police or their designee. That's because no-knock warrants were severely restricted by police reforms passed in 2020. But it appears those reforms have done little to change the way the MPD handles its warrant business.
We'll see if the mayor's moratorium is more effective than the tepid reforms enacted following the killing of George Floyd by Officer Derek Chauvin. The undetectable change in tactics following the 2020 reforms doesn't exactly give one confidence a citywide moratorium will keep MPD officers from showing up unannounced and killing people during the ensuing confusion. It only took nine seconds for officers to end Amir Locke's life. Given what's been observed here it will apparently take several years (and several lives) before the Minneapolis PD will be willing to alter its culture and its day-to-day practices.
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