Her hearing implant was preapproved. Nonetheless, she got $139,000 bills for months.
Ways to deal with surprise medical bills
02:03
Caitlyn Mai woke up one morning in middle school so dizzy she couldn’t stand and deaf in one ear, the result of an infection that affected one of her cranial nerves. Though her balance recovered, the hearing never came back.
Growing up, she learned to cope — but it wasn’t easy. With only one functioning ear, she couldn’t tell where sounds were coming from. She couldn’t follow along with groups of people in conversation — at social gatherings or at work — so she learned to lip-read.
For many years, insurers wouldn’t approve cochlear implants for single-sided deafness due to concerns that it would be hard to train the brain to manage signals from a biological ear and one that hears with the aid of an implant. But research on the detrimental effects of single-sided deafness and improvements in technique changed all that.
recent report by Crowe, an accounting firm that works with a large number of hospitals, found that more than 30% of claims submitted to commercial insurers early last year weren’t paid for more than 90 days — striking compared with the lower rates of such delays in Medicare, which were 12% for inpatient claims and 11% for outpatient claims.
The Crowe report found a particular justification for denying claims was cited at 12 times the rate by commercial insurers as by Medicare: that they needed more information before they would process the submission. Such a request allows insurers to sidestep laws in most states that require claims be paid in 30 to 40 days, automatically granting health plans the right to delay payment.
In a separate analysis, the American Hospital Association complained that increases in insurance denials and delays “strain hospital resources” and “inhibit medically necessary care.”
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But perhaps no one is harmed as gravely as the patient, who is barraged with bills and believes they must pay up — particularly when the missives are stamped “past due” and contain offers of prompt-payment discounts or no-interest payment plans. “The stress and anxiety was huge,” Mai said.
Caroline Landree, a spokesperson for UnitedHealth Group, said the insurer could pay Mai’s claims only “after receiving a detailed bill from her provider.”
“We encourage our members to contact the number on their insurance cards for more information on the status of payments,” she added.
The Resolution: Mai estimated she spent at least 12 hours on the phone doing tasks that typically fall to someone working in a hospital billing department: making sure the bill was coded as needed and that the insurer had what it wanted to process the payment.
More than 90 days after her surgery, after Mai had received four terrifyingly huge bills, her insurance finally paid the claim. Mai owed nothing more.
She added: “I’ve never got that call back from a supervisor to this day.”
The Takeaway: It’s not uncommon for an insurer to delay paying a claim until it receives an itemized bill; providers sometimes get creative with billing codes to increase revenue, and studies show that more than half of hospital bills contain errors. But studies also suggest insurers are wont to drag their feet, niggling over coding and charges — and, in doing so, delaying reimbursement and holding on to the cash.
Medical billing experts say it may not seem right for patients to receive bills as this process plays out but that it’s probably legal.
“Laws say ‘hold the patient harmless,'” Benjamin said. “What we didn’t say is, ‘Don’t send them a bill.'” She said it is also unfair that patients may be forced to act as the go-between for providers and insurers who should be talking to each other.
What’s a patient to do? First step: Don’t pay the bill (aside from a copay or coinsurance) for care or services preapproved by insurance. Call the health care provider and explain they should take up their bill with the insurer.
Second, ask the provider to send an itemized bill with all billing codes used, then review it for errors. As the patient, you would know that you never had an MRI, for example. Your insurer wouldn’t.
If submissions to “Bill of the Month” are reflective of trends, many patients these days are finding themselves ping-ponging between representatives for providers and insurers to get bills resolved and paid.
“Bravo for Ms. Mai for having the energy to keep at it and get resolution,” Benjamin said.
Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!
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Source: cbsnews.com