Preparing for medical costs and correcting errant medical bills shouldn’t be a full-time job. I’ll provide tips to navigate the process, so you can save inordinate amounts of time.
After:
- receiving a denial of insurance benefits for a previously approved procedure with an in-network provider at an in-network facility (my responsibility would have been a cool $65,000+),
- the hospital’s failure to send my payment to the insurer to count toward my deductible, which affected all later medical bills and out-of-pocket calculations throughout the year, including potentially paying over my out-of-pocket max, and
- receiving repeat bills: which I already paid, which I disputed, and which were then sent to collections,
I can empathize with medical bill madness. Even with multiple calls, escalations and diligent documentation, my health insurer and providers caused me to fall into a seemingly inescapable black hole of wasted time and stress. I’d like to help you avoid both.
In part 1 of “How to Navigate Endometriosis in an Unhealthy Medical System”, I discussed diagnosis dilemmas and empowering, experience-based propellors to diagnosis clarity: be your own documentarian and diagnosis detective, and choose a transparent physician who listens and makes time for you. Here, in Part 2, I focus on easing health insurer and medical bill uncertainties. Part 3 will address post-surgery disappointment and symptom management.
For those suffering from endometriosis, or any condition with medical bill madness, this series is for you. You’re not just another patient, who moonlights as an accountant to fix wack medical bills.
Some Consumer Protection
Let’s start with better news. In the extreme frustration of my medical bill madness, I learned about consumer protections for medical bills.
No, thank you, to surprise bills.
The federal No Surprises Act for Insureds protects consumers using insurance from surprise, out-of-network costs. For instance, if you have emergency services at an out-of-network ER, you cannot be charged more than the in-network cost. Or, if you go to an in-network hospital or surgical center for a non-emergency service, and there is an out-of-network provider (anesthesia or lab, for example), you must be charged the in-network cost.
See previous link for exclusions, like: short-term health insurance, health care sharing ministry plans, vision only or dental only plans, if you sign a consent form, and ground ambulance services. Air ambulance services are included in protections for consumers.
For self-pay patients, the federal No Surprises Act for Self-Payers requires providers to give a written, good faith cost estimate, if requested at least 3 business days prior to scheduled treatment. Then, if the charge for a single provider is at least $400 different, you may dispute your bill. Be sure to request a written good faith estimate from each provider in your care (facility, labs, anesthesia, physician). You must dispute your bill within 120 days of receiving the initial bill.
The good faith estimate for self-payers doesn’t apply to emergency care. The uncertainty of ER treatment explains uncertainty of ER charges.
Yes, please, to price transparency.
Although good faith estimates for self-payers don’t apply to emergency care, there is consumer protection against hidden hospital charges. Hospital Price Transparency requires hospitals to publicly disclose standard charges in a consumer-friendly format. I found standard charges on my hospital’s website. This particular hospital was noncompliant and previously fined nearly $1M. Here is CMS’ list of noncompliant hospitals, which received a civil monetary penalty.
Insurers are also subject to price transparency. The Transparency in Coverage Rule generally requires health insurers to make cost sharing and negotiated rates available to plan participants.1 I called my health insurer to determine how to search cost sharing and negotiated rates for billable codes online, since this search function wasn’t available on the insurer’s app. The search worked on a web browser and clarifies out-of-network costs, including likely balance billing outcomes (the difference between what the insurer will pay and what the out-of-network provider will bill).
Even with Consumer Protection, Health Insurer Evasion
Clarifying coverage to prepare for medical costs should be straightforward and simple; it wasn’t. Prior to my endometriosis surgery, I called my health insurer to confirm coverage. The first representative couldn’t give me a clear answer but did gift me a very long, confusing phone call. When I called back, I spoke to another representative, who confirmed coverage.
I saved the reference number from the confirmation call. I was a bit overkill: I confirmed the surgeon, the surgeon’s back-up, the procedure code and the hospital were covered. Predictable plot twist: even though I confirmed coverage, my health insurer dodged full coverage.
Alarmingly, I received a $65,000+ denial of coverage after surgery. During surgery, the surgeon unstuck organs, and part of the bad stuff inside me (no, not my silent rage at reckless medical billing practices – the endometriosis stuck to organs) burst open. To aid healing, the surgeon decided to apply regenerative treatment to scarred, internal areas. Notably, after the insurer sent me the denial, the insurer didn’t even know what the treatment was for and couldn’t explain the charge. I wasted several hours on the phone with the insurer, who couldn’t even identify what occurred during surgery to incur a $65K + charge. At a follow-up with my surgeon, he clarified.
The insurer contended the regenerative treatment was investigational, despite: 1) stage IV endometriosis, which had invaded multiple organs in and outside my reproductive system, 2) internal scarring, and 3) internal acute chronic inflammation, which is known to be a precursor to cancer. I appealed the denial and specifically requested an endometriosis specialist review, since multiple OB/GYNs misdiagnosed me. Reading the insurer’s appeal response was intellectual masochism.
Its response was materially incorrect, and the reviewing physician didn’t appear to have read more than a word of my medical records. For instance, her summary stated I had a “non-inflammatory disorder”; this is directly contradicted by my pathology records from the time of surgery. Any person (and, one can hope, doctor), who reads a sentence on endometriosis, realizes it’s inflammatory. I looked up the reviewing physician from the “independent medical review.” She’s an allergist and immunologist, although this doesn’t excuse her pathetic, materially incorrect analysis. This physician is even an assistant professor at a well-known medical school. What a cruel, consequential joke. The physician professor didn’t win the battle, though.
Gain Clarity from Your Insurer with These Tips
With a Health Savings Account, the annual out-of-pocket max can be a financial planning mechanism. Searching by billing code (“CPT code” – Current Procedural Terminology) is the easiest way to confirm coverage; your doctor’s office should provide these codes for you to check the exact procedure with insurance.
However, insurers, like mine, may find a coverage loophole, if they claim the procedure is experimental, investigational, or elective. When the insurer unexpectedly and unreasonably denies coverage, the Transparency in Coverage Rule becomes meaningless. Contacting my doctor and the hospital’s compliance department saved me from coverage denials.
In my case, the surgeon chose regenerative treatment while I was under general anesthesia; I didn’t consent. I’m thankful the surgeon maximized my healing potential, but if I’d known it cost over $65,000.00, I wouldn’t have consented.
After the insurer denied my appeal, I could have moved to the next appeal step by requesting an external review by an independent review organization. However, since the insurer already used an “independent” review organization, whose analysis was a joke, I opted to reach out to the biller’s compliance department. Thankfully, I already asked my surgeon about the charge. He said the hospital should waive it. After contacting the hospital’s compliance department, the hospital dropped pursuit of the charge. To avoid a misunderstanding, the hospital had not sent me a bill; I anticipated the bill, because the insurer sent the denial with my listed responsibility as $65,000+. I wanted to prevent receiving an artery-blocking bill.
My insurer also unexpectedly denied coverage for a common vitamin D test. When I reached out to my doctor about it, she said insurers just started this denial trend. The insurer, again, denied my appeal. But, I requested the provider pay it, since I wouldn’t have gotten the test if I’d known it wasn’t covered. My doctor’s office took care of the nearly $250 bill.
Even with Consumer Protection, Medical Bill Madness
In order for me to undergo surgery, the hospital required prepayment ($3,000+) at my preoperative appointment, based on my insurance benefits. When I asked if the hospital notified my insurer, the hospital employee confirmed my payment would apply toward my deductible.
But, the hospital didn’t inform my insurer. Instead, my insurer determined I owed a lesser amount for the surgery, and the hospital didn’t refund the difference. In the meantime, I received several other bills, which, when added with the $3,000+ I already paid, would have forced me to pay over my out-of-packet max. Thanks to the hospital’s billing incompetency (a generous description of potential fraud), the insurer was calculating my out-of-pocket max without my $3,000+ payment, and the other billers relied upon the insurer’s inaccurate calculation. The other providers had already processed insurance claims. The insurer’s poor recommendation was to pay more than my out-of-pocket max, instead of obtaining rightful reimbursement from the hospital first.
It was a nightmare. A corporate medical mammoth was the sole cause of the problem, wouldn’t fix the problem, and left me holding the bag. Notably, the same hospital system duplicated its potentially fraudulent behavior with a friend of mine: the hospital required prepayment for surgery, overcharged him, and, at first, didn’t refund the difference.
When I called the hospital’s compliance department, only then did the billing department refund the difference. This allowed me to pay the other bills without exceeding my out-of-pocket max.
The hospital wasn’t the only medical billing madman. After scheduling a needed test, I confirmed coverage. But, when I arrived for the procedure, the staff informed me insurance hadn’t gone through.
I was in severe pain that morning and could barely make it out of the house for the test, but I needed that test. My husband had to reorganize his work schedule to drive me. After the front desk delivered the news, I decided I needed the test enough to self-pay, even though I had insurance, and even though I confirmed coverage before the procedure.
I paid fully in cash (at a cost more expensive than with insurance – another example of potential fraud), but (at this point is it any surprise?) I received a bill, which I disputed. Although I disputed the bill, I received more bills for the same amount. I disputed each bill, every single time, escalated the bill to the office manager, and informed my doctor, until the bill incorrectly went to collections. Twice. I’m still fighting this particular bill.
I could go on with medical billing errors that would drive the sane to lunacy. Medical billing is the opposite of medicinal.
Bring Order to Medical Bill Madness with These Insights
Although there were a few angels who helped me in various billing offices, unfortunately, the incorrect, repeat bills continued. Contact someone (the doctor, office manager, or compliance office) who is empowered to stop or correct the bill. Ideally, meet them in person at your next appointment.
Document your insurer approvals (including call reference numbers), biller estimates, your payments, and your appeals. Keep these in a well organized file. Then, if you have evidence your biller or insurer is breaking the law, you may file a claim with CMS for surprise bills, file a claim with CMS for insurer’s violation of the Transparency in Coverage Rule, file a claim with CMS for hospital’s violation of Hospital Price Transparency, and/or file a claim with your state attorney general’s office.
For ER treatment, if you have health insurance, due to the protections of the No Surprises Act for ER treatment (no out-of-network bills), use insurance. ER visits aren’t the time to self-pay.
Although I haven’t tried this option, you could discuss an insurer’s poor performance with your employer, assuming your employer contracted with the insurer for employee benefits.
A Different Medical Billing System?
With a McDonald’s located in a prominent hospital nearby, I struggle not to question motives of medical billers. In my medical billing madness, I’ve reviewed the patient bill of rights from providers. Not one included financial informed consent, even though it’s indisputable: medical billing uncertainty, confusion and chaos can affect health options.
Notably, one patient rights document only listed financial disclosure in the past tense, “You have the right to receive an itemized and detailed explanation of hospital charges for services rendered . . . .” Another patient rights statement listed, “The right of complete information in terms the average patient can reasonably be expected to understand[,]” and “The right to informed consent and full discussion of risks and benefits prior to any invasive procedure, except in an emergency.”
To me, failing to disclose the potentially immense financial burden of treatment or lack of coverage does not vindicate patient autonomy or reduce risk of harm. The distance between the consumer and the consumer’s genuine financial consent regarding health insurance coverage and health costs is mental outer space.
Ideally, prices for every treatment would be measured and listed like any other purchase: before or at the time of treatment, there is a price tag, and after treatment, the price doesn’t change.
Medical billing madness is an insult to responsible consumers, not to mention the anti-consumer health insurance appeals process. Even when you proactively educate yourself about your insurance plan and analyze the options with your employer, coverage surprises and billing errors are a black hole of wasted time. After all, time is the scarcest resource.
I hope this post saved time and money for you. Comment below to share feedback.
Coming soon
Don’t miss Part 3 of “How to Navigate Endometriosis in an Unhealthy Medical System: Post-Surgery Disappointment & Symptom Management”, where I’ll share tips to alleviate post-surgery distress, including a “diagnosis worse than cancer” and aggravated symptoms.
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