Thursday, January 22, 2009

On medical bills and health insurance, part II

So with the worst of the situation behind me, and only a reasonable amount of manageable debt in front of me, part 2 of this series is where I would like to focus on the sort of 'take-home' messages I've learned in the hope that they give you ideas if you find yourself in this conundrum.

1. The first thing the insurance company tells you is most likely not the whole story. In my case, not a single EOB they sent me was accurate the first time. I had to write letters of appeal for each.

I realize I fell prey to this, especially, because I received emergency care at an out-of-network provider. But, on the flip side, you must push back when the insurance company tells you "no" -- especially if you've had health care provided as the result of an emergency. Even HMO plans account for treatment that is emergent in nature, even if it's out of network. True, you might not end up getting what you believe to be a fair shake, but chances are good that the company should be paying out more than they are.

2. The insurance company is a business. Businesses are designed to turn profits. The way they make profit on your health insurance is by avoiding paying for your coverage in any way possible. Normally, of course, they avoid paying for your coverage because you remain healthy, and that is ultimately a good thing. But when it comes to paying out on a bill, they will fight tooth and nail over every last penny. Their strategy is, in essence, to pay as little as possible, in the hope that you go away. If you do not think you've received adequate coverage, there are remedies available to you, which leads me to point three...

3. Write letters of appeal. Do not call to appeal. If you write a letter of appeal, your appeal will be acknowledged, considered, and possibly acted upon; not to mention the fact that you have a record that you did in fact file an appeal. If you call and appeal, you will speak with a person whose job it is to tell you as little as possible and get you to hang up the phone. They are called 'customer service' but they're not there to serve you -- they're there to prevent you from seeking information or filing a successful appeal. They're 'service avoidance specialists'. The people on the phone can sometimes -- sometimes! -- help you ascertain why a claim was denied, but otherwise, they're pretty worthless. You are much better off keeping the communication in writing so there is clear evidence of the decision-making process.

4. Know the laws of your area. I was fortunate enough to discover that California, for example, has a series of income thresholds under which discounted care is provided by public hospitals. As a result, I discovered I would be eligible to receive a discount on my share of the bill if I filed for the discount and met certain requirements. It took a little bit of time, but moved my share from an unfathomable $40,000 to a still-unbelievable-but-possibly-manageable $12,000. I don't know about you, but my time is worth 28 large.

5. Contact an advocacy agency, or at least learn about their services. I was lucky, also, to find a local advocacy agency that had lots of literature online about the right, legal way to approach hospital bills: what you can contest, what you should pay if you can, where you should plan to fight in court if you need to. I never wound up consulting with them directly, but they gave me the confidence to prepare to, and to interact with the insurance company as though I were willing to put up a legal fight, which, incidentally, I was.

6. Be prepared to use threat of legal counsel for leverage -- but only if you are actually prepared to do so. The final step in escalation is, of course, the threat of legal action. In high-stakes poker games like this, though, the last thing you want is for someone to call your bluff. I eventually won my battle with the insurance company, after a year of back-and-forth, when I realized I was no longer able to negotiate the situation on my own. I knew the next step would certainly have to be one of the following: Escalate my case to the California Department of Insurance Consumer Protection division, escalate my case to the courts and hire a lawyer, or possibly both. At wit's end and exhausted by the fight, I told the insurance company I would need all materials related to their decision to withhold an extremely large chunk of coverage so that I could provide it to the Department of Insurance and, if necessary, legal counsel. I do not know if, perhaps, the insurance company had a sudden change of heart like The Grinch (their hearts grew three sizes that day?) or if they realized I had fought them this far and I would certainly continue to do so... Ultimately it doesn't matter. I held off on the "I'll sue you!" threats as long as I could. I worked toward an amicable resolution, and I was stymied at every chance. I was serious, I would have retained a lawyer, and I would have taken the bastards to court. But I would also add, do not play with that fire if you are not prepared to be burned. Theoretically, the court could've said "Sorry, Charlie, you lose" and I would've been out the 12 grand for hospital bills plus the attorney fees. So seriously, don't play fast and loose on that one.

7. The people in the billing office can be your friend. Empathize with them as best you can. You'll be frustrated as hell and want to scream at them, but ultimately it's the billing office, not insurance, that decides when your account is irrevocably in arrears and seeks collections action against you. Having even a begrudging ally in the office helps. San Francisco General Hospital Medical Group's billing office was full of pawns and douchebags who would do nothing to help. Nothing. Not help me, not help me with a billing plan, not help deal with the insurance or explain the surgical situation to them (it was a long, difficult surgery). So I hope the head bastard there -- whose name I keep to myself out of an inexplicable sense of goodwill towards man -- rots in hell or at least, before he dies, is treated to the same offensive indifference to his well-being that I was. On the other hand, San Francisco General Hospital, while not helpful really at all, was at least understanding and patient in regards to my battle with insurance. I kept them appraised, faxed them the documents the insurance company and I were exchanging, and helped them to realize I was not, in fact, ignoring my medical bills but rather, working my ass off to insured they got paid as quickly as possible while also maintaining financial justice for me.

8. You are not alone. Your medical debt is not a mark of shame, but a call to action. If you have been fucked by this system that is more than happy to feast on the carcasses of the dead and diseased, the poor-to-moderately-successful, the insured-but-not-well-enough... Speak up. Put a face on the situation. Let your friends and family know that it's not just somebody else getting screwed by the system. Let them know that capitalism does well, but when it comes to medical care it does not do well enough. Say your piece, express your anger, share your despair. There are lots of us out there who have been through this and who know better not because of ideology but because of bloody, nasty, stressful, awful experience. The system is broken and more markets and more greed and more profit over patients is not the answer. Let's fix it. Soon.

Sunday, January 11, 2009

Rock Concert

I'm in San Francisco for a very long weekend, due to the Linguistics Society of America conference which has just been amazing.

I love getting in touch with my researcher friends and advisers, and it really makes me miss my studies in the field.

I really wonder if I won't end up back at study some day soon, as my participation over the last few days has reminded me that I love this field and am so fascinated by the work of linguistics.

Before heading out for a social gathering with friends and colleagues, we encountered a concert on the sidewalk.

Random, but still, I'm so glad I live here! :-D

Sunday, January 4, 2009

On medical bills and health insurance, Part I

Having spent more than a year struggling to get just treatment in the runaround that is the patient-insurance company-hospital fiasco in the US, I'm writing these two (perhaps three) posts detailing my experience and how I've learned individuals can advocate for themselves in the health care and billing industry. Part 1, below, is a straightforward account of the steps I've taken to seek appropriate remedy for my medical bills, along with a brief bit about how I wound up acquiring those bills in the first place. Part 2, forthcoming soon, will be some reflection and suggestions with respect to how to handle a situation like this. God willing, you and your family will never need them. Nevertheless, I want to put them down in writing so that they might possibly help someone avoid some of the time, worry, and indigestion this kind of situation causes.


Last October, as my surgeon put it, my "face got stomped on". I don't remember what happened; I was walking to the train to head home for the evening, stirred slightly when there were flashing lights and paramedics cutting my (incredibly cute, brand new, and now ruined) zip-up sweater off. I wouldn't say I actually regained consciousness, though, until some time later, in the hallway of the ER, lying in a hospital gown on a bed.

Also, for the record, everything is now put back together, aside from a little more dental work, and the inside of my mouth and my jaw is essentially as normal as it'll ever be. For some extra-exciting freak-out factor, here's what my X-ray looked like while my jaw was immobilized to allow the bones to heal (sorry if this seems gratuitous, but it's a really cool picture):

Without putting too fine a point on it, let's just say that my initial impression of what was "fair" for me to pay on this experience was the "out of pocket maximum" cap that the insurance company espouses in their policy: $6,000 per year for out-of-network expenses. Given that San Francisco General was an out-of-network provider, you can understand why I was expecting to pay about that amount. You can also understand my surprise, horror and anger when insurance refused coverage almost the entire way, leaving me with a tab far in excess of six large. The 'happy ending' is that I wound up paying about the maximum out-of-pocket cap amount for my medical services in the end, even though it came about through ways I find unacceptable. I am healthy again, and aside from a credit card balance (low interest til 2011, thankfully), I'm none the worse for the wear financially, either.

So what follows here is an account of the appeal and grievance processes I went through to settle my hospital bills. Several things of note here:

1. Not a single bill was correctly processed by the insurance company on their first 'try'.

2. Some coverage errors were the result of the service provider, but most were the result of screw-ups, or possibly just posturing (I have no evidence of malice, but lots for complete ineptitude), at the insurance company.

3. I'm including vague dollar amounts here not to show off, but to give you an idea of how terrified I was throughout this 14-month process of just trying to be treated reasonably by the insurance company and billing offices. When was the last time you got a $96,000 bill for anything? Exactly. It's a great motivator, but I'm sure the process was damaging to my health and recovery because I got to spend so much time worrying myself sick over how I'm going to cover these amounts without going into collections or bankruptcy or just a lifetime of insurmountable debt.

4. There is hope if you A) have appropriate insurance and B) are willing and able to be a vigilant, tenacious, almost-annoying fuck about it. You can't just be a nice, reasonable person because the companies involved don't care -- nor are they nice or reasonable. The trick is that you can't be a jerk, either, because everybody knows (and every piece of paper you sign at the hospital says) you're ultimately the one left holding the bag.

A brief glossary:

EOB -- Explanation of Benefits. A good document to have, as it outlines for you A) the amount the insurance company is covering, B) your copay and deductible amounts, C) the amount the insurance company is not recognizing, and D) the amount the provider is allowed to charge you for the items considered in the claim.

Deductible -- The amount you're required to pay out of pocket before your insurance actually kicks in.

Copay / Coinsurance -- The amount you're required to pay to make up the amount due for covered charges.

Out of pocket expense -- The amount you pay out of pocket but only for covered charges. N.B. charges the insurance company chooses not to recognize as Usual, Reasonable and Customary do not count toward any out of pocket expenses, even though the expenses are out of pocket. Lovely phraseology, huh?

Usual, Reasonable and Customary -- Excuse used by an insurance company to literally ignore charges in your medical bills. This is allegedly related to the services rendered and the average cost of said services in a given area. Insurance companies will not provide you with their methodology for arriving at this figure, though they will hold you responsible if your costs exceed the Usual, Reasonable and Customary amounts. If any of your fees get UCR'd it's literally as if they don't exist -- except, of course, that you still have to pay for it, you just get zero insurance consideration at all.

Hospital bill ($96k):

-Received notice from insurance while at home with my jaw wired shut that my case is going to "utilization management" and will have to investigate medical necessity on receipt of my medical records.

-Received an EOB covering $0 of $96k in hospital charges.

-Called insurance company to verify; was told that I should have chosen an in-network provider. We determined the charges were for OB-GYN procedure and diagnostic codes. Data entry error at the hospital.

-Hospital corrects and rebills insurance.

-Received notice from insurance that due to lack of receipt of my medical records, they are denying coverage.

-Write appeal letter to insurance co. Sternly worded.

-Hospital writes sternly-worded appeal letter to insurance, indicating the emergency admission and expectation of payment for that reason.

-Contact hospital for fully itemized bill. No progress on appeal or new EOB.

-Appeal is granted; insurance company agrees "to pay for dates of service at the participating [i.e., in-network] benefit level."

-New EOB arrives covering $55k of $96k. $41k remains my responsibility due to treatment at out-of-network facility and charges exceeding Usual, Reasonable and Customary rates.

-Contact insurance co. via phone to explain that "the participating benefit level" means they do not get to pull out-of-network excuses or Usual, Reasonable and Customary rates. Of course, no progress because phone calls are worthless for resolving anything.

-Appeal again to insurance, this time citing for them their description of their coverage for these services "at the participating benefit level." Point out that in the plan, it says "When you choose a participating provider, you will not be responsible for any amount in excess of the negotiated rate", so if they are covering the dates of service at "the participating benefit level" then in no way should I be held "responsible for any amount in excess of the negotiated rate", whatever that rate may be.

-File for charity / discount care program which lowers charges for individuals below certain income thresholds. I was eligible for the very top level of discount care, meaning the charges certainly weren't going away, but the hospital agreed to lower the amount due from about $41k to $13k. When you're as desperate as I was then, you take the victories however they come.

-Receive notice of adjustment by the insurance company as a result of my appeal: They agree to cover the entire amount less copay and deductible.

Final outcome: Receive bill from hospital: $450.

Ambulance bill ($1k):

-Receive EOB covering charges at a level the policy doesn't even allow (In my case, 70% out-of-network coverage, 90% in-network coverage, 90% emergency, with ambulance service necessarily qualifying as an emergency).

-Write appeal to insurance pointing out the policy says they cover all ambulance service at 90%.

Final outcome: Receive new EOB & appeal response indicating correct 90% coverage rate.

Professional Services bill ($6k):

-Received EOB indicating ~$1k applicable to deductible and my responsibility; $5,400 of anesthesiology eligible for $144 in payment (in other words, I owe $5200 on that bill).

-First threat by San Francisco General Hospital Medical Group (SFGHMG) of account collections.

-Appeal to insurance co. on the basis of unreasonable coverage due to emergency admit.

-Appeal approved, but only to pay the allowed benefit at 90%, resulting in about $40 additional coverage, thanks.

-In phone call with insurance company, discover I have no grounds to appeal the amount of allowed benefits, meaning only the service provider can do so.

-Appeal to SFGHMG to forestall collections while dealing with insurance; request review of file to make sure correct procedure and diagnosis codes; request SFGMG file appeal over amount of allowed benefits.

-Discover SFGHMG has not complied with my request to appeal the amount of allowed benefit by the insurance company. Write an angry letter to them requesting more time without collections action; request they clarify with insurance company the emergency nature of the admit, the lengthy nature of the procedure, and defend their billing as "reasonable and customary in fact".

-No one can or will help with insurance. More collections threats; I acquiesce but manage a 20% discount for in-full payment.

-Move balance to a well-timed, low-interest balance transfer offer on a credit card.

Final outcome: Still paying off a bit by bit, cussing under my breath each time, but thankful it's manageable.

Surgeon's bill ($3k):

-Receive EOB denying coverage.

-Follow up with insurance company via phone; they say the procedure and diagnosis codes are wrong.

-Contact billing office. Procedure and diagnosis codes are wrong. Will rebill.

Final outcome: Receive EOB allowing coverage; billing office confirms insurance payment is adequate to close the account.

Saturday, January 3, 2009

Charitable giving in tough times

You know those things on your to-do list, the ones that just sit around because, well, that whole litany of excuses?

Yeah, me too. But I got around to one of them just recently. is, as they like to say, all about "loans that change lives".

This is absolutely not charitable giving in the traditional sense, where you give some organization some cash and they do whatever they want with it leaving you to question the efficacy of your dollars and cents. Kiva is different, because at Kiva, you fund a loan to an individual. Kiva is the mouthpiece to the internet, announcing which initiatives need money and keeping the user, you, as the underwriter of the loan, informed about what's going on. Kiva also deals with the balance sheets, making sure that the on-the-ground organizations they connect to users are appropriately distributing funds and collecting loan payments. And the real kicker, of course, is that like any loan, if it's successfully repaid, you end up with your money back; preferably, to loan to another entrepreneur in a developing area.

For me, the time wasn't right with Kiva when I first learned about it. I wasn't sure of my employment situation, I wasn't sure how much of the massive medical bills I had at the time would end up as my responsibility. I was still giving to other organizations as I continue to do today, but believe it or not, the downturn in the economy has made me realize the time is better now than ever for giving through this micro-loan system.

What I keep coming back to is that the money comes back to you. This isn't a donation, where your cash just disappears. It's a loan to help out an entrepreneur. And when the term is over, you can loan that same cash out again to someone else. Is this not an incredibly novel and opportune way to help people at an economically uncertain time?

To me, this seems like an fantastic opportunity to really drive some effect out of money you'd normally consider a charitable donation. I think I'm in a position now to really give this a shot. My challenge to you -- and to myself -- is: barring some unforeseen hardship, I'm going to loan $25 per month through the micro-loan system Kiva has set up, for all of 2009. My first loan is to Nancy from Bolivia, who's going to use her short-term loan to buy additional goods to stock her grocery store. Nancy's had a loan before, and is rated as a top-notch client who is always prompt with her loan payments. The company on the ground she's dealing with has loaned over $500,000 to over 1,000 entrepreneurs. Together they have a delinquency rate of 0.02% and a default rate of 0%. Good luck, Nancy!

You can check out my progress and loans here. Please feel free to drop me a line if you're up to the challenge so we can connect on I think we'll have a good time giving this a shot, and I think we'll make a difference while we're at it.