Balance Billing

Here is some follow-up from my daughter’s broken arm billing thread from earlier today. By way of background, my 13 year old daughter fell and injured her wrist when she was snowboarding in February. We were on vacation in Tahoe, about 180 miles away. My wife took her to the “Emergency” clinic at the base of the mountain where she was seen and evaluated. She was x-ray’d and diagnosed with a buckle fracture of the left radius. She was given a temporary splint and told to see her doctor when we got home on Monday. The whole visit took about 2 hours. Much of that time was spent getting a prior authorization from our insurance company. We paid the $20 copay required for this kind of visit (Urgent Care).

We did eventually go to the UCSF orthopedics clinic where she was seen and treated again (and again x-ray’d). This time, she was fit with a custom splint and this took about 2 hours.

Yesterday, I got a bill for $448.66 which was for the balance of what was not paid by my insurance company. Even after 26 years in medicine and even growing up with a father who is a doctor, I did not understand that there is no deductible for my HMO insurance plan for emergency or urgent care. My obligation was and is to pay the $20 copay.

So to learn more, this morning at 9:25, I called my insurance provider. I had a pleasant conversation with the representative and explained that I had gotten a bill from the provider. I said I wanted to call to understand what my obligation was. He said that I was obligated to pay the $20 copay and that was it. He said, “it is odd that they are balance billing you”.

He advised me to call them and gave me a number to provide to them for them to call the insurance company with questions about billing. That call took 9 minutes.

Next, I called the 800 number on the bill. It seemed to be a big billing company. I waited on hold for 10 minutes while listening to muzak. I eventually spoke with the agent and explained the issues again. He said that the insurance company had not paid the full amount and he explained to me that since this was out of network, there was no contracted rate.

He said that there had been an appeal sent to my insurance company on May 10 and that it had not yet been paid so he explained that I am obligated to pay the balance.

I said, that sounds like “balance-billing” and I understand that to be illegal in California. He said that was not true and invited me to write an appeal letter.

He said that I should call back my insurance company to understand why they did not pay the full amount. I responded that I had been spending a lot of time on hold and on various calls. He apologized and said Mondays were busy. He suggested that I try to set up a 3-way call between them and the insurance company.

I asked him if he thought the bill was coded correctly and he said he was not a coder. I asked who coded the visit, whether it was the doctor’s office or them. He said they coded it.

Next, I called my insurance company back. As an aside, they were extremely nice. She went through the notes and the bills and said, “they are balance billing you”. I said, that was my thought too. She said she would be willing to call them on my behalf. I told her that the billing agent had suggested we do a 3-way call. She agreed and asked for the number.

She conferenced me in and after we introduced each other, the insurance company rep told the billing agent (someone new) the story and explained that they paid this as a part of a multi-plan contract and the balance of $438.66 was not allowable per that contract.

The billing agent asked if the insurance company had submitted the explanation of benefits (EOB) when they made their payment of $1125.34. She said they had not. The billing agent asked if they could please send over the EOB. The billing agent asked what the status of the May 10 appeal was. The insurance rep said she did not know. The billing agent said she would re-submit the bill.

The insurance agent then asked what they could do so that her member (me) was not sent to collections. The billing agent said they would put a 35-day hold on the bill and said for me to call back when I get the next bill. And then again, she asked to please send the EOB.

We hung up with the billing agent and the insurance rep asked me to stay on the line. When we were back alone, she said, “they cannot balance bill you”. I said I agreed. She told me to please keep them updated. I promised I would.

Overall, this took just under an hour. At the end of the day, it is not resolved. There is a dispute between the billing company and the insurance company over this bill but the person left responsible is me. I am an experienced physician and even I did not understand any of this. I was not aware of multi-plan contracts or that they existed. I just feel like I am stuck in the middle of a dispute between two parties, but that somehow I am the one with the most to lose. I can only imagine how a lay-person might feel and fully expect that most people end up just paying this bill. The cynic in me wonders whether there might be an effort to bill like this expecting that most people will just pay it.  It is astonishing really.


  1. Have fun. This is going to take you more time than you think. If all else fails contact your state's insurance commission and ask them for assistance. Make sure everyone documents everything in your account even if calls are recorded. That may or may not save your butt if things really go south with this. Then someone will be forced to backtrack because you do understand don't you that in the end no one cares that anyone screws up because it isn't their money and the people you deal with get paid whether or not your bills are paid correctly.

    My insurance horror story... Longer than 140 characters - and longer than the 4096 characters comments can have according to the error message. MS word tells me 11,811 characters counting spaces … So since I can have only 4096 characters in a post there will be 4 of them counting this one.

    1. Part 1

      I have cancer, in fact have had several of them, and the year of chemo for #3 I spent over 180 hours trying to sort out the bills. In the end I had to have the Insurance Commission for my state get involved. They fixed the problem in the end. Took them 6 weeks. Then, because it took so long, I lost the (back then, it is less these days) $5000 the leukemia and lymphoma society was going to give me to help pay for treatment because I missed the deadline to submit paid bills (and was told to wait until they were right - they left out the part that the deadline wasn't going to be adjusted and I didn't think to ask). I was unsuccessful in forcing the insurance company to give me the money or the facility to write off that much. Sigh.

      It doesn't end there though. The year before last (maybe it was the year before that... I no longer remember as each year I have rinse and repeat) I had to be the one to figure out why the radiologist was considered medically unnecessary to read the CT scan. Turns out it was a wrong dx code used by the cancer center. *I* had to be the one to tell them what code had been approved and had to be used with each provider and procedure. Of course the insurance company didn't want to tell me what the code that approved was. I had to go up the chain to find that out. Now the facility didn't know this for what reason? This is something that needs corrected each and every year.

      Then, of course, we have wrong codes used for office visits. Instead of my copay, I end up being charged 20%. Turns out they were billing as if this was a hospitalization follow up (about 15 hours to get the correct answer to that one). Seriously? I never was hospitalized. This has been a multiple year rinse and repeat as well.

      Then we have the internal to the facility policy that my primary cancer clinic has to make a referral to the other clinic and my current cancer dx code is the one that has to be used on everything (umm and I am supposed to anticipate that this is needed? I should need to know whether or not I need pre-approvals from my insurance company but not the facility's internal policy). Two years running that didn't happen. I found out the reason why there was that problem by accident out of the clinic that had assured me I had pre-approval.

      Oh. Did I mention each year (both the insurance company and the facility) now I call to make sure all the pre-approvals lined up and that all my ducks were in a row? Well this year a new wrinkle. The facility only got the pre-approvals for 2 things, not all of them. But when I asked if all my pre-approvals were lined up I was told yes. Same by the insurance company. It was only because I asked as an after thought did I find out, the week before I was to be there that they hadn't submitted for the rest because this year they didn't realize that they needed approval for each molecule of air I breathe there (only sort of kidding). Now why would that be? New computer program where some Einstein chose not to talk to the users so removed the feature that allowed them to know that petty little detail about my particular insurance company and plan. So then I lucked out. I was on the phone with the insurance company (after a 1.5 hour hold) and the facility called on my other phone. Put both on speaker phone. For that we were on the call for over an hour. That was a fortunate coincidence as the facility couldn't' get the insurance company to pick up the provider line after being on hold for 3 hours (not sure if that is true but that is what I was told). I was then told by the facility to keep my apts 450 miles away even if the rest of the pre-approvals hadn't come though yet. I made sure that was documented because if for some reason the rest of the pre-approvals didn't come through I was going to force the faculty to write off what hadn't been pre-approved and I needed that paper trail. Luckily it was all pre approved about an hour before I was done with my 2 day visit.

    2. Part 2

      I finally met on this last trip, in person, 2 of the 3 people who deal with these (my) issues (pre-approval, sort out the disaster after the fact, and the director of the entire department mess - she probably is sorry I have her email address LOL). Figured I'd thank them (read bribe them to keep doing helping me- only half kidding) although some years what I would have liked to do would have likely been considered justifiable homicide for all the lack of help I got; and for having to learn how all this works in minute detail so I could tell them why things were screwed up and what they needed to do to fix it. This is my unpaid job as a patient. Right? OK got it. Need a PhD in pre-approvals, referrals, billing and coding to be a successful cancer patient. (Side note: I do not work in the medical field, but I doubt doing so would give you much of an advantage for dealing with my mess for the last 7 years). Anyway I was told I wasn't allowed in the building where they worked (in fact no one would even tell me where it was). HA! Tell that to someone who has been through the mill with insurance and facility mistakes. Walked 1.5 miles to the building (got that info out of an insurance guard) since I was unsuccessful in talking my way onto the employee shuttle. Employee sitting outside the locked everywhere building told me where to find them in the building (25 or so story building that is huge), another one held open a door for me you can otherwise only get into with a key card and told me which elevator to take for one office and which for the other. Then knocking on a locked door I was let in. In the other office employees going in let me in. So much for security and keeping patients out that place.

      Near the beginning of my mess for my first cancer some years back I managed to get into the CEO's office despite being stopped 3 times and everyone but one person denying knowing where his office was (entire top floor of the main clinic building - seriously no one who worked there knew that? LOL). When I was finally on the right floor and was stopped 3 times just told them I was headed to see his administrative assistant (like I would have been turned back if I said the CEO). That person made calls that finally got people to pay attention and start to try to fix my first mess with them back with my first cancer which was 7 years prior. With that disaster they mistakenly accepted my insurance (different one than the current mess), multiple times, over 7 months of treatment, surgeries... Umm you make medical decisions based on who will accept your insurance as in network. Can't return treatment like a couch Although I facetiously told them I'd return the treatment, pull the tumor from the trash and put it back in, etc. and I'd go get it treated elsewhere. In the end they finally wrote off the difference (took 7 years though to get to that point, in collection multiple times, told it was written off multiple times but then it didn't stay that way...) since it was their mistake, over and over, to begin with. Nope don't have ESP to know not to believe what they tell me.

      And could someone explain to me why I have to go through all these gymnastics each and every year? This is NOT my job. Both the insurance company and the facility hire people whose job it is to deal with this crap. I am so glad I am not elderly with memory issues. There is no way I'd have ever figured it all out. Instead I'd be denied admission to this major cancer center for treatment because they had cut off care (multiple times with cancer 1 and threatened to do so with cancer 3) in the past for unpaid bills (despite the fact that it was their fault, they weren't sorted out completely yet and said they wouldn't do that). Seriously folks? I should over pay you and then believe I'd ever see the money back with how poorly this has all been handled?

    3. Part 3

      I figure if I charged them $50/hour for my time doing their job (and mistakes have been both on the side of the provider and the insurance company) they'd owe me money. They'd owe me even more if I fined them for all the times I have been sent to collection over their mistakes and charged them for the lost LLS money. Instead I have had to resort to a gofundme to pay my bills (in the end I lost my job over cancer and had to choose to be homeless for 19 months as I had to pick between paying health insurance or rent - no medicaid expansion in this state but that is a different story) and still owe thousands even though they have removed thousands of dollars from my bills (am on a payment plan so hopefully won't be cut off again).

      Unfortunately my story is not unique. The entire insurance/facility interface is a disaster (not to mention what goes on inside of each that contributes to this) and everyone blames everyone else. The patient, meanwhile, is left holding the bag and trying to figure out how systems work so they can continue treatment, keep their credit score in one piece, and not lose their sanity while trying to get bills paid correctly or even getting billed correctly. Not to mention doing it while dealing with, oh, say, like one and a half years of treatment with a cancer with no cure, financial problems because of that, the emotional earthquake of all of this and feeling like crap because chemo sucks and nausea that isn't responding to anti-nausea drugs is horrific... fatigue is getting worse, job is forcing me to come to work after chemo if I want to keep my job since I have no sick days...(was dumped in the end for being "too expensive for their insurance") and I have to spend a zillion hours to solve insurance and billing issues. Really? It is supposed to work like this? If not then why the heck aren't people held accountable for their screw ups?

      Something has to change. Of course with what is currently going on in DC over who even "deserves" to have health insurance I won't even have health insurance next year if the bunch in charge have their way. There is an upside to not having insurance though - I won't need to deal with problems like this in the future.

      Again, good luck with your issues. You have my sympathies. Better bubble wrap your kids (and everyone else on your insurance plan) though if you want this to be the only inning you will be playing in this game.

    4. This is an unbelievable story. Except of course I believe you. Nobody can think this kind of thing is ok. Nobody. Thank you for sharing. Stories like yours need to be told over and over again.

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    6. You said, "Nobody can think this kind of thing is ok. Nobody". While that may or may not be true depending on who you are talking to, I don't think most of the actual decision maker executives involved consider that particular issue one way or another. Why? Because the health insurance company has an incentive to deny services even if they are wrongly denied and the facility has no incentive to do anything about it because the patient ends up holding the bag for whatever is not paid. Thus both are financially incentivized not to try to fix the underlying issues unless it is less expensive to fix the underlying issues than it is to leave alone the status quo and untangle an individual patient’s problem (and a few people likely hope the patient will give up in frustration). In addition I'd bet both the facilities you and I are dealing with did a cost/benefit analysis and decided it was cheaper for them to fix the problems for complainers than fix the underlying systematic problem(s) that are causing the issues to begin with.

      Example: There is not much cost to a facility to code wrong, etc. other than when a patient makes them to spend a lot of time fixing the problem. As a result they'll likely only fix the system when it becomes more expensive to deal with the fall out of a mistake ridden system than deal with those who complain. And I'd guess many people don't read their bills/ EOB's closely enough to even catch most mistakes. As a result whomever makes the financial decisions for the facility (and thus affects how things are done) gambles they mostly won't be challenged. Thus it will likely continue to be a PTIA to solve these kinds of problems.

      And the real customer is not the patient (they are the hostages). Physicians are the ones who affect facility prestige (which attracts patients and thus income, accolades, facility prestige, etc.) and so they are the actual *business model* customer. Now a facility can't treat a patient too poorly with respect to the non-medical side of what goes on or there is other fallout, however there is considerable leeway since the medical industry is not a "free market" situation. And when using the for profit business model some places are already using (even if they are non-profit as they still need to break even) I think this kind of thing is only going to get worse. Medicine should operate as a public good (eg like public education, city costs for electricity in rural areas even though it costs more to deliver it…) and instead it is increasingly not (we only have to look to DC right now to see that – my comment in the original post of no more worries for me about insurance problems as I will have none if DC continues down their current path, they don’t care about treating my cancer as I will be on the other side of the “value of human life” financial line – right now DC is just arguing about where that line is, rather than whether or not there should be a line to begin with).

      As a result insurance issues for the patient are largely irrelevant to the facility because (1) we are stuck holding the bag for mistakes anyway and the facility and insurance company don't lose money - in fact the insurance company will save money and (2) since they can throw us out as patients then the facility doesn't suffer much in the way of consequences when we don't pay the $ balance, even if it the $ balance is wrong. In addition (3) the patients have little leverage. So it is mostly the patient’s problem to figure out how to sort out issues like you and I are having. There is little incentive for it to be otherwise since the patient is the one left with the negative consequences, not the facility and the insurance company is incentivized not to fix mistakes in their favor.

      Don’t even get me started on the application of for profit business models to the practice of medicine (even in the non-profit sector), the consolidation of medical practices into near monopolies and the unintended consequences of that…

  2. it's always interesting to me when docs get directly involved in medicine as a patient or family member. it's a jungle out there every single day.

    1. Yes it's a good (bad) experience for us to have from time to time...


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