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.

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