Hello, family and friends of Paul and Kimberly, and welcome to another episode of Fun with Medical Billing. Perhaps you thought that our show had been cancelled due to a lack of new material; that’s certainly what I thought. As it turns out, that assumption was incorrect. Sadly incorrect. Frustratingly incorrect. And so I’m here to tell you all about it.

But first, a little back story: Our firm’s medical insurance policy comes up for renewal each year on the first of October. In early September, I learned that the folks at Group Health Uncooperative were going to make changes to their insurance plans, and that the plan under which we had been covered would no longer exist. Instead, they had several new plans from which we could choose. Our office manager reviewed plan benefits and premiums with a GH minion, and found that there was a policy that was very similar to the one that we had. And the monthly premiums would be lower! But wait, the out-of-pocket limit (OOPL) would be higher. In network, we would pay $500/year more before reaching the OOPL. For out-of-network providers, such as Dr. Futran and the UWMC team, the OOPL would be $1000/year higher than the old OOPL. (Lower premiums and higher limits are a way of adjusting coverage so that those who need lots of health care pay more than those who don’t. But the politics of health care are not my topic for today.)

For the first nine months of the year, Paul and I had paid for the old medical insurance policy. We paid the higher premiums, and, as you saw in a previous episode, we hit the $4000 out-of-network OOPL before the end of February. What, I wondered, would happen when we switched to the new policy, which had an additional $1000 dollars of OOPL? Given Paul’s CAT scans, doctor appointments, physical therapy and such, he might incur an additional $1000 in payments by the end of the year. (With 60% out-of-network coverage from Group Health, it would take only $2500 of medical charges to reach that point… and it’s amazing how quickly one can rack up that amount.)

I asked our office manager to contact Group Health and discuss this issue with them. She did, and was told that this would not be a problem, as the payments that we had made for the previous “plan year” (October to September) would be applied to this calendar year (January to December). Does that sound a little odd to you? It did to me, too, but that’s what she had been told, and I accepted it. OK, now we’re all caught up.

So, imagine my surprise when, a couple of days ago, we received an Explanation of Benefits form for one of Paul’s physical therapy appointments, and it showed an out-of-network OOPL of $5000. And $100.20 was shown as “your total responsibility”. Better yet, $10 was indicated as a copay, because, oh, I forgot to tell you, the new plan has copays… and copays are not applied to the OOPL.

You will have to imagine for yourselves the words… no, the epithets… no, the flat-out cursing that was heard in our house on top of Queen Anne hill, because this is family programming and I don’t say those words here (here being in cyberspace, at PvTSM, not here where I am physically). Well, I use them only very occasionally, and today is not one of those occasions. However, that day was one of those occasions.

I have yet to contact my friend… what was her name?… Marcie! my friend Marcie at Group Health Uncooperative to discuss this, as I have not yet had a chance to discuss it with our office manager. (I hope that she has the name of the GH minion with whom she discussed this.) And I’ve been trying to figure out exactly what to tell Marcie that I expect, what makes sense, what is “fair.”

For the first 3/4 of the year, we paid higher premiums, and had the lower OOPL. For the last 1/4 of the year, we’ve paid lower premiums. If we are going to have a higher OOPL for the last 1/4 of the year, it seems to me that the increase should be prorated for the percentage of the year in which the new plan has been in effect. Rather than raising Paul’s OOPL by $1000 to $5000, I would be willing to accept their raising it by only 1/4 of that, or $250. Barring that, I want a refund for nine months of the difference between our current premiums and our old premiums: $52.64 x 9 = $473.76.

Before I mention to anyone at Group Health that we’re willing to consider paying anything more for Paul’s health care this year, I want a letter from Group Health stating their policy regarding changes in health plans (and premiums and benefits) during the middle of a calendar year. On the letter, I want the signature of a person who has sufficient rank to do something about this, and the direct line at which I can reach that person. I also want a pony, delivered personally by Santa Claus. However, Santa Claus probably won’t care if I send him a letter stating that my attorney will be in touch if he doesn’t deliver.

Well, folks, the resolution will have to wait, as we’re out of time for tonight. Tune in again next… well, who knows when. That’s part of the hilarity of Fun with Medical Billing. Thanks for watching our show.

Yes, it’s time for more wonderful stories of medical billing. We had none of them in August, and I’m sure that you missed them just as much as I did. So, gather round, children…

You remember that little issue of the medical appointment at UWMC that got coded “in network” (where Paul hasn’t hit the out-of-pocket limit) when it should’ve been “out of network,” the one about which I spoke with Marcie at Group Health weeks ago? Marcie left a voice mail for me last week, saying that the appointment had been “authorized”, by someone at Group Health I guess, and was therefore being considered in-network.

I called Marcie the next day, only to discover that she had gone on vacation for a week. So, I left her a message saying that: 1) Paul did not have any sort of authorized referral to UWMC from anyone at Group Health. 2) The bill from UWMC that was coded “in network” was the clinic portion of Paul’s first appointment with Dr. Futran. However, the bill from UW Physicians for that same appointment with Dr. Futran was coded “out of network.” All portions of the appointment should be one or the other. 3) Group Health had denied coverage of Paul’s treatment at UWMC at “in network” rates because the care was available at Virginia Mason. We knew that going in, and made that choice. All billing from anyone related to UWMC should be out of network.

Today Marcie called me back. She told me that she had been notified that the appointment had been authorized, and should be in network. Furthermore, she had already filed the preliminary appeal, based on my phone message to her last week, and it had come back denied… even though she mentioned that the physician portion of the appointment had been coded out of network. Marcie agreed with me that this made no sense. However, she was calling to tell me, my only option at this point is to file a written appeal with Group Health, in which I should include all the back-up documentation, etc. etc. etc.

DAMN, but this is annoying! I could just let it be, and pay the $21.25, but there’s that whole principle thing that I have trouble giving up on. I’ll write the letter over the weekend; it will go out next week. Marcie says that I’ll hear something from an appeals person within 10 days.

It’s nice to know that I’ll have something to write about in a couple of weeks.

There was a message this afternoon on my cell phone’s voice mail. It was from Marcie at Group Health. Marcie Wheeler. (This is the first time that she has ever used her last name.) She called to tell me that – seven weeks and one day after I first contacted them – Group Health has taken care of that little matter of $1558.02 that they had incorrectly stated we owed to UWMC. According to Marcie’s message, the claim has been reprocessed to show “no patient responsibility” for that amount. (Perhaps she used her last name because she’s no longer afraid that I’m going to send harassing mail or stalk her. Or maybe she’s expecting a thank-you card.) Although she didn’t say, I assume we will receive paperwork to back this up… and that Group Health will fork over the money to UWMC. I’ll call Marcie on Monday to see if she can tell me what the process is, and when it might be completed. That other matter of a small procedure at UWMC having been coded as in-network rather than out-of-network? It’s still in the works. The way I figure it, the correction is still about a month out… but I’m willing to be wrong about this.

Perhaps someone else would’ve felt relieved at hearing Marcie’s message. I was still in my angry place (I’d been there writing the letter about billing errors to UW Physicians), and as Marcie’s chirpy voice is part of the ambient sound there, hearing it set me up nicely for a little rage… and suddenly, the problem was (apparently) solved. I felt stymied. All worked up, and nowhere to go…

Until tonight, when I had a little chat with our attorney (who also happens to be my sister) regarding the draft of the letter that I’ve written regarding UW Physicians’ billing errors. (Yes, I know we should have a local attorney. We just hadn’t seen much need for one up ’til this point.) Anyway, Melanie and I discussed my letter, and she dictated several much more directly threatening sentences to include. I do angry well. I do explication-of-why-I-am-angry well. I do this-is-what-I-expect-you-to-do-to-fix-it well. It’s the or-else that still gets me; writing if-you-do-not-fix-it-we-will-sue-you just isn’t in my repertoire. Or wasn’t, until today.

A cartoon clipped from the New Yorker arrived from our friends Bruce and Jo today. It shows a man in a hospital gown, pushing an IV pole toward a hospital ward door. The sign on the door reads, “Intensive Billing Unit.”

Their timing was impeccable. In today’s mail we also received our monthly bill from the University of Washington Physicians, who have contributed mightily to our intensive billing experience. Having read the title of this post, you will know that all was not right with this bill. (If you are tired of gory medical billing details, move along. There’s nothing more for you here. If you are willing to read yet another of my stress relief exercises, then read on.)

In late June, I called UW Physicians to pay Paul’s bill. By that time, I had determined that, with the exception of one charge that was new on the June bill, we did in fact owe UWP exactly the amount that was shown on the bill.

(I feel compelled to insert a caveat or two here. I really have no idea whether or not the doctors’ charges are correct. I know that Paul saw the doctors listed, on the days listed, and that Group Health has approved the charges, sometimes with adjustments, and that the amounts that we’ve been billed were included in the Annual Limit Tracking Summary… that’s what I mean when I say that we owe what they billed.)

So, I called to pay (because I don’t want to send our credit card number through the mail), and because I was feeling so good about the whole thing, I neglected to write down the name of the person with whom I spoke, but I very clearly remember telling her (also very clearly) that I wanted to pay everything except the one new charge on the bill. I wanted the payment to be applied to the amounts on the bill that had migrated into the 31-60 and 61-90 days categories while I was trying to find out from the not-so-helpful folks at our insurance company exactly what we owed to whom. And I said so.

So what was the problem with today’s bill? First, the Previous Balance shown at the top of the page was not the same as the ending balance on last month’s bill. (Hunh???) The balance had mysteriously decreased by $15,813.97, of which I know I paid ~$1210, but there was no indication on the bill of payments for these amounts, either from Group Health or from me. Oh, wait, there was $20 listed under Patient Payments. I wonder what happened to the other $1190?

But it gets better. The payment that I made appears to have been applied to the various physicians’ accounts randomly… but starting with the new charge that I specifically stated I did not want paid. Because of the “a few dollars here, a few hundred dollars there” approach it seems they took in distributing the payment, there is now $6.70 in the 91-120 days column, which got us this lovely little notice at the top of the bill:

FINAL WARNING: Past due balances may be referred to Merchants Credit for collection. Please remit fully within 15 DAYS or contact our office at 206-543-8606 or 1-888-234-5467.

And the final straw? The date on the bill: 07/10/04. The envelope postmark date: JUL 19’04. Nine g**damn days between printing and mailing! (Sorry, Mom.) I am so pissed! (Sorry, Dad.) And yes, this is all in writing, in a somewhat less irate form. Right now, I’m sorely tempted to use my lunch hour to pay a visit to the UW Physicians’ administrative office to deliver it in person, along with a nice helping of vitriol.

I’ve now paid almost all of the uncontested parts of Paul’s medical bills. I used our favorite regional airline’s mileage reward credit card, which gives us one frequent flyer mile for every dollar spent. (At the same time, I wrote a check to the credit card company for the amount charged. The plan is to get miles without paying any interest.) Paying all of the medical bills on the card will generate enough more frequent flyer miles to get one of us 25-30% of a trip anywhere they fly. I do not recommend following this procedure for increasing your frequent flyer miles. The payoff isn’t anywhere near good enough.

The contested parts of of the billing haven’t yet been resolved. I want to circulate a petition among the “members” of my insurance company, requesting that the name be changed to Group Health Un-Cooperative.

Yesterday, 2 weeks had passed since my last conversation with Marcie, and 6 weeks since my first call to “Customer Service”, so I decided to call and check up on the status of the outstanding issue ($1558.02 not applied to stop loss, blah blah blah, ad nauseum) that I’d left in Marcie’s care… and to put another little item on her plate. This really is a little item – a $70.00 charge from UWMC that was incorrectly coded in-network (where Paul has not reached his out-of-pocket limit) rather than out-of-network (where he’s WAY over the stop loss), resulting in a charge to us of $21.25. Yes, I’m doing this one on principle. We’re not going to pay these guys a penny more than we have to.

Whoops. Sorry. Back from tangent-heading-in-direction-of-rant now. As I was saying, I called to talk to Marcie. When I asked to speak to her, I was connected instead to her unnaturally cheery voice mail message. She did, in fact, return my call, leaving a message on my buried-so-deeply-in-purse-as-to-be-inaudible cell phone. She has put in a request for the small item to be recoded, which will then result in their paying UWMC the $21.25. And she has sent a message to the auditor person who is supposed to be fixing the $1558.02 problem, asking what’s going on, and requesting that processing be expedited. Holding my breath on this one? Yeah, right.

Paul called me at work today to tell me that Marcie from Group Health Customer Service had called. I promptly returned her call. While on hold, I imagined her telling me that, yes, the auditor had found the error, and they were so sorry about it, and they would revise the billing, and they were so very sorry about the whole thing, and while they were at it, to make up for their error, they’d just go ahead and pay the whole hospital bill (yes, I have an active fantasy life), and…

That’s not what happened. And I’m not just talking about the overactive imagination part.

When Marcie picked up the phone, she told me that an auditor had reviewed the claim in question “by hand”, and that the claim co-insurance amount had been applied to the out-of-network stop loss, and that we had reached the stop loss in early March, and that all subsequent costs had been fully covered. Clearly, she thought that was the end of it.

I knew otherwise.

“I know that the claim was applied to the stop loss. Therefore, all of the amounts shown as our responsibility on the claim should also show up on the Limit Tracking Summary, right?”

“Right…”

“The problem,” I said, “is that one of the amounts in that claim is not on the Limit Tracking Summary.”

She pulled up the claim and – much to my surprise, as she said last Friday that she didn’t have access to it – the ALTS.

“So you can see that there are three items on the claim for which we are shown as having co-insurance responsibility? And one amount is around $1560?”

“Let’s see, one of them is $1558.02…”

“Right. Now look at the Limit Tracking Summary. Only two of the three amounts from the claim are shown there. Those two items, and the amounts from the other claims shown, add up to the $4000 out-of-pocket limit. The $1558.02 is not on the Summary. That. Is. The. Error. We are not responsible for that amount; Group Health is.”

“Oh… I see… oh.”

AT LAST! I have made someone at Group Health see the problem. “It looks like a clerical error to me,” I said.

“Well, yes…” And then Marcie tells me that she will have to send this back to the same auditor who reviewed it before, with an explanation attached… because Marcie can’t do anything about it!!!

I tell her that UWMC is waiting for payment of that $1560, and she tells me that, if I call her tomorrow with the account number at UWMC, she will call and talk to them “so they won’t bug you about it.” And that is the closest thing to an apology that I got.

By my count, our “case” (their term) has been handled by at least six different Group Health employees in the past month… and not one of them has seen the very-glaring-to-me billing error, until I took Marcie by the hand today and dragged her through it. The customer service folks are given little access to any information until someone further up the food chain has approved that access (and no power to change anything); there’s a drone in the accounting office churning out ALTS forms without any review of them; and at least one of the auditors either is lazy (and just matched up claim numbers, but not amounts), or bad at math, or both. Our insurance premiums are paying the salaries of these folks; no wonder health insurance is such a mess.

Paul noted today that I’m well-equipped to fight this battle, and I’m still having trouble resolving this problem. What about those folks who aren’t so bright and detail-oriented? Or those who have trouble questioning authority? Or those who aren’t so damned persistent?

I now have the names and addresses of Group Health’s executive officers and trustees; they’ll all be getting some mail soon. Sadly, I doubt that they’ll be willing to pay our hospital bills by way of apology, either.

Yesterday, we received a bill from MD Anderson Cancer Center in Houston. It has been over 4 months since Paul saw the doctors there, and this is the first billing paperwork that we’ve seen from them. There have been a couple of “Explanation of Benefits” forms from Group Health pertaining to Paul’s appointments there, but not enough to cover all of his appointments, and nothing from MD Anderson. While I have wondered about the charges, I have not been willing to initiate a conversation with them about their billing.

But send me a bill – especially a confusing and incomplete one – and I’ll certainly react. The bill showed a “balance forward” of several hundred dollars in both the “pending insurance” and “patient balance” columns. Hmmmm. For it to be a balance forward, shouldn’t there have been a previous bill on which the amount was a current item? And of course, since the amounts were shown as balances forward, there was no listing of the physicians’ names (or numbers, as that’s often all that shows on the bill), appointment dates, and charges.

So, today I called MD Anderson’s toll free Customer Service number, and spoke with Christina. (Christina? Maybe real names, rather than flower aliases, are the norm at MDA.) Apparently they’ve been having some problems with their accounting software, so that some people who should’ve been billed haven’t. This problem with the software was recently fixed, which is why we got a bill. I said that, before paying anything, I’d need a complete, detailed statement of Paul’s account. Christina said that she’d be happy to send that to me.

Then I asked about the $400 deposit that they had required us to pay before seeing Dr. Weber. (When we were there, we hadn’t yet paid any of Group Health’s out-of-network deductible for the year… so they collected the entire amount from us.) Oh, Christina said, that’s showing as a credit on your clinic account. (As at UW, the doctors’ fees and the hospital/clinic charges are billed separately.) The $400 didn’t show up on theclinic portion of the bill as a credit… but perhaps I expect too much. I told her that Paul had been there for a second opinion, that there wouldn’t be any clinic charges as he was treated elsewhere, and would she please apply that amount to the physicians account. She said that she would put in a request to transfer the credit.

I neglected to ask how long I should expect these things to take. I wouldn’t be surprised to see the statement from MD Anderson before the statement from Group Health that I requested almost 3 weeks ago.

Dear Group Health Options Incorporated Appeals Department,

My husband, Paul Davis (member ID ********), had major surgery at the end of February. This surgery was performed at the University of Washington Medical Center.

Since this was out-of-network care, there is a $400 deductible. After we have paid the deductible, you pay 70% of covered expenses (that means that we pay 30%). We have a stop loss of $4000. That means that, once we have paid $4000, all covered expenses are paid in full by Group Health. I have read our insurance policy (more than once). As my reading comprehension is really quite good, I believe that I understand our coverage. In addition, several Group Health employees have explained the coverage to me… in detail… as if I were a small, rather slow child. You do not need to explain it to me again.

We received some very large bills from UWMC and the UW Physicians for the surgery and associated hospital stay. Subsequently, we received quite a few “Explanation of Benefits” statements from you, indicating adjustments you made to their charges, what you would cover, and what amount it would be our responsibility to pay. The Byzantine structure of these forms was enough to test even my quite good reading comprehension and math skills. In an attempt to fully grok the situation, I set up an Excel spreadsheet to correlate billing from UW and your coverage. Please see the attached four pages. Please note that the amount indicated as our balance due (“patient responsibility” on your forms) is $5500, which is $1500 over the $4000 stop loss (see above).

Two weeks ago, I called your customer service number to discuss this issue. I spoke with Jasmine, who, after explaining our coverage to me, told me that, while she couldn’t review the amounts with me, she would put in an order for a complete detailed benefit statement to be sent to us, showing how much of each bill had been covered, and at what point we had reached the stop loss. (Apparently the computer file to which she had access did tell her that we had reached the stop loss, but did not provide additional information.) Jasmine told me that it would take about 5 days for the request to be processed and the statement mailed.

When 10 days had passed, I called your customer service number again. I spoke with Rose, who, after explaining our coverage to me, told me that she could see in our file that Jasmine had requested the statement, but that it had not yet been processed. I mentioned the 5-day time frame, and Rose said that sometimes it took “a little longer.” She suggested that, if we didn’t receive the statement in a few days, I call again and speak to Jasmine (who was not available at the time). I asked if it might be possible to speak with the person who would be processing the request. No, I was told, that’s the accounting office, and we can’t connect you to them.

Several more days passed; no statement. Yesterday, I called your customer service number again. When Lily answered, I asked to speak with Jasmine. Lily put me on hold, and shortly came back on the line to tell me that Jasmine was not available. I explained why I was calling. (Lily did not explain our coverage to me. I hope that this was not a failure on her part to follow your guidelines for customer calls. I did not mind.) I asked if Lily could tell me whether the benefit statement had been mailed. No, she said, it had not been processed yet, but the order was there in the file. I asked when we might expect it, alluding to the 5-day and “a little longer” time frames mentioned by Jasmine and Rose. Well, according to Lily, it usually takes about a month for such requests to be processed. I told Lily that we had outstanding medical bills, and that I wanted to pay them, but didn’t want to pay more than we really owed. She said that any overage that we paid would be refunded. I told her that I did not want to pay $1500 that we did not owe, because we needed that money for other things. She said again (and yes, more slowly and a little more loudly) that we would receive a refund for any overpayment. What could I say to that? I gave up.

I’m hoping that, by putting this in writing, I’ll get a more timely response. Is there someone with whom I can speak about this directly? I don’t think that your statement – whenever it finally arrives – will provide me with any information that’s not already on my Excel spreadsheet. Could you just give my spreadsheet to one of the folks in accounting, and have them call me? Really, I don’t even need to talk to anyone, if they’d just make the corrections to our account, and send UWMC an additional $1500.

Thanks in advance for your attention to this matter.

Sincerely,

Kimberly

p.s. I just have to ask…What’s with the flower names? Does everyone in customer service get an alias? Or would I have to change my name to Tulip or Pansy or Iris to get a job there?

The news from Paul’s barium swallow test today was not good. Speech pathologist Marie saw only small changes from the test that Paul had just over a month ago, and considers him to still be at high risk for aspiration. We did, however, get more information from her today than we did from the speech pathologist who administered the last test. I haven’t yet been able to write about the medical details; when I try to do so, my writing ends up disintegrating into lines of “damn, damn, damn, damn, damn” across the page. I’ll try again tomorrow. The upshot is that we won’t be able to chuck the spacefood for a while. In the meantime, we’ve got to figure out how to make the tube feeding work well enough that Paul can spend some time and energy on something other than trying to get in – and keep in – enough calories.

This afternoon, in an attempt to exert control over some part of this amusement park from hell, I got out the folder full of medical statements. You know, it’s the one I labeled “I can’t think about that today. I’ll just go crazy if I do. I’ll think about it tomorrow. After all, tomorrow is another day.” Well, I don’t know nothin’ ’bout medical billing, but I do know how to put together one hell of an Excel spreadsheet. Every line item on each statement from UWMC or UW Physicians has its own row in the spreadsheet. If we have received an Explanation of Benefits form from Group Health for that item, the amounts adjusted, paid and due are shown as well. So… Two months after the surgery, there has been no response from Group Health regarding billing for almost $23,000 of surgical costs. And, when I total the amounts that are shown as “Your total responsibility” on all of the Explanation of Benefits forms, said total is $1340 over the policy stop loss of $4000. That’s a 33% overage… and that’s only on the UW part of the bill. (We haven’t yet received any billing from MD Anderson for their services, so the Explanation of Benefits forms that Group Health has sent for a couple of the appointments there make no sense.) Perhaps I shouldn’t be surprised, but I am… and angry, too. I don’t want to spend my time writing letters to or on the phone with some Group Health lackey in order to get this all straightened out… unless I can bill them for the time I’ve spent fixing their mistakes. Say it with me, please: single-payer health coverage.