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Surviving the High-Deductible Health Insurance Labyrinth

For various reasons I am not going to use names in this post.

Piggy Bank with money

High deductible insurance seems designed to cost money through confusion.

Several years ago we (my family and I) were forced to change our health insurance from a classic HMO plan to a “high-deductible” one. That plan is effectively incomprehensible; ever since we were switched to that plan, we’ve been in collection or sued several times every year. As has everyone else – literally – that I have spoken to, who is on one of these plans. All of them. Every single person I’ve spoken to who is on a high-deductible plan has faced multiple medical collections and/or lawsuits. I am not kidding.

The cost has been staggering.

Now, the supposed principle behind high-deductible plans is to force medical consumers (i.e. everyone) to be “wiser”. To make better choices. Not to get wasteful and expensive MRIs, for example, when an x-ray will do just as well.

There’s just one problem with that noble concept: it’s bullshit. Who among us is qualified to know whether an MRI is more or less suitable than an x-ray for any particular case? A doctor, that’s who. And certainly not the vast majority of patients! Most patients couldn’t tell you the difference between an MRI and an x-ray if you pointed a gun at their heads.

But of course, the real purpose of such plans isn’t to make health consumers wiser. It’s to shift costs, away from the employer and health insurer, and onto – you guessed it – the patient. Never mind that since 1980 wages for the middle class and working class have flatlined or declined, while health costs have skyrocketed; we’re scheduled to get the shaft on medical costs nonetheless. Which is why medical bankruptcies have skyrocketed in recent decades.

As has, I strongly suspect, the medical collection industry. Who might be profiting from this explosion in medical costs and lawsuits? Somehow I doubt that it’s the middle class or the poor.

So here’s the most recent thing that happened to us. We got a collection letter from a local hospital. Teri’s doctor had sent her there for some tests a few months ago; nothing terribly unusual, just the kind of test that every woman probably ends up having done sooner or later.

Just to be clear, she’s fine. But there was good and sufficient reason for her doctor to order those tests – they were certainly appropriate and necessary. She’d had such tests before and they’d been fully covered without question.

But this time we got a bill from the hospital where she’d had the test for $1560.00. Need I say that we were horrified? I’ve been through hell with these medical situations before; the thought of going through all that again was really almost unbearable. Still, I girded my mental loins and plunged in.

There are several things to remember when you’re dealing with this sort of situation:

1. Document everything. I normally make the calls sitting in front of my desktop, with an open Gmail to myself (and I’m running the Lazarus add-on for Firefox, so even if power fails I won’t lose anything). Write down the phone number, the name of the person you’re speaking to, the time of the call and  which organization it is, and anything specific they tell you.

2. Always get confirmation numbers. You WILL need these when speaking to other parties to the issue – and there are almost always other parties. Pulling as many different parties into the issue is what makes them so hellishly effective. I suspect that most people give up and pay rather than persist against a multifarious bureaucracy in which different organizations never seem to speak to each other.

3. Collect as much information as you can. Speak to each party initially just to get a record of anything that they can tell you. Don’t commit to anythingespecially payments.

4. If you’re calling for a family member, make sure to have their birth date and Social Security number on hand. The Social Security number should not be required (and I’d be damned careful before giving it out), but it’s better to be prepared.

5. Get any documentation that has been mailed to you in front of you before you start making calls. Plus your health insurance card – as well as the card number of the family member, if you’re not calling for yourself. You don’t want to have to call back because you didn’t have an account number or diagnosis or procedure code, or didn’t know the precise date of service.

6. Don’t lose your temper. The system was designed by the most brilliant experts money could buy, and I believe that it was designed to frustrate and confuse victims – that is, “patients” – so much that they will give up and simply pay, even for services that they’ve already paid for via their health insurance premiums. It’s almost certainly a billion-dollar industry. If you lose your temper, they don’t necessarily win – but you will lose. Also, remember that the people you’re dealing with are generally low-paid customer service workers, which must be a thankless job. They aren’t responsible for the system, but they can make your progress much harder. A kind word can make a big difference.

So here’s what I did: I called the hospital where the test was performed (who were the ones who had billed us) and asked for the precise procedure that had been performed. That information had not been included on our bill; under the “Description of Services” section, it only said “Total Charges”. I also confirmed the date of the test.

That done, I called the referring doctor’s office. I had to wait for a call-back from their billing office, but they gave me the  diagnosis code – which was vital. Without a diagnosis code, you’re very often lost. I also chatted with them a little to get an idea of some of the referral process.

Next, I called my health insurance company. From them I discovered that the diagnosis code that they had didn’t match the code that the doctor had sent to the hospital when she’d requested the test.

(Here’s how the flow worked, in this case: The doctor sent the patient to the hospital with a diagnosis code. The hospital ran the test and submitted a claim to the health insurance company, passing along the doctor’s diagnosis code. The health insurer told the hospital to go fly a kite, because the code they’d received apparently indicated that this painful test wasn’t medically necessary, and had apparently been chosen by an “unwise” patient purely for fun. The hospital then billed us directly – at a grossly inflated cost. Q.E.D. R.I.P.)

Cue sound of trumpets: aha! Somewhere along the way the code had changed from a medically-valid diagnosis to an “unnecessary” code. Whose fault was that? We’ll never know.

Oh, something funny: when I had first called the health insurer, weeks earlier, they had told me that if the hospital hadn’t told us that we would have to pay those costs when the test was performed, WE should tell the hospital that we weren’t obligated to pay for them.

Let that soak in for a moment. Either the hospital or the health insurer screwed up – not us. But the health insurer told us to tell the hospital to go fuck themselves, in so many words. Why don’t I think that this would have worked out well? Somehow I don’t see the hospital simply “letting it go”. They use collection agencies, and those guys are nasty.

With that critical piece of information, I fished for a bit more information. I asked the health insurance rep if the correct code – which I was able to give her exactly – would have been a covered service. She confirmed that it was. She also offered to initiate a re-check on the claim; it would take a month or two, but they’d go back to the hospital and see if the diagnosis code had been correct. She volunteered that it would be faster if I contacted the hospital directly and had them re-submit with the correct code.

As one last belt-and-suspender check, I asked her if doing BOTH processes at once – that is, having the health insurance revisit the claim, but also having the hospital re-submit it – would be a potential problem. She assured me that it couldn’t hurt.

I thanked her profusely, and got a confirmation code. Then I called the doctor’s office and told them what had happened. They offered to contact the hospital with the correct diagnosis code and have them re-submit the claim. I gratefully accepted.

Lastly I called the hospital, gave them the health-insurance confirmation code and the correct diagnosis code from the doctor, and told them to re-submit.

All in all this took quite a bit of time and caused me a lot of stress. The scary thing is that this sort of thing happens several times a year just to my family – and this was a relatively easy  incident. Multiply that by the millions of Americans who are on high-deductible and similar plans, and you have…what?

A medical system designed to plunder, rob, and deny services that patients have paid for – that’s what!

Photo by 401(K) 2013 released under a Creative Commons Share Alike license.

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