After receiving another notice from our insurance company that a payment for service was denied, I thought it was time to share my family’s experience with the American healthcare system. I’m not going to get political about it. Individuals will define root causes based on where they lie on the political spectrum. I am not interested in placing blame, because it is far too convoluted. I am more concerned about how the disarray built in to the American healthcare system is going to give an otherwise healthy individual like me, a stroke.
I am not a healthcare expert, nor a political pundit. But I am one of those Americans who falls in that gray area that none of our politicians seems to know what to do with. I’m self-employed, and I make about as much as a public school teacher. My wife Anne is in graduate school full-time along with an unpaid internship, so as a family of four, we’re making just enough to shave by. Thankfully we have some savings from a house sale, along with a thoughtful extended family. Many Americans in our situation don’t have those safety nets to utilize in the case of an emergency. I don’t really know how they can manage.
15% of my gross income goes toward healthcare expenses, after the subsidy. If it weren’t for the subsidy, it would be 30% or more. The important thing to note here is that we are a healthy family. Outside of routine checkups, there is the occasional issue that Anne and I have to deal with as part of the normal aging process. We don’t have cancer or kidney disease. The good news is that, as a small business owner, I can write off a chunk of those expenses. The bad news is that when there is a billing dispute between a provider and the health insurance company, I take on a second job as a liaison, despite having no experience or qualifications to do so. If I lose the negotiation, then we’re fronting another few thousand dollars that might otherwise go into that thing that people keep talking about. I forget what it’s called. Oh yeah, “savings.”
A couple of years back I listened to an interview with a healthcare economist who described her experience after a cancer diagnosis. I am paraphrasing her statement, but it went something like this, “I am a healthcare economist with a PhD, and I don’t understand the bills and letters that I am getting from my insurance company. So if I can’t understand it, then it will definitely be impossible for anyone not in this field to understand it.” I continually have this experience with what should be routine procedures for a 42 year old man in generally good shape. I never know if I commit to a procedure whether it’s going to cost me $0 or $7,000. Here is a copy of a letter I wrote to a vascular surgeon after receiving a varicose vein diagnosis. I’ve omitted the first couple of paragraphs because they’re just boring details about the procedure:
“…To be perfectly frank, out-of-pocket medical fees have just been killing us for the past 3 years. It never lets up. I spent an hour on Friday trying to get someone at the imaging facility/health insurance company to give me a general idea of what I would be paying for just the MRI/MRA, and no one was able to give me any kind of answer. Our savings is dwindling, and I’m still negotiating other hospital bills. I’m not mentioning this because your office has anything to do with that stuff, as I realize you all have to deal with the same health insurance billing frustrations that I do as a small business owner. Your team is simply practicing safe care and presenting me with viable options. I’m mentioning it because my wife will be done with grad school and working in a couple of years…right about the time we stop paying $1,500 per month to put two kids through preschool. Point being — if this can wait a couple of years without doing irreversible damage do my leg, then it needs to wait. But if I’m playing with fire then I just have to suck it up and move forward into this year’s medical cost black hole. So I need an honest opinion about what my wiggle room is here.”
Fortunately, she responded by telling me that this condition has a slow progression, and unless certain symptoms begin to arise, there is no rush. But this is the standard medical routine in my experience. Specifically, with this vein diagnosis:
– Step 1. See a PCP about an issue, where I sit in the waiting room for almost an hour.
– Step 2. 3 weeks later, take 3 hours off work and drive 45 mins to see a specialist. Get a diagnosis.
– Step 3. 3 weeks later, take 3 hours off work and drive 45 mins to get an ultrasound.
– Step 4. 3 months later, take 3 hours off work and drive 45 mins to get a follow up about the ultrasound. Get a prescription for an MRI.
– Step 5. Start paying the out-of-pocket expenses for the previous 4 doctor visits and the ultrasound.
– Step 6. Contact the hospital that does the MRI to find out how much it might cost me out of pocket. Get transferred to a billing estimate place. Get transferred to a billing counselor. Call my insurance company. Find out absolutely nothing.
– Step 7. Ask the doctor if I can put this process off for a couple of years.
– Step 8. Cancel the MRI.
Four months, a couple hundred dollars, and about 12 combined hours of driving, waiting, consulting, and calling. The only thing that has changed since step 1 is that I bought one pair of vein compression hose for $70. Insurance doesn’t pay for that after all. I mean, how else are they supposed to rake in billions of dollars in profits?
Two days ago, we received a new notice from our insurance company stating that they are denying payment for a procedure that my wife had done last May in the amount of $4,500. The reason for the denial is that the claim was not submitted by the hospital in a timely enough manner, despite being in-network, and previously approved. Nevermind that insurance companies and hospitals can send the patient a bill out of the blue whenever they feel like it. Apparently those rules don’t apply if it’s a major corporation billing another major corporation.
I’ve been through this song and dance before. Ultimately what this means is that the hospital will now send us a bill for $4,500. I will then spend hours working my way up the chain to explain to a disinterested supervisor that, “I did my part. I pay my premiums on time. We made sure that the procedure was in network, and that it was approved. I don’t file insurance claims, you do. If I had known that a billing window was closing, I would have filed it myself. But I did not know this. No one tells me these things.” To which they will reply that since the insurance company isn’t paying, I will have to take it up with my insurance company, or pay the bill myself. To which my insurance company will reply that the hospital did not submit the claim in a timely manner, and I will have to take it up with the hospital.
I already went through this last summer over Anne’s same procedure. The insurance company denied a claim for the testing of a tissue sample, because the lab wasn’t in network, so we received a bill from the lab for around $1,000. I called the hospital, lab, and insurance company to find out why, if we had chosen a doctor in-network, a tissue sample would be sent to a lab that was not in-network. Turns out that the lab was in network when the tissue sample was sent, but it was no longer in network when they billed the insurance company. So…naturally, after all of these companies finish arguing over who is supposed to pay whom, I get the bill. To which I patiently and calmly responded to the last person I spoke with, “I know that you personally are not the orchestrator of this confusion, but please put yourself in my shoes, and then explain to me WHY THE FUCK any of this is my responsibility.” “Sir…I can understand your frustration…”
This situation wasn’t actually resolved. It is under review. I was told it could take 9 to 12 months before a resolution is reached. I assume that once I’ve completely forgotten about this whole thing, and just as I’m thinking about doing something wacky crazy like putting some money into an IRA, I’ll get another bill for $1,000. Because, why shouldn’t I? I don’t have a team of lawyers to fight this screw up. I’m the low-hanging fruit. It’s easy for the hospital, or insurance company, or lab, to sue me if I refuse to pay it. They have a lot less to lose. So I’ll just pay it, and then cynically wait for the next costly expense that I didn’t know was coming. Oh, wait, there already is one!
For this same procedure, we also received another bill last fall from the hospital for around $5,000 (separate from the most recent insurance company denial). Look, I know that we are required to pay a certain amount of money out of pocket each year to meet our deductible. We paid a $500 co-pay, along with another amount up front that I can’t remember. But this was all really starting to add up. The bill indicated that the hospital had been trying to collect the money from the insurance company to no avail, and that I needed to call my insurance company to try to get them to pay. You know, my volunteer job as a debt collector when I’m not at my actual job, trying to raise my children, or on the phone with some other medical organization about another bill that doesn’t seem quite right.
Insurance company — “They aren’t supposed to send you a bill for that amount. Your responsibility is $200 something plus your $500 co-pay.”
Me — “But they did send me this bill.”
Insurance company — “But they’re not supposed to. You’ll have to call them.”
Hospital — “The amount due is $5,000.”
Me — “The insurance company said it’s $200.”
Hospital — “It’s $5,000.”
Me — “Here’s a crazy idea. I know this is totally insane, but how about if YOU call the insurance company. Here is their phone number. They have customer service representatives available 24 hours per day.”
Hospital — “We don’t do that.”
Me — “You don’t talk to the insurance company?”
Hospital — “No. But what we can do is submit this for review, which could take about 9 to 12 months…”
If you’ve made it this far through this rant, I’ll go ahead and share a final medical anecdote from a couple of years ago. We had just relocated to Texas, and most of our life was imploding due to circumstances outside our control. I’ll spare the details, but it was getting pretty ugly. One afternoon, Anne decided to take our son Parker to my Mom’s house so that Anne and I could try to figure some things out without downloading all of the stress onto our 3 year old. A few minutes after she left the house, as I was walking down our hallway I began to experience stabbing chest pains and pressure that pulsed in time with my heartbeat. This had to be a heart attack. I quickly chewed a baby aspirin and drove to the ER a half mile away. In hindsight I probably should have called 911, but you just do what you do in those situations.
The staff quickly hooked me up to a bunch of monitors, gave me some medication to ostensibly calm the effects of a possible heart attack, and conducted a prompt interview. Within a few minutes I was sent through a battery of medical tests. After the doctor reviewed the information he concluded that my heart was fine, and that I had probably pinched a nerve somewhere in my thoracic cavity due to the extreme stress, which was mimicking the symptoms of a heart attack. Whew! What a relief. He also told me that the symptoms I was describing were either a pinched nerve, or an aortic dissection, which would have killed me within a few minutes. Thankfully he didn’t tell me that until after I was in the clear.
Well, it’s a good thing I have health insurance and that the ER is only a half mile away. Sometimes there are happy endings. Oh, wait…the ER isn’t in network and it cost me $2,500. Since the source of our stress was a near disastrous financial situation, I had to ask myself, if I had known in advance that it would have cost me $2,500 to go to the ER for what I thought might be a heart attack, would I have gone? Might I have just taken the aspirin and waited around until I was sure it was a heart attack? Then what? My wife finds me dead on the living room floor? Or maybe I was supposed to call around to different hospitals, and wait on hold with the insurance company, to see which provider was in network, all while possibly in the midst of having a heart attack. If I had called 911, would the cost have doubled or tripled for the ambulance ride?
I am well aware that there are countries which have no hospitals at all. Many don’t even have safe drinking water. I have much for which to be grateful (no debtor’s prison in the U.S. for one). But I can’t help but think that in one of the wealthiest, advanced, and most powerful nations in the history of the world, something is seriously wrong here. To be perfectly honest, I often think about what I could do to help people who aren’t as lucky as I am. Unfortunately, when I have any sliver of free time or extra money that might be dedicated to such a cause, it gets parasitically absorbed by this kind of bullshit.
Stay healthy! (No, I mean really stay healthy so that you don’t have to go see a doctor for any reason…ever).