How to Fight Your Medical Insurance Bill!
How I reduced a $577,000 medical bill to $5,000.
On December 14, 2014, my best friend Deb died of a brain aneurysm. From the moment she was transported to the hospital to the time she died was 59 hours. Her medical bills for this 59-hour period totaled $577,349.00! This is a story of how I fought for the rights of her daughter (her sole beneficiary) to pay the $5,000 that was owed vs. the remaining $244,000 that initially Blue Cross and Blue Shield invoiced as uncovered charges.
Deb and I were best friends for 42 years. We were college roommates and stayed close throughout our lives. We became family of choice, weaving our lives and families together through the many journeys that create a lifetime. Deb had acted as executor and trustee for her mother, grandmother and aunts estates, and I had done the same when my husband died. We agreed to take on the duties of durable medical power of attorney for each other, as well as trustee of our respective estates.
When Deb’s daughter called to tell me that she had been taken to the hospital and was unconscious, I caught a plane and flew to be with her. She lived in Monterey and had originally been taken by ambulance to the hospital there. The ER doctor had been in contact with a neurosurgeon at Stanford and after talking with him, I agreed that she should be flown to Palo Alto for emergency surgery. A second ambulance took her to the Monterey Airport where she was airlifted to Stanford.
After an eight hour surgery, we waited to see if there would be signs of recovery but it was obvious in the first 12 hours that her brain was too injured to recover in any meaningful way. Her daughter and I agreed to remove her from life support. She was an organ donor and so was kept in ICU for an additional 12 hours to facilitate the transplant teams time constraints. Eventually, she was moved to a private room, and all medical support was rescinded.
After her death, I began the sad task of unraveling her estate. As a self-employed psychotherapist, Deb didn’t have a lot of assets but she did have a house, modest retirement savings and other small investments. The medical bills began trickling in and I didn’t pay attention to the first few bills but when I received a hospital bill that showed Patient Responsibility of $227,000 after insurance had paid what they deemed covered expenses, I knew it was time to get to work!
Medical Billing Errors are Likely
Current estimates put medical billing errors between 60-80%. Put another way, there is only a 20-40% chance that you’ve been charged correctly. It’s important to keep this in mind before paying a bill.
The advent of computerized billing and record keeping has increased the likelihood of errors over the last few decades. All medical services are coded using CPT (Common Procedure Technology) codes. These are usually 5 digits that are used by insurers to determine how much will be covered for any particular service. There is plenty of room for error in these codes. If the procedure is off by one digit it could mean the difference between of thousands of dollars in charges.
You can check to see if these codes are correct by referencing them against the list of codes https://coder.aapc.com/cpt-codes/. There might some discrepancies based on contracts between insurers and providers but you can get a general idea if your treatment codes reference the actual care provided.
If you are covered under Medicare or Medicaid, the coding system is different. In a future blog, I’ll share some tips if you’re enrolled in these systems on to verify correct billing.
What is Your Out of Pocket Maximum?:
This is the maximum amount you should pay out of pocket for all in-network medical services. There is an individual amount for each insured, and a family maximum that includes everyone in the family covered under the same plan. If one family member reaches their individual out-of-pocket maximum, then their insurer must pay the remainder of their medical bills.
One of the great features about the ACA is that it embeds this out-of-pocket maximum and the amount is capped each year. Insurers cannot exceed the upper limits though the amount has increased each year. In 2019, the limit is $7,900 for an individual. This amount includes deductibles, co-pays and co-insurance but not insurance premiums, dental or out-of-network services that are not pre-approved.
Deb’s insurance policy had a $5000 Out-of-Pocket maximum and like most catastrophic health events, she reached that in the first hours of treatment. So, how could we get bills for a quarter of a million dollars?
I called Blue Cross to find answers but ran into a major roadblock. They would only talk to the insured, not her agent. After explaining that she had died, I was told to file an appeal along with proof of that I was her trustee. I complied and waited to hear back…. that didn’t happen. So, I called again and was given exactly the same advice. Seems they had no record of receiving my information and request. So, I refilled using certified mail. Waited several more weeks to call again only to get the same response.
What Constitutes an Emergency to Insurance Companies?
After writing 5 appeal letters, I was finally given the information that her aneurism was not deemed an emergency, thus her care was not fully covered!!! Wait, she was unconscious for the entire duration of her care but not an emergency? I went back to her policy to find out the definition of emergent care. I started laughing when I found that they used a brain aneurism as an example of what an emergency might look like. Yet another appeal letter with a copy of the paragraph lifted from their information. I found out later that this is a common “error” for insurance companies to make.
The bills were recalculated and I received a notice (addressed to Deborah K, my deceased friend) that everything would be covered except for the air and land ambulance charges.
In-Network vs. Out-of-Network Insurance
The air ambulance bill was $44,000 and the land ambulance charges totaled $12,000. The ambulance rides were all considered non-emergent and out-of-network and deemed not covered at all by insurance. This is a growing issue when it comes to coverage for ambulance cost. In an emergency, the closest ambulance responds. We don’t expect or want paramedics to determine if insurance is going to cover their services. Your insurance policy likely doesn’t stipulate that you use an In-Network ambulance in an emergency, and will likely only cover an Air Ambulance if land transport is deemed as impeding your emergency care.
Back to the appeals process one more time. After more than a year of calls and written appeals, all of the responses were still addressed to my deceased friend, Deborah K. I decided to let Deb respond from beyond the grave….
Thank you for your recent letter, since I died on in December, 2014 I don’t get much mail. I’m writing in response to your assertion that the ambulance services received for the brain aneurism that killed me did not fall under your guidelines as an emergency. I suppose they could have shoved me in the back seat of a car, but getting the life saving equipment in can be problematic.
At your request, I am including (for the 6th time) all information related to my care.
If a person is reading this, I ask that you review it and respond to my Trustee who is still alive. If a machine is reading this….I’m looking forward to getting more mail.
I did receive a response…. addressed to Deborah K. Apparently, machines are the only ones reading their mail.
At this point, I had been fighting with BCBS for over a year. My friend’s daughter suggested that we should just pay the bills as we had reduced the totals so dramatically. Unfortunately, this is what insurers are hoping for. When tragedy strikes and health is diminished or death occurs, fighting the monolith that is the U.S. insurance system is overwhelming, tiring, and it’s hard to maintain the bandwidth to persist.
Health insurance is an interesting product. For many Americans, monthly premiums now meet or exceed their rent or mortgage payments. You buy the product with the hope of never needing it, but when you do you must be prepared to fight for the product to be delivered. Imagine paying your mortgage and then having to fight to live in your house each month. This is the reality of our current system.
After 19 months, countless phone calls, letters, appeals documentation, and persistence, Deb’s medical bills were reduced to the $5,000 out-of-pocket maximum that was owed. It was a bittersweet victory but a win none-the-less.
The Most Important Steps to Take When Fighting Your Medical Bill:
Know what your policy includes. Pay attention to your out-of-pocket maximum.
Pay attention to your EOB (Estimate of Benefits). This is a document that is sent before you’re billed for care. It’s often easier to spot mistakes before they are billed.
Determine if your bills are coded properly for the services that you received. You can request an itemized bill. Double billing for services is a common error.
If you’re hospitalized check to make sure that your billed for the correct dates and number of days. Generally, you’ll be charged for the day your admitted but not the day you’re discharged.
Check to see if you’re billed for a shared or private room, and that it matches what situation was true.
Notice if charges are considered In or Out-of-Network. If you’re hospitalized, there should not be out-of-network charges for physicians or other practitioners.
If you think there are errors in your bill, call the hospital and your insurance company. Be sure to log your phone calls with the date, time and name of anyone you talk to.
Put it in writing. If you are not getting responses, put the info into an email or letter, or both. Get the names and email address for supervisors that can take action.
Be persistent. This can be as important to your financial health as treatment is to your physical health.