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.
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.
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.
“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 and/or software.
In this case, your provider’s billing staff was just being lazy, and probably costing the physician a lot of money.
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 and their decisions reflect that.
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 everyone else to reinvent the wheel. But the transmission is busted, how does “the recipe” get into the hands of those who need it?
I agree strongly with your comments on provider pricing! I wish I saw more discussion of that in reform efforts…
Peter, I’m talking about patient to patient information sharing. We have the most responsibility for ensuring payment but the least visibility of the billing process between insurer and provider. Our one advantage is collective experience, but right now that just gets thrown away.
“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 paying cash. This story is not about failure to provide a forwarding address or picking up your mail, it’s about a perverted system that works on bait and switch when you least expect it and can’t afford it. As I said, the student would have been better to put her $2000 premium in the bank, then at least she would not have paid $1500 for treatment AND $2000 in premium for about $800 in care. Most health insurance works out to be just an expensive loan.
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 Medicare price which is published (but not that clear itself since it is subject to many different adjustments).
Very few medical facilities will give you a firm price on anything. The best you can get is an estimate which is usually not even close to the final bill.
If you compare this to the rest of the civilized world where insurance coverage is complete and pricing and payment is transparent, I think you would come to the conclusion that our “system” is badly in need of radical reform. This could be private insurance or “socialized” medicine but what makes the system work in other countries is that it is highly regulated and transparent. Insurance companies have standard comprehensive coverage and prices are regulated and published.
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.
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:
You will need the 5 digit procedure code which should be on the bills you received from the lab. Sometimes these have a 2 digit modifier code. Enter these codes into the web site and it will tell you what Medicare pays for the procedure. I think you will be shocked at the difference between the price you were charged and what Medicare actually pays.
You can use the Medicare price as a starting bid. Offer to pay the Medicare price and see if they will negotiate. This will be difficult and they will most likely delay and threaten, etc. but hold your ground as long as you can.
Most insurance companies pay about 20%-30% more than the Medicare price so you may have to go to a higher price but it will still be a big discount from the prices in your bills.
There is more pricing and cost information on my web site:
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 to both correctly submitting billing information to insurers and the spread between the list price and what they actually accept as full payment.
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 would at least know in advance that disaster is about to strike.
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 from the hospital, surgeon, anesthesiologist, radiologist, lab and pathologist.
When you have insurance, you think you are “covered”. Most people don’t realize that they have huge gaps in their coverage and they will have significant out of pocket expenses. Our insurance system is just a facade to collect money from patients and to avoid paying as much as possible. It would be nice to have real insurance which actually paid for health care.
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 gives you a heads up on what medical bills are coming, it lets you plan ahead of time how you want to deal with the bills either by paying or appealing a coverage decision. From my experience most providers will let a bill slide for a few months if they know coverage is in dispute, just let them know what’s going on.
But at the end of the day it comes back to responsibility, health care isn’t free regardless of insurance and patients are responsible for seeing that providers get paid.
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 another case where I have no way of knowing if it is covered.
Even without the state mandate i would thinkt he vision test would be covered as you were now trying to diagnosis something.
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, I was diagnosed with a neurological disorder by the provider within the Department of Oral Medicine.
Finally, your comment that, “you’re asking them to pay your bar tab,” is offensive. You don’t know anything about who I am, how hard I work, how much money I pay for my insurance, etc. Perhaps, if you don’t have all the information, you should keep your comments more general and not respond in the form of a personal attack.
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 during my pregnancy? They couldn’t say until after the procedure was done to see how it got billed.
– Would my insurance cover a trip to an oral medicine provider to determine the cause of burning in my mouth, which, of course, wasn’t covered by dental insurance (I’d already seen my PCP 3 times, my dentist, an ENT and a GI doc; I was headed next to Allergy)? Maybe, maybe not. Apparently, your mouth is not a part of your body.
– Would my daughter’s failed vision test at her PCP visit and subsequent referral to the optometrist (same large provider practice) be covered under my health insurance? I was told no by the doc’s office and then later discovered that my state MANDATES a kindergarten pre-screening vision test which must be covered by my health insurance.
And, NO ONE could tell me how much these procedures would cost if I had to pay out of pocket.
I have a Master’s degree in public health, work at a hospital and speak English as my primary language. I knew what questions to ask and possess the tenacity to hunt people down. And, I couldn’t get any answers.
“If the insurance company said they cover every doctor in the country, that means they have negociated rates with none.”
PCP this is incorrect, any PPO plan covers every doctor in the country. If they are a PPO doctor they are covered under the PPO benefits with a discount, if they are non PPO then they are covered under the OON network benefits without a discount. Either way every doctor is covered. A doctor being covered is a different question then them being contracted.
You’re correct, but we don’t know if this was a PPO. But have you ever tried to collect from an out-of-state PPO? To say they “cover” every doctor in the country is being extremely generous!
Though the poster made a lot of mistakes, the doc’s office also blew it by not explaining to her how much of the bill she would be responsible for. You don’t let a patient walk out the door owing $1600 without a plan to collect it.
“While I know that you are a staunch defender of the insurance companies ”
By no means am I a defender of insurance companies. I make my living pointing out everything wrong with them and will be the first to tear into them when they do wrong. Just becuase I don’t blame them for everything doesn’t mean I am defending them. The problem in the sitution was not the insurance company.
“This person has an expensive insurance policy,”
$2000 per year is an expensive insurance policy? That is under $200 per month for a women in her reproductive years, that is not cheap. I am sure it had limitations, like no pregancy coverage, or it would have been considerably more.
” called the insurance company to see if she would be covered out of state, was lied to about her coverage”
No where does it say this. This is what she provided;
” 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.”
Are you privy to information that wasn’t provided to the rest of us? I don’t see any mention of her asking her insurance company about lab work. I also don’t see where she said they didn’t pay the insurance company. Show me the lie, where did they not do exactly what they said they would do?
“I don’t know what low standards you have for behavior by insurance companies but to me it is unconscionable for the insurance company to exclude lab from the policy”
This is just stupid, you sound like your somewhat in the industry but someone in the industry would never make such a blanket stupid statement. As with all these sob stories we have no idea what the condition was or what lab work was done, funny how these all lack any meaningful details. We get bills from a place called myriad labs, we deny them all the second we see who its from. They do gentic testing and its never a covered benefit or medically necessary. It cost $1500 to $2500 and they sneak enough through that it is worth it. Do we have low standards becuase we deny this non covered lab work? Members never call and ask if genetic testing is covered, they will call and ask for the lab benefit. I can’t read them a 100 page document on the phone, its their responsbility to either ask detailed enough questions or read their document.
Your claim they lied is completly unsupported.
” I only hope that enough people get mad enough to demand more regulation of these unethical practices.”
I only hope people stop lying and spreasing BS and discuss the facts. People want to run off and cast all sorts of blame with no basis for doing so then wonder why nothing gets fixed. You can wrijte all the disclosure and mandate laws you want but until people ask the right question you won’t know what your going to get.
I expect you will be apologizing for your baseless attack and do better to get all the information before you go accusing people in the future.
Lots to discuss.
For starters, a well-run office would have told you at chec-kout how much you owed and collected it, or at least set up a payment plan.
If the insurance company said they cover every doctor in the country, that means they have negociated rates with none. You’re being billed full retail costs that nobody pays, and you should ask the office to adjust the charges to what other insurers pay. (This is why I don’t see how selling insurance across state lines without a network of providers is going to be viable).
Yes, stupid student, doesn’t she know that she should always take a complete copy of her insurance contract with her to the doctor so that they both can review what is and is not covered before treatment. And why was she so naive to believe that the doctor actually knew what he was doing to order those tests, why she should have told him they weren’t necessary after all and at least $1500 was gouging. The lesson learned is as a young student don’t waste your money on health insurance, bank it instead for future health care.
” the insurance companies have many devious ways of avoiding payment ”
Thats right it was the insurance company that gave bad addresses so she wouldn’t get the bills.
It was insurance companies that after she knew about the bills told her to just ignore then until the sitution got even worse.
And it was insurance companies that ordered $1500 of lab test.
What I want to know is how did you manage to become a graduate student, let alone get a degree? You somehow managed to make it through the maze of financial aid, college applications, course work and everything else but couldn’t figure out how to find a stable mailing address or follow through on your office visit? Did you ever call the lab and ask them for a discount? How did you not see the bill comming, you saw the doctor poke you with a needle and take blood, what did you think they were doing with it? Did you ask what they were doing? The doctor never discussed test results with you?
The reason the problem never gets solved is we never place blame where it belongs, its esier to blame the evil insurance company for what the patient and doctor did wrong.
While I know that you are a staunch defender of the insurance companies against “stupid patients” and that I expect this response from you, I must admit that I am appalled at your condescending tone in this post.
This person has an expensive insurance policy, called the insurance company to see if she would be covered out of state, was lied to about her coverage and ended up with a large bill.
I don’t know what low standards you have for behavior by insurance companies but to me it is unconscionable for the insurance company to exclude lab from the policy and it is unconscionable to not inform the patient when they call that lab is not covered (this is a lie of omission and clearly unethical).
To you and the other posters who have blamed the victim in this case I would like to say that it is a sign of the deep corruption of our health insurance system to allow policies to be written which exclude in fine print usual and customary medical care and which require the services of a lawyer to understand the benefits.. I only hope that enough people get mad enough to demand more regulation of these unethical practices.
This is an unfortunate situation. College/graduate health plans are some of the crappiest out there. Health insurance is a ‘caveat emptor’ product: buyer beware. Like a used car, you HAVE to know what you are/are not buying. I’ve always been an advocate for colleges to really educate the students buying these policies.
The posters asks, “ How else should I have handled this situation? Would I have been better off just bleeding indefinitely?”
– This is a tough lesson to learn, but this is the reason that every financial advisor on the planet advocates for an emergency fund. Graduate school or not, emergencies happen. If not health-related, what about a terrible auto accident that leaves you holding the bag for $1500 of car repairs your insurance won’t cover? What if your apartment gets robbed and you lose your laptop (and haven’t bought renters’ insurance because it was too expensive)? Or what if (God forbid) there is a death in the family and you have to fund last-minute cross-country plane tickets? Even when you’re scraping by on student loans, students should always make sure to have money squirreled away, just in case.
– you should have found a way to collect your mail for the summer. Perhaps a PO box would have been a better solution, or perhaps you should have continued to have all your mail sent to Michigan while you were living in California. If Michigan is like other campuses, they forward mail for students over the summers.
– Never ignore a bill. The longer you wait, the less likely you will have any chance of sorting things out. The poster mentions this twice:
* “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.”
* “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.”
I understand that graduate school is time consuming– I was working two jobs while in grad school–but you’ve got to find the time to sort out the financial stuff.
– Seek medical attention earlier– you were bleeding (albeit lightly) for three months…if you’d gone to the doctor while still in Michigan after a month and a half of bleeding, you may not have had all this trouble getting services covered. Again, the poster chalks this up to being a busy graduate student. Completely understandable…and it is always hard to put your health first. While this mistake has financial ramifications, at least be thankful it wasn’t a more serious problem that went undiagnosed for three months.
– Finally, (and this is the hardest to do), always ALWAYS verify that everything being dnoe to you will be covered (or not) by health insurance.
You shouldn’t have done a thing differently. We are the ones who should have somehow lived our lives so that you could go to Grad school and not have to worry about unexpected expenses.
so this story says what.
whats your point in publishing this story.
This entire blog is like health affairs but with some sad story published every time and again with the others.
Maybe you should have paid for a premium for additional care .
Maybe you should have read you insurance and understand terms.
you were a graduate student right?
or maybe, you can go to the county hospital and claim no insurance, and get free service.
or maybe you can get a life.
i would never hire you. stay in your box.
oh yes, it is clear for us, tax wealthy to solve this problem.
A Solution that which is better than finding the real problems.
SINGLE PAYOR !
all you lackey’s on this blog are nothing but single payor ideologues. Some place you got here Holt. I guess it strokes your ego in the friends you walk with.
Has This Story Not been written ? Blog with all left/liberals for a single payor healthcare system?
The only real answer is to pay to have an experienced lawyer read through your health care plan so that you can be sure you understand the plan. Most people do not understand what is in their plans. Many people run into the problem you describe.. In my corporation of all doctors and advanced practice nurses we run into this kind of problem yearly. The other option is to have lots of money.
Sorry to hear your sad story.
This points out one of the many problems with the US health insurance system. Even when you have insurance and think you should be covered, the insurance companies have many devious ways of avoiding payment and you often don’t know in advance if you will be covered even if you ask. The system is rigged against you. It would be nice if we had real health insurance or universal care like the rest of the developed world but we are the victims of the US medical industry.
The only advice I can give is to question the insurance policy again. They shouldn’t be able to say “doctors only, no tests” (but they probably can and do).