Uncategorized

Unlucky Student

Last
 July,
 I
 found
 myself
 needing
 to
 visit
 a
 doctor
 for
 an
 urgent
 medical
 issue.
 My
 period
 had
 started
 in
 April
 and
 never
 stopped.
 It
 was
 light,
 so
 it
 wasn’t
 too
 much
 of
 an
 annoyance, 
but 
after 
three 
months 
I 
figured
 I
 needed 
professional 
help.

I
 had
 started
 graduate
 school
 in
 Michigan
 the
 year
 before
 and
 was
 back
 home
 in
 California
 for
 the
 summer.
 I
 wasn’t
 sure
 if
 the
 new
 insurance
 that
 I
 paid
 over
 $2,000
 per
 year
 for
 through
 the
 school
 would
 cover
 a
 doctor’s
 visit
 in
 a
 different
 state.
 I
 called
 the
 insurance
 company
 to
 check
 and
 they
 said
 they
 cover
 any
 doctor
 in
 the
 country.
 Happy
 to
 hear
 this, 
I 
called 
and 
made 
an 
appointment 
with 
the
 doctor 
I 
had
 been
 seeing 
for 
years.

Though
 my
 insurance
 had
 changed,
 my
 doctor’s
 appointment
 was
 the
 same
 as
 always,
 I
 just
 had
 a
 slightly
 higher
 co‐pay.
 I
 had
 a
 routine
 check‐up
 and
 the
 doctor
 ordered
 some 
blood
 tests 
to 
help 
diagnose 
my 
problem.
Within
 a
 few 
weeks,
the 
doctors 
figured 
out
 what
 was
 wrong
 and
 cured
 it.
 I
 returned
 to
 school
 in
 September
 happy
 and
 healthy.
 As
 far
 as 
I 
knew, 
my
 business 
with 
the 
doctor 
was 
finished.

While
 in
 California
 for
 the
 summer
 I
 didn’t
 have
 a
 permanent
 address.
 I
 stayed
 with
 friends
 for
 a
 few
 weeks
 at
 a
 time
 and
 house‐sat
 for
 other
 friends
 while
 they
 were
 on
 vacation.
 This
 arrangement
 allowed
 me
 to
 live
 cheaply
 for
 the
 summer
 and
 save
 money
 for school. 
However, 
when
 the
 doctor’s 
office 
asked 
for 
a 
local 
address, 
I 
didn’t 
have 
one. 
I 
gave
 them
 the
 address
 of
 a
 good
 friend
 I
 was
 staying
 with,
 figuring
 my
 friend
 would
 tell
 me
 if
 mail
 arrived
 for
 me
 at
 her
 house.
 Although
 I
 wasn’t
 expecting
 to
 receive
 any
 mail,
 I
 tried
 to
 have
 my
 mail
 forwarded
 to
 my
 school
 address
 at
 the
 end
 of
 summer,
 just
 to
 be
 safe.
 The
 Postal
 Service
 said
 they
 were
 unable
 to
 forward
 my
 mail
 because
 my
 school
 address
 was
 considered
 a
 business
 address
 and
 they
 don’t
 forward
 from
 residential
 addresses
 to
 business 
addresses. 
This 
frustrated 
me, 
but 
as 
I 
said, 
I 
wasn’t 
expecting
 any
 mail 
anyway.

Around
 October
 I
 received
 a
 call
 from
 a
 representative
 of
 the
 doctor’s
 office
 saying
 I
 had
 an
 unpaid
 bill
 in
 the
 amount
 of
 around
 $100.
 I
 told
 her
 that
 I
 had
 moved
 back
 to
 Michigan
 and
 never
 received
 a
 bill.
 She
 said
 she
 understood.
 She
 allowed
 me
 to
 pay
 my
 bill
 over
 the
 phone
 with
 a
 credit
 card
 and
 updated
 my
 address
 in
 her
 files.
 A
 week
 later
 I
 received
 a
 voicemail
 about
 an
 unpaid
 bill
 from
 the
 same
 office
 and
 dismissed
 it;
 I
 had
 just
 paid 
my 
bill 
a 
week 
earlier.

In
 November
 the
 friend
 I
 had
 stayed
 with
 in
 California
 informed
 me
 that
 she
 had
 a
 stack
 of
 mail
 for
 me
 that
 she
 had
 forgotten
 about
 and
 would
 send
 it
 right
 away.
 When
 I
 got
 this
 mail,
 I
 saw
 that
 there
 were
 several
 copies
 of
 an
 unpaid
 bill
 from
 the
 doctor
 in
 the
 amount
 of
 $1,500,
 and
 they
 were
 threatening
 to
 send
 my
 account
 to
 a
 collection
 agency.
 I
 was
 shocked
 and
 horrified.
 I
 didn’t
 have
 $1,500,
 so
 I
 couldn’t
 pay
 it.
 I
 was
 also
 heading
 into
 finals
 season
 at
 school,
 so
 I
 didn’t
 have
 much
 time
 to
 sit
 around
 and
 think
 about
 what
 to
 do
 with
 this 
bill.

A
 few
 months
 later
 I
 got
 a
 letter
 from
 a
 collection
 agency
 saying
 that
 I
 now
 owed
 them
 $1,500.
 I
 realized
 I
 couldn’t
 ignore
 the
 bill
 any
 longer
 and
 called
 my
 doctor’s
 office.
 A
 representative
 at
 the
 office
 told
 me
 the
 bill
 was
 for
 blood
 tests
 and
 mailed
 me
 an
 itemized
 bill,
 which
 had
 never
 previously
 been
 sent
 to
 me
 at
 any
 address.
 She
 also
 said
 that
 my
 insurance
 should
 have
 paid
 for
 it
 and
 that
 I
 should
 ask
 them
 about
 it.
 I
 called
 the
 insurance
 company
 and 
they 
said
 that 
my 
plan 
“doesn’t 
include 
all 
diagnostic 
tests.” 
So 
that 
was 
that. 
I
 was 
stuck 
with 
this 
$1,500
 bill 
that 
I 
never 
saw
 coming 
and 
couldn’t
pay.

As
 a
 graduate
 student,
 100%
 of
 my
 income
 was
 student
 loans.
 Financial
 aid
 very
 specifically
 only
 covers
 school
 expenses
 and
 minimal
 living
 expenses,
 including
 my
 health
 insurance
 premiums.
 However,
 there
 isn’t
 an
 “unexpected,
 huge,
 medical
 bills”
 line
 in
 my
 financial
 aid
 award.
 No
 amount
 of
 frugal
 living
 would
 have
 allowed
 me
 to
 pay
 this
 bill.
 How
 else
 should
 I
 have
 handled
 this
 situation?
 Would
 I
 have
 been
 better
 off
 just
 bleeding
 indefinitely?

Kimberly Seelye is a graduate student at the University of Michigan.

Costs of Care (Twitter: @CostsOfCare), where this post was originally published, is a Boston-based nonprofit organization that collects anecdotes from doctors and patients. We feel these stories are poignant because they put a face on some of the known shortcomings of our system, and also because they unveil how commonplace and pervasive these types of stories happen.

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Barry CarolMargalit Gur-AriebjcefolaJudypcp Recent comment authors
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nate ogden
Guest
nate ogden

Submitting a claim under an “unspecified” or “non-specific” code is an error on the part of the provider, which does happen infrequently,

I wish it was infrequenty. Poor billing and bad addresses are two of my biggest pet pieves.

nate ogden
Guest
nate ogden

bjcefola, that is one of the main roles of insurance brokers, they are that resorvior of knowledge to assist their clients in solving those types of issues. They know how things should work and who to call when they don’t.

Margalit Gur-Arie
Guest

“The provider bills the service using a generic code that trips an exclusion with the insurer. Coverage for the service exists, but the insurer needs a specific code not the general one. I appealed and won” You should have never had to deal with this type of denial. Your provider’s billing person, or department, should have fixed the code. Submitting a claim under an “unspecified” or “non-specific” code is an error on the part of the provider, which does happen infrequently, but it’s not really the patient’s problem, since the correct codes are clearly marked in any insurance billing manual… Read more »

Peter
Guest
Peter

bjcefola, your idea about an appeal process already exists and is probably part of the patient information disclosure if a payment is denied, I guess depending on your state’s insurance law. But you’ll find the process is rigged in favor of the insurance company, at least it was at my appeal. All the so called, “independent” reviewers at the hearing were insurance industry insiders paid for by the insurance company. You’ll also find this is the case with arbitration clauses in many contracts like car sales that have you sign your rights away. The “arbitrators” are paid by the company… Read more »

bjcefola
Guest

Mark, I’m thinking of nuts and bolts advice based on peer experience. Example: I had service x at provider y with insurer z. The provider bills the service using a generic code that trips an exclusion with the insurer. Coverage for the service exists, but the insurer needs a specific code not the general one. I appealed and won, I now have a recipe for anyone in that circumstance to get coverage to which they are entitled. This is what I mean about information sharing and unnecessary suffering, if one person does the hard part there is no reason for… Read more »

Peter
Guest
Peter

“I think there is a lot of unnecessary suffering out there that could be alleviated by just spreading knowledge.” bjcefola, Mark is right, and further just who is going to “spread the knowledge?” Certainly not the school that won’t tell you the insurance was picked based on the largest kick-back from the insurance company, not the best student policy. Not the insurance company that won’t give you anything but glossy brochures and vague coverage outlines. Not the doctor who won’t tell you he’d accept half the $1500 from the insurance company while billing the student the full list price for… Read more »

Mark Spohr
Guest

bjcefola, This is an interesting question. Do we teach people to “work the system” or do we reform the system? We can try to educate people about health care costs, the fine print of insurance contracts and to “take responsibility” but we run up against the perfidy of insurance companies who intentionally write obfuscated insurance policy rules which leave much to interpretation (by the insurance company itself) after the time of the care. In addition, medical pricing is complex and opaque. There is a “top price” and many layers of secret discounts. The only price you can determine is the… Read more »

bjcefola
Guest

Mark, a meta question: What is more effective, pushing for system wide reform or promoting the knowledge and skills to successfully manage the system we have?

I ask because this patient wasn’t the first person to get lab services, and with your example you weren’t the first person to have surgery. Why is so little information available to the public describing what to expect and how to deal with it? I think there is a lot of unnecessary suffering out there that could be alleviated by just spreading knowledge.

Mark Spohr
Guest

Barry brings up a good point. Your $1500 in lab bills are probably at the top tier “retail price” which no insurance company actually pays. This is roughly similar to airline pricing where they establish a high reference price and give large discounts to various groups. You should try to negotiate with them for a lower price (although this will be difficult after the service). A good reference point is the Medicare price which you can look up on this web site: http://www.cms.gov/apps/physician-fee-schedule/overview.aspx You will need the 5 digit procedure code which should be on the bills you received from… Read more »

Barry Carol
Guest
Barry Carol

In my considerable experience as a patient over the last 15-20 years, I’ve had billing foul-ups with labs more often than all other providers (hospitals, doctors, rehab centers, etc. combined) by far. Sometimes they don’t enter my insurance prefix number correctly or at all. Sometimes, I’m told that they’re out of network when they turn out not to be. Even when no billing errors occur, the EOB shows that their list price for each lab test is often five times or more what they accept as full payment from the insurer. In short, labs are the worst when it comes… Read more »

Margalit Gur-Arie
Guest

This is what happens when the free market is at play and any insurer can sell anything that can be documented in tiny print on dozens of pages full of clinical terms, and call it health insurance. I actually fault the University here, which has no business peddling this type of reckless non-coverage to their students. On a different note, and to pcp’s point, there is technology today that could prevent these types of errors. Claims can be pre-adjudicated and even fully adjudicated at the time of service. If payers and providers would get on board with this technology, patients… Read more »

Mark Spohr
Guest

It is true that in our insurance system which is full of holes that you need to check to see what the insurance companies are covering and what they don’t pay for… However, in this case, our “unlucky student” did pay the doctor and thought that she had taken care of her obligation. She was perhaps naive about this but most people are not medical billing experts and are shocked when they receive separate bills from people they haven’t even met. I know that I was amazed when a “simple” four hour stay in the out patient surgery generated bills… Read more »

bjcefola
Guest

One thing I haven’t seen mentioned is patient responsibility. People need to realize they are responsible for seeing that the bills for their health care services are paid. Insurance is merely a tool towards that end. And note, there are many ways a claim can be adjusted even if someone on the phone says “the doctor is covered”. What that means in practice is that at a minimum, you should check your Explanation of Benefits statement for every service you receive. It will say plainly what the insurer paid and what you are expected to pay. Checking EOB’s not only… Read more »

nate ogden
Guest
nate ogden

without knowing what is being done how do you expect an insurance company to tell you if it is covered? To answer your first question if the genetic test was to diagnosis a condition it would usually be covered, if you were just having it to know then it would not. Without knowing the ICD9 your doctor was going to bill with it how would they know what sitution applies? I have never heard of an oral medicine provider, first thing that comes to mind is your asking them to pay your bar tab. Without more info that would be… Read more »

Judy
Guest
Judy

Nate, I did not provide the gory details in my post to keep it short. Suffice it to say is that I discussed all if this in much detail with the various parties involved, including the insurers. All off these tests and referrals were suggested by my health care provider at the time and were not luxuries or things that I just made up and wanted to do for fun. Just because you haven’t heard of something doesn’t mean it doesn’t exist — my Top-10 ranked US News and World Report hospital has a Department of Oral Medicine. In fact,… Read more »

Judy
Guest
Judy

While I do agree that Kimberley could have managed her side of the situation a bit better (early doc visit, PO box, etc.), the REAL issue here is the lack of transparency, both by insurers and health care providers in that it is nearly impossible to determine 1) what tests costs [the docs NEVER know this] and 2) if the procedures are covered under your insurance plan. I’m a 48 year old mom of a 5 year old. Three examples I’ve experienced (2 in the last 6 months): – Would my insurance cover an early screening test for genetic problems… Read more »