In September of 2009, my wife developed an infection in her tooth. She had previously scheduled an appointment with her dentist for a root canal but they couldn’t perform the procedure until they cleaned out the site. They put her on a low grade one-two combo punch of penicillin and pain killer. Two days later she realized this wasn’t enough.
As we’re travelling in the car, she nearly doubles over in pain. Her entire mouth is throbbing and she’s feeling pain all through her jaw and creeping down towards her neck. The medication she was on wasn’t strong enough. We needed something more. The problem was that this was Saturday. I called the dentist’s office and the office was closed. I left a message just in case someone might hear it before Monday. Then I called our primary care physician and talked to the on-call doctor. He listened to the scenario and said there was a good possibility the infection was spreading. His advice: “get to the Emergency Room. Fast.”
We’d never used our insurance for anything more than a routine doctor’s visit and so, not wanting to travel to an out of coverage hospital, I called up our insurance company. As a sidenote to people outside the United States reading this: most American insurance companies have in-network and out-of-network doctors and hospitals. The former is the preferred method where services are mostly paid for through insurance coverage. The latter has either a greatly reduced coverage or you get no benefit whatsoever from insurance as they will simply refuse to pay for your treatment.
So I called the number on our insurance card and got an answering machine. I called another number. And another. And another. I called every number on my card (there are eight) and could not reach an actual human being to direct us to the appropriate hospital. So we chose one we believed was covered based upon what we recalled from the 100 page booklet sent to us a year ago which was probably in a filing cabinet at work that I couldn’t get on Saturday even if I wanted to drive downtown to retrieve it. The hospital we chose was one that, we discovered later, turned out to be in-network.
It was our lucky day.
The hospital visit was quick and efficient. We got in to see an intake nurse and then into a patient room within 20 minutes of arriving. A Nurse Practitioner took my wife’s vitals, did some checks, and then they wheeled her off to get a CAT scan to see if the infection had spread. An hour later they determined that the infection had not spread, though they were glad she came in rather than waiting until Monday to get this resolved because there’s no telling what would have happened by then. She was given a higher dose of pain meds/antibiotics and 2 hours after we arrived we were on our way.
A few weeks later we received notices from the insurance company. We got letters that stated THIS IS NOT A BILL but just lets you know how much is covered and how much you can expect to owe when the bill(s) arrive.
Total cost for the radiology doctor: $320.
Total cost of the hospital visit: $4,959.
Total amount covered by insurance: $0.
We would be getting two separate bills from two separate entities for a two hour visit and not a single dollar of it was being covered by insurance. Potentially we’d be on the hook for $5,300. We don’t have $5,300.
I called up the insurance company. The representative on the phone said this was a dental procedure and dental procedures aren’t covered. What dental procedure? I asked. This was a CAT Scan for an infection and was treated using medications only a doctor could prescribe. No, the rep stated. According to the hospital this was a dental procedure.
So I called up the hospital. I told them what I had been told by the insurance company. They were confused. “We don’t put ‘dental procedure’ on bills to insurance companies,” she said.
“Well they’re refusing to pay it based upon the claim. What do you put on there?”
“I’ll fax it over to you.”
So I get the fax of all the charges listed. If you’re curious, it was $3,503 for a CT, $1,500 for the ER, $4.80 for Oxycodone, and $1.43 for Ibuprofen. Nothing about dental. I call the insurance company again and tell them what I’ve discovered. It doesn’t make a difference. I ask to speak to a supervisor knowing that this too will be fruitless because even a supervisor doesn’t have the ability to make a decision in covering $5,000 of what had previously been determined to be non-coverable activity. And, as I suspected, nothing came of that conversation either.
By now it’s early November and I decide to bring my HR Department into the picture. I let them know of the scenario, e-mail them all the appropriate documentation, and hope that they can help. They contact their insurance rep and get back to me.
“Good news!” they state.
“What?” I ask
“All you need to do is get the hospital to change their coding and resubmit the claim.”
“OK, thanks!” I say, thinking this is now going to be an easy fix.
But, of course, it’s not. I call up the original person at the hospital I spoke with.
Change the coding? They can’t do that, it’s illegal.
“No, I’m not asking you to change the procedures done or the tests run. I just need you to get rid of anything related to dental.”
“But there isn’t anything related to dental. There’s nothing to change.”
“I know that. I honestly don’t know what you need to change either. But can you just resubmit something?”
“No, we can’t. You’ll have to talk with the insurance company.”
So back and forth I went on multiple phone calls to multiple people at both the insurance company and the hospital. The insurance company said it wasn’t their fault, they just need the coding changed. The hospital said it wasn’t their fault, you’re going to need to appeal it to the insurance company. Back and forth and back and forth. It felt like it was a game of Keep Away as they threw the blame over to the other entity.
At times, we idly wondered if it wouldn’t have been better to have my wife suffer in excruciating pain for 48 hours in order to ensure we were travelling the appropriate avenues of bureaucracy for health care. But, as ridiculous as that might sound to wonder, even that wouldn’t have worked. In two days the infection quite possibly would have spread and what was an easy (if costly) fix on Saturday could have turned into a complex (and more costly) procedure on Monday and there’s no telling how much money that would have ended up pulling out of our own pockets.
The hospital at this point has pretty much determined that insurance will never be paying and recalculates payment based upon what they would bill people without any insurance. We get a new bill for $1,800. For two hours of care, this is still extremely costly but, if push came to shove, would at least be manageable in our finances. Still – and if I may be just a tad uncouth here – Eff that Ess up the Bee. $1,800 for what? What in the heck were we paying insurance for every single month if they refuse to provide the very services we’re paying for?
And can we take a step back at this point and examine something? I want you to take a cold hard look at those numbers. It costs a person with insurance $5,000 and an uninsured person $1,800 for the exact same visit. Why? If you’ve been sitting there under the impression that your money is not going to cover the uninsured in this country, take a third or fourth look at those numbers. Far be it from me to generalize, but I’m just going to go out on a limb and say that every single hospital visit in this country by someone with insurance will cost more than the same visit without insurance specifically because the hospitals need to make money from the entities that pay to offset those who come in that they must see without the ability to pay. Hospitals cannot refuse service but neither can they remain open providing free or reduced priced care to everyone without compensating for it somewhere. It’s a simple matter of budget. And the insurance company doesn’t eat that cost. They just pass it onto you in the way of increase premiums and, well, reduced coverage.
It’s late January now. Still nothing’s been resolved but we do get something in the mail from the radiology doctor’s office. Remember that $320 bill? It’s gone to collections. This, despite keeping them in the loop every few weeks about our progress with the insurance company. Great. Our credit score could be slashed because of some bureaucracy snafus. So now I call up their billing office, they see that they’ve logged several calls from me, and recall the notice from the collection agency (but not until after my wife had fielded several calls already from them). Obviously we’re reaching the end of our leeway in payments to these groups so I’ve got to redouble my efforts and getting this whole mess resolved.
I go to the hospital. I sit down with someone from billing and discuss the entire situation. Half an hour later they can’t solve the problem, but they give me the direct line to the hospital’s national billing office and hopefully it can be resolved there. I called the number and, well, would it make an unbelievably long story just a believably long story if I said they couldn’t help either? Apparently to change the coding would take either 1) a panel to convene to discuss my case which probably wouldn’t be changed or 2) the ER doctor to go in and manually change his coding, which he wasn’t going to do. I kept those two ideas in mind, thanked them and hung up.
I figured at this point that since I’m already at the hospital, I may as well make the most of the situation. I head down to the ER to see if the doctor who treated us was in so that I could discuss option 2. He wasn’t though I got to explain the situation for the 137,987th time to the receptionist and then 137,988th time to the office clerk who they referred me to. She then wrote another name and number down on a sheet of paper and said to call her as maybe she would help.
I get out to my car and make the phone call.
She answers. I tell her who I am. I explain the situation. I detail the problems with the hospital. I rehash the steps I’ve taken. I clarify our position and the position of the insurance company. I beg and plead with her to do something, anything, to rectify this problem.
“oh yeah,” she says “let me just change toothache to headache on the initial documentation and resubmit the claim.”
“…what?”
“Yeah, I’ll just change the wording on the form and refile it with the insurance company.”
“What?”
“This sort of thing happens all the time. Insurance companies are constantly refusing claims. This usually takes care of the situation.”
I could have kissed her. I could have reached through the phone and made mad passionate love to her. I have no idea if she was telling the truth or not and I honestly didn’t care. She was the first person ever that said “yes I can fix this problem.”
And she did. It took a couple back and forths with the insurance company but it all fell into line. I let the doctor’s office know what to do, they tried it, and we got a letter a couple of weeks ago that our $320 bill was being covered. Then, last night, we got in the mail a notice from the insurance company about our hospital bill. The $5,000 was now covered. We just owed the co-pay.
It was over. Well, almost over. I’m holding out until I see a bill from the hospital. But I really, truly, think this entire ordeal is over.
I really don’t know what the heck this story’s about. Is it a tale of a (mostly) inept or ignorant health care billing office? Is it a story of an evil corporation bent upon world domination? Is it a dramatic retelling of a hero’s fall from grace and his triumphant resurgence? Is this now a novella with 2,000 words and counting? Maybe all of the above.
But it was seven months. Hundreds of phone calls. Participation, time and paperwork from at least a dozen hourly or salaried workers at the hospital, the doctor’s office, the insurance company, my HR Department, and the collection agency. Stress and worry and anger and frustration. How much did this cost everyone? How much money was lost by everyone involved dealing with this problem rather than just paying it like they were supposed to? And I’m not just talking about the insurance companies who probably earned more in interest keeping my money for seven months. I’m talking about the two health care providers who went seven months without payment and still had to employ people whose sole job day in and day out is dealing with the constant stream of problems like this one arising from insurance companies? Seven months to deal with a problem that should never have arisen in the first place and could have instantly been rectified if only the right people had been contacted sooner. How many hundreds or thousands of people before me have given up and paid out of pocket thinking that they’d exhausted all their options and insurance was never going to pay? This entire process is scary and disgusting and nauseating all at the same time.
This is being placed in MPSIMS because it’s not a rant. Well, not entirely a rant. And it’s not a debate. There’s really nothing here to debate. These are the facts of what happened to us.
I guess I just wanted to share.
