This month, we wanted to do something a bit different and share an article that addresses a serious issue we all face, healthcare billing. It is so important to be diligent and detailed with your healthcare bills and never be afraid to ask questions. Pay attention or you could pay too much.
You’ve gotta celebrate your medical billing victories.
And today, we have a huge victory to celebrate! The generosity of this newsletter’s subscribers helped a family save almost $88,000. That’s huge!
But sometimes the size of the win underscores the way our health care system preys on vulnerable patients. That makes the victories bittersweet.
Today’s story has a little bit of everything when it comes to medical billing atrocities: an insurance company denial, an overpriced and uncooperative surgeon, a double-dipping doctor and numerous hospital billing errors. Trust me — you’ve never seen one like this. Read on for all the drama.
The setup.
A mom named Jenny has a college-aged daughter with multiple chronic conditions who needed a complicated spinal fusion surgery. I’m not identifying the family to protect the daughter’s privacy. Only three surgeons in the country had the skill to do the operation, and Jenny picked what she considered to be the best one, who lived across the country in New York.
Weeks before the April 2023 operation, the insurer, Cigna, put up a roadblock. It said that based on the surgeon’s documentation the operation could not be considered medically necessary. Jenny felt desperate to ensure her daughter got the surgery she needed. Which put the family in an extremely vulnerable financial position.
The surgeon’s cash price
The surgeon’s office gave Jenny a cash price. Here’s where I got sticker shock. It was a 12-hour operation, with multiple procedures – extremely complicated. And I respect that the surgeon is one of the few with the skill to do the procedure. But the cash price for the surgeon’s fee alone came to $125,000. I’m not sure where the line is between profit and profiteering, but when you charge a desperate family more than $10,000 an hour, you may have crossed it. Reasonable people may disagree about this. I asked a surgeon friend of mine how a doctor could get away with charging so much. “Supply and demand,” he replied. Yeah, I get it. Supply and demand. He can charge so much because he’s The Man and the family is desperate. But as you’ll see, there’s even more to the story that highlights the surgeon’s greed and selfishness.
The hospital’s cash price.
The hospital provided a Good Faith Estimate to the family. Again, a cash price: $98,902. Jenny’s daughter stayed in the hospital for nine days, so that’s a bargain compared to the surgeon’s rate.
The plastic surgeon’s cash price.
The surgeon said he’d need a plastic surgeon to do the closing of the incision. That rang the cash register at an additional $18,000 cash. Total price tag: $241,902. Cash. That’s almost as much as I paid for my first house. Jenny and her husband don’t have that kind of money. Her mother, the patient’s grandmother, paid the tab out of the inheritance that she had been saving for the family. The entire bill was paid up front. The operation took place without any unexpected complications. It’s too early to tell whether it’s been fully successful, but Jenny’s daughter has been able to return to college, so she’s thankful.
Then came the bills – and this is where I got involved. It would be one thing if the hospital and doctors had made this vulnerable family pay an exorbitant price and then walked away. But the hospital returned to the scene of the crime. It sent a bogus bill.
The hospital’s balance bill.
Two weeks after the operation, the hospital billed Jenny an additional $69,805. Jenny didn’t understand how that could be possible, because the hospital had set its cash price up front and she had paid in full. She could see one obvious problem – the hospital had billed Blue Cross Blue Shield and her daughter was covered by Cigna.
Side note: Never underestimate the incompetence of medical billing departments.
Jenny requested that the hospital conduct an internal review of the bill. The hospital did its review and stood its ground with the bogus bill.
Jenny hit a breaking point. She sought help and got referred to me in June of last year. Fortunately, I have an account set aside to help patients who are ensnared in these types of medical billing fiascos.
My generous paid subscribers.
As you may know, this newsletter is free, but I invite people to become paid subscribers. I use that money to provide scholarships for my health literacy videos and to hire patient advocates to help in cases like this one. The Victory Stories that come out of this work are life-changing. One advocate we hired saved a patient $224,000 in medical bills. Another saved a patient more than $42,000 after her insurance company denied 273 claims at once. Another rescued a man who was Down Bad and Buried in Medical Bills, helping him get hundreds of thousands of dollars in expenses covered. All that work has been funded by the paid subscribers of this newsletter. Thank you! Want to take part in something bigger than yourself? Join us now as a paid subscriber! We are just getting started!
The advocate steps in.
The funds donated by this newsletter’s paid subscribers allowed me to hire Lisa Berry Blackstock. I paid her initial fee, and then Jenny and her husband paid the remainder. Lisa, who I feature in my book, Never Pay the First Bill, is a pro. She dug in and immediately found big problems.
The surgeon couldn’t be bothered to help.
It’s tempting to blame Cigna for denying payment for the surgery, but Lisa said the surgeon’s office provided incomplete information to get the operation pre-authorized. Then the surgeon took $125,000 cash from the family. Lisa contacted the surgeon’s office to see if they would provide the documentation to Cigna on the back end. That could enable the insurance company to pay for the operation, so Jenny could get reimbursed. The surgeon’s office refused. He had a signed contract from Jenny and $125,000. His office staff couldn’t be bothered with helping the family recover their money. I’m not naming the surgeon or the hospital in this story, because Jenny’s daughter might someday need to return to them for medical care.
The plastic surgeon’s billing department had double-dipped.
Lisa suggested that Jenny request an itemized receipt for the plastic surgeon’s fee, so it could be written off as a deduction on her income taxes. They discovered that the plastic surgeon had already been fully reimbursed by her insurance company — without telling her. That resulted in an $18,000 refund of the money Jenny had paid. That’s disturbing — but also a big win!
The hospital’s balance bill contained many mistakes.
Lisa found multiple errors in the hospital’s balance bill.
• There was still the problem with Blue Cross Blue Shield being billed, when it should have been Cigna.
• The markup on the screws used in the spinal surgery was 50% higher than the prices listed on the hospital’s website.
• The itemized bill included a mysterious $14,582 “surcharge” that the hospital claimed was some sort of state tax. There was no such tax, Lisa said.
• Jenny’s family had paid $98,902 for the hospital bill, but the itemized bill showed the payment as $96,208 – an obvious error an elementary schooler could have identified.
It took Lisa about 15 hours, dozens of phone calls and several FedEx letters to billing departments, but the hospital eventually dropped the entire balance bill. Bam – $69,805 saved. Another big win. But again, it feels bittersweet to me. The surgeon charged an exorbitant price and refused to help the family get it covered by insurance. That’s a cruel and uncaring way to treat a family in need. Plus, at that price we know it creates issues with access to care. Jenny recognizes that most families would not have the means to pay cash for such an operation.
Lisa said the case underscores the importance of bringing in a patient advocate early – especially when the stakes are high. Earlier in her career she did estate planning, a field where people know they need an expert and readily hire one for guidance. People need to bring in a professional patient advocate to assist with their medical decisions, she said. If she had been involved earlier, she might have been able to get the surgeon’s fee covered by insurance. When health care providers are setting cash prices, Lisa said, they know they can name any cash price on any given day. “There are no price constraints on cash pricing,” Lisa said. “Often, there’s no legitimate basis to what you are being charged – none, absolutely zero.”
Jenny feels like she’s been bludgeoned by the American health care system – the same system she has to trust for the ongoing care of her daughter. “This shouldn’t be happening,” she said. “This isn’t right. It’s just unfair.”
A similar bludgeoning, by the way, is what happens every day to employers and working Americans, who keep paying more and more for health care and getting less and less for their money. After months of anxiety and sleepless nights over the bogus bill, Jenny is also irked that the hospital never did admit fault. It just wrote off the balance to zero. That’s a nice outcome, but doesn’t reassure her that the same thing won’t happen again to someone else. “Not to sound too negative, but I think our health system is extremely dysfunctional,” Jenny said.
This content has been reposted to share this valuable information. Full credit goes to the original author Marshall Allen. Read the original article.