My Experience as a Pawn in the Health Insurance Game

Hardly a day passes that I don’t hear a news report or see a post on social media or talk to someone who complains about the high cost of insurance and/or medical treatment. I guess I’ve been somewhat naive about the reasons, but something happened to me today that brings it into crystal clear focus.

First, a little background. More than a year ago I had a diagnostic procedure performed locally, at the recommendation of a surgeon. I was told upfront that my insurance wouldn’t cover the procedure; despite the intense pain I was experiencing and the absence of a diagnosis, I would first have to undergo weeks of physical therapy – even though the therapist wouldn’t know what he was treating, only the symptoms – before I could have the tests that would diagnose the cause. Makes perfect sense, doesn’t it?

The procedure was expensive, and the surgeon’s office kindly directed me to the lowest cost provider they knew, although I wasn’t told upfront what the cost would be. But when it came time to pay, the clerk told me that no payment was due; my insurance would pay. I was puzzled, but happy. I assumed that the doctor had managed to convince my insurance company of the medical necessity of the procedure, and all was good.

Imagine my surprise when, more than six months later, I received a bill from the clinic in the amount of about $5,000. Perhaps the doctor wasn’t such a good negotiator after all.

I immediately called the toll-free number on the face of the invoice to speak with someone from the billing department, and I was connected to Julia (not her real name). I explained the situation to Julia, emphasizing that her clinic (I assumed that she was affiliated with it, and not just an outsourced billing department) had expressly told me that my insurance would cover the bill, and that I had never received any communication from my insurance company regarding the claim. She agreed that seemed odd, and when she pulled up my file, she had a good explanation: a claim was never filed.

I asked if they would file one, because I was getting conflicting messages from them. On the one hand, yes, insurance will cover it; on the other, a bill for $5,000, without ever checking with the insurance company. She agreed to do that.

But, in addition to asking for an actual claim to be filed, I noticed on the bill they sent that there was a 50% discount if it was paid within 14 days. That’s quite a savings, and I assumed it was designed to stimulate payment and avoid the expense and hassle of a collection agency. I asked for and got Julia’s assurance that if the insurance did indeed reject the claim, I would still be able to take the 50% discount (bringing the bill down to $2500 – I don’t doubt your arithmetic prowess, but keep that number in mind).

This commenced several months of back and forth that I won’t detail except to say that Julia didn’t follow-up with the insurance company, and I began to receive additional invoices, now stating that if I didn’t pay up, a collection agency would be called in. Oh, and the mention of the discount was absent. Each time, I called Julia and she promised to work things out, to put the account on hold pending a final answer from the insurance company…an answer that wasn’t coming because someone obviously wasn’t asking a question.

That brings us to this afternoon, when I called once more, only to find that Julia was out of the office, but Maria (not her real name) was covering for her. I dreaded having to start from scratch, but Maria quickly came up to speed on the situation. She promised to call the insurance company immediately and let me know the outcome.

“Immediately” was actually a couple of hours, but Maria did call and said that she had called the insurance company and they were denying the claim. I then asked about the discount, pointing out that Julia had consistently promised me I’d be able to take it.

Her quite unexpected response? “Oh, I think I can do better than that.”

*crickets*

“Oh, really,” I replied.

“Oh, yes…we can offer our self-pay discount.”

“And…what would that be, exactly?”

I could hear her doing the math. “You would owe us $1,100. That’s a better deal, isn’t it?”

*crickets*

“Oh, yeah, I think I can swing that.”

Let’s recap, shall we?

• My insurance company insists on treatment for an undiagnosed malady before I can get a diagnosis.
• The cheapest alternative for the diagnostic treatment (and trust me when I tell you it was nothing exotic) still costs as much as a decent used car.
• The diagnostic facility misinterpreted my insurance coverage, and then never followed up to confirm it, until I pressed the issue.
• And once we resolved the insurance issue – and only then – they offered me a 75% discount on what they were planning to charge the insurance company*.

Our entire medical system appears to be a huge game between healthcare consortiums and insurance companies, the rules of which seem to change arbitrarily and illogically, and the playing out accompanied by a series of knowing winks, with the patient caught in the middle, hapless and clueless. In this case, the system worked to my advantage (I think; perhaps I just have lowered expectations), but no wonder Americans are increasingly cynical about the the whole thing.

And the sad thing is that no one has the solution, and if they did, they wouldn’t have the will/power to implement it.

*As my wife pointed out, had the insurance company agreed to cover the procedure, it’s a sure bet they would have negotiated a significant discount with the provider. Nobody ever pays list price…except those who don’t know any better.