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Sandra Shea

I'm no stranger to dealing with the medical world and its billing systems. I'm a triple cancer survivor, had knee surgery in 2012 and now have ulcerative colitis. All told, I've had eleven surgeries and fourteen colonoscopies. Paperwork is practically my middle name.

But the last twenty-four hours have been ridiculous.

In that time, I've had three different encounters with healthcare billing--each absurd in its own way, and each more challenging than the last. Things got to where I almost had to laugh. And if almost $10,000 of my money hadn't been at stake, I would have.

Yesterday morning and early afternoon were punctuated by the following events:

(1) I received a call from Enforcers, a collection agency. Their representative, Ms. Clementina Davenport, demanded payment for an emergency-room physician's bill dated eighteen months prior. I pointed out that I'd paid my share almost a year ago, and that my insurers had paid theirs four months later. "No," said Ms. Davenport. "We've received only partial payment" (my share).

(2) I received a statement from Gotcha Covered, my insurance company, saying that they would pay only $250 of a $5750 colonoscopy bill from two months prior. The remainder was my responsibility. Commence cardiac irregularities.

(3) I received a bill from X-Rays & More, a radiology group, saying that I owed $414 for an MRI done three months prior: "No payment from your insurance company has been forthcoming."

I dealt first with #3, the MRI bill. I pulled my Gotcha Covered paperwork, called X-Rays & More and was connected to Jane Cratchit in their billing department.

I suspected that X-Rays & More's bill and Gotcha Covered's acknowledgment had crossed in the mail. Ms. Cratchit confirmed this: "Yes, we have marked the amount as covered by insurance," she said politely, "and we'll wait for Gotcha Covered to provide compensation. Thank you for calling." Simple, straightforward and pleasant.

I then tackled #2, the colonoscopy bill. Gotcha Covered had paid for my previous colonoscopies, so I called them. The representative, Mr. McTeague, pointed out that this procedure had been performed by a different physician and at a different clinic.

"But it was preauthorized," I said. "How can $5,500 not be covered?"

"Well," said Mr. McTeague, "that clinic has been redefined as out-of-network, and we pay only $250 for those. We preauthorized it under those terms. Didn't anybody tell you?"

"Nobody told me," I replied stiffly, "or I wouldn't have had the procedure done there."

"But you did have it done, and that is what we will pay," stated Mr. McTeague. "Click" went the phone.

So I called my doctor's this morning and spoke with his office manager, Ms. Marlowe.

"Oh, you don't owe them that much," she said, laughing. "Did you get a bill from the clinic?"

"No, just the insurance statement."

"Well, we'll have the clinic business office call you." In less than five minutes, they did.

Their Mr. Hendley said that I owed not $5,500 but less than $100.

"In fact," he added, "given that your deductible is paid, you might not owe us anything."

He started talking very quickly; I gathered that the clinic is trying to recruit more referring physicians and more patients, and the only way they can do that is to charge in-network rates to those new clients.

It felt like being scammed, but in a good way. After all, if a $5,500 bill had just shrunk to zero, I wasn't going to object.

Bolstered by this, I called Gotcha Covered to talk about item #1, the Enforcers claim. Together, Ms. Araminty Brown, an agreeable woman with an English accent, and I reviewed our respective records and agreed that we'd received acknowledgement of payment. Why was Enforcers calling?

"Wait," said Ms. Brown after a pause. "Four days after we paid the claim, the ER physicians sent us an erroneous second claim, and we denied it. Maybe they sent that claim to Enforcers."

We scheduled a time to call Enforcers later in the afternoon. Before then, though, the Enforcers' Ms. Davenport called and asked snarkily, "Why haven't you called with any information that might support your account?"

"My insurance-company representative and I planned to conference-call you today at four o'clock," I said.

"You said you'd call within twenty-four hours," she snapped. "Now, which credit card do you want to pay with?"

"I never said any such thing, and I won't be using a credit card, because I don't owe any money," I said, trying to keep an even tone. "I had to speak to my insurance company before calling you back. And anyway, it's been only twenty-two hours since you and I talked."

"Call us as soon as possible today," she said, and hung up.

So I called Ms. Brown, and together we called Ms. Davenport.

Ms. Brown backed me to the hilt, verified the payment, pointed out the erroneous second claim and sternly but professionally overrode every one of Ms. Davenport's objections.

Ms. Davenport backed down a little. "I see," she said, sounding considerably more civil. "Well, I'll talk to the physician's billing department and let you know the result." She hung up.

"Let me know if you hear from them again," said Ms. Brown. "They have no case." I thanked her fervently. Then I sat for a moment and looked back on the whys and wherefores of my ordeal.

The X-Rays & More physicians could have their bills say something like, "We've billed you the total amount, but don't pay us until your insurance company tells us how much they will cover."

The colonoscopy site (or my physician's office) should have told me in advance, "Gotcha Covered will say that we aren't in network, but don't worry, you'll be billed at in-network rates."

The ER physician should have sent out only unpaid bills for collection. I mean, really, how hard is that?

Because none of the aforementioned parties did these things, it fell to me--a patient with a disease made worse by stress--to sort things out. Patients shouldn't have to spend sleepless nights worrying about this kind of thing, as I did, or have to take time off from work to make phone calls, as I also did, and I'm sure that I am not alone.

Is this the best we can do? I thought. Until a simpler, more rational way of financing health care comes along, it would help if health providers and institutions devoted as much attention to their billing practices as they do to delivering competent care.

It seems to me that health providers need to own their offices' mistakes and to acknowledge the heavy toll that these take on their patients' peace of mind. After all, isn't helping your patients to lower their stress a part of caregiving?

Postscript:

Ms. Davenport never called back. Six months later, a different collection agency called, demanding payment for the same erroneous bill; Enforcers had sold my "debt" to them. This time it took the combined efforts of my insurance agency and the physician's billing office to stop the calls and (hopefully) erase the blot on my credit score.

Shortly after these events took place, I suffered another one. A bill arrived for my stay in a local hospital. Total owed: $49,862--"not covered by insurance."

Feeling an eerie sense of déjà-vu, I called the hospital billing office.

"Oh, somebody keyed it incorrectly," said the woman who answered. "That's the amount that is covered by your insurance." Then she laughed.

Somehow, I couldn't.


About the author:

Sandra Shea is an associate professor and first-year curriculum director in the Department of Family and Community Medicine at the Southern Illinois University School of Medicine. "Most of my writing is for work--emails, lectures, tutor guides, cases--but writing prose or poetry for fun, for reflection or for just the sheer fun of storytelling is a completely different mental discipline. My father's side of the family is all Irish, and we learned early not to spoil a story in the telling!"

Story editor:

Diane Guernsey

 

Comments   

# Carol Gerson 2015-02-06 12:27
And if you had any cognitive decline, imagine how impossible all of the corrections would have been! I have been doing the same things for my daughter who has a chronic disease and the idiocy of not having a single payer system becomes more clear every day.

However, when the politicians who "don't believe in science" have power to prevent us from getting a single payer system and are intent on taking away new coverage for those who were uninsured and preventing those who are still uninsured from getting coverage, I lose hope for any improvement in the future.
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# Margaret Fleming 2015-01-30 13:26
WOW
This should be published over and over everywhere for everyone to read. Partly as a consequence of electronic un-useability creating - GIGO.

Also, I'd love to hear about Ms. Shay's Tutor Guides, as I am an ESL advanced tutor and dedicated to medical communication issues. Feel free to use my email for that.
Thanks.
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# Barbara Cohen-Kliger 2015-01-26 08:40
Given that this type of experience is not uncommon for patients, why have people fought the Affordable Care Act so vehemently? The Affordable Care Act recognizes that our health care system is broken and is an attempt to repair it.
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# Alan Harris 2015-01-26 08:50
Great point, Barbara. Unfortunately we have an ideological clash of titans not much interested in facts.
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# Tuyet Phan 2015-01-24 08:58
Thank you for sharing ! My son was also involve caces like that. Hospital send lawyers I sit the money . Call the insurance company, they say they have paid already . And when the company with new boss they demanded more money again from two, three years ago ! I think billing system of hospital need to be corrective.
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# Muriel Murch 2015-01-24 03:13
This is heartbreaking - and as you say - funny - except that it isn't. How many patients don't have the strength to do battle as you have?
It really wouldn't be that difficult for those agencies to do their work 'right' for the patient, IF they were working for the patient and not 'the man.'
Thank you for writing this. Now where else to sent it?
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# Patricia Schoch 2015-01-24 00:08
Thank you for posting an informative story detailing the flaws in our health care industry. Your story needs to be sent to every congressman. I feel I should be grateful that I have full medical insurance coverage, but with every procedure requested by my doctor I wait nervously to understand the breakdown in the column's listed "covered" and "uncovered services".
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# V. Hietpas 2015-01-23 22:26
This saga should be sent to every member of the House of Representatives and the Senate. What the medical insurance system does to patients in America is an embarrassment and an obscenity. I am ASHAMED that patients become victims in the AMerican system of healthcare.
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# Alan Harris 2015-01-23 22:20
Great story with a writer's touch regarding the "rule of three." I have to say that after reviewing each incident, the insurance company was not the issue--and in one case, extremely supportive. The commentator pulling for a single-payer system may have a point--but their point has nothing to do with your stories. Collection agency bullies will always be there. Non-par providers working back-door scams to get referrals will always be there. And paperwork will always cross in the mail. Great job for being your own advocate. But kudos for your insurer as well. From my reading they got it right in all three scenarios.
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# Sandra Shea 2015-01-24 12:46
You are correct - in the end the insurance company got it right every time (and a couple of times since). But, trust me, there was some editing involved to make the story of a readable length. In some cases it took several go-rounds with the insurance company to find the right person and get on the same page. The "Araminty Brown"'s at my insurance company have been fantastic!
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# Genevieve Yates 2015-01-23 21:08
Thank you so much for sharing, Sandra. I'm a family physician in Australia and thankfully such stories here are uncommon. However, I know firsthand that this is not the case in the US.

Last December, while on vacation in the US, I developed pyelonephritis. The infection brought on premature labour. My newborn daughter, Amalie, was rushed to the NICU, and I found myself in a high dependency unit with early sepsis. Four days later, my beloved daughter’s system was overpowered by the E. coli infection, while my body, with the help of modern medicine, was on its way to recovering from it.

Within hours of losing Amalie, I was presented with hospital bills (not including physician fees or other charges) for over $70,000 US. Salt was rubbed into my already almost unbearable wound.

I couldn’t get back to Australia fast enough.

I'm still fighting my insurance company who have (as yet) denied the claim.
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# Sandra Shea 2015-01-24 12:42
I am so sorry. Makes my story pale in comparison.
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# Bob Finlay, PAC 2015-01-23 21:53
Sorry for your loss, embarrassed by our system.
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# Elaine Whitman 2015-01-23 20:58
Horrific story, brilliantly told. It was deja vu all over again for me... I had a mess that was so badly snarled that I finally had to turn the whole thing over to my LSH (Long-Suffering Husband) to unsnarl it. As an RA patient, stress makes my disease worse, and I found myself in tears after every phone call. Does it REALLY have to be this complicated?
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# Sandra Shea 2015-01-24 12:41
No, it doesn't have to be this complicated. I am sorry for you and your LSH (love that!).
While many times this is un-necessarily stressful, there are times when I have found exactly the right person who can push the right buttons and solve the problem in a matter of minutes. One of the lessons I've learned is to make phone calls right away, as soon as the first letter comes. It doesn't always work, but it starts the process. Fresh problems are often easier to solve than stale ones.
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# Lee Kagan 2015-01-23 20:28
The current issue of the NYRB has an essay by Marilynne Robinson on Edgar Allan Poe's short fiction. I have to say that none of his tales of horror made my skin crawl as much as your chilling piece in this week's Pulse. The medical billing nightmares you describe comprise a new ring in our modern version of Hell. It's one that resonates with most readers as we've all been there. Thank you for sharing - I guess. The story is wonderfully written. Let's hope a saner, single-payer system shows up soon.
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# Sandra Shea 2015-01-23 20:50
Poe can always make me sleep with the light on, so I very much appreciate the compliment.
The only good thing about my experience was that things got so bad I closed my office door and started to write. When I was done venting to my keyboard I felt so much better. I was hoping nobody else had gone through this sort of thing, but the more I tell my story, the more stories I hear that are even worse than mine. Good luck to us all!
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# Randi Kaplan 2015-01-23 23:08
This horror story is so real and so frequent that unfortunately we have been desensitized to the toll it takes on anyone who has to fight it, but what about the insured person with stage IV cancer? Should she and her spouse have to spend endless hrs. trying to sort through the Kafkaesque maze that is designed to thwart people's efforts to make sense of, keep track of, and understand a legitimate charge from billing snafus and mismanagement along with the nastiness of bill collectors. Our system ensures an increase in stress, frustration, endless hrs. On a phone- going from one menu to the next, to ultimately reach an endpoint that instructs you to leave a voice mail , only to learn that the voice mailbox is full. Tear your hair out...? Unfortunately the patient I tried to assist today didn't have the ability to pull her hair out, the chemo had already took care of that for her. At no extra charge.
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# Stephanie Friedman 2015-01-23 19:43
Wonderful awful story. Probably there's not one among us who doesn't have a similar story. I had one that lasted the better part of a year to straighten out. It is too painful to relate, fortunately, so I am spared the full memory of it, and so are your readers. I agree with Sandra Shea that our health system often is bad for our health.
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# Sandra Shea 2015-01-23 20:55
I'm sorry to hear of your long horror story, and maybe the more we tell our stories the greater the chance people will listen.
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# Robert F. 2015-01-23 19:30
I was the recipient of an inflated, flawed, and outrageously expensive E.R. bill once, including items such as "Urine Strainer" (ACE HARDWARE calls them paint strainers, for $0.49) a dose of Odansetron IV, costing the hospital $1.19 at the time, was billed at over $300. Drug screening blood and urine tests were billed to me since I had a kidney stone and they wanted to be sure I wasn't a drug seeker. $600 for those tests. I was CT-scanned, without being offered an ultrasound, and the CT was billed as UPPER and LOWER abdomen for the same session in the machine, over $2000. All in all, I was tested, and never given the opportunity of informed consent, and inflated costs of treatment were over $4000 for a total visit of less than 2 hours I was billed over $8000.. BC paid $2300 and I was billed for the rest. I offered them $1500 as my best offer, and reported the fraud to BC/BS which withdrew their payment. They refused my offer, so they have received $0, and will NEVER get a cent.
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# Sandra Shea 2015-01-23 20:56
Wow. That's all I have to say. Wow!!
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# Maggie Genius 2015-09-20 19:44
At 63 I sold my home and moved to a state where I could purchase a house for half the price without feeling like I was moving into an unsafe neighborhood. My pension of $14,000 doesn't cover my many medical problems. It took a year for the house to sell. I need extensive back surgery that the doctor's in my last state would not do because of complications involved. I will see a doctor in my new home area, but worry about finances. The only money I have is what I made from the sale of the house and it has to last as long as God keeps me on this earth. My back is only one of many medical issues, but as it gets worse, I loose bodily functions. I wrote A to Z on a sheet of paper and listed past and present medical problems. The page was full.
Is this living when you either are in pain or stressed about the future and money?
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