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.
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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.
