Since joining the Philadelphia Inquirer a year ago, I’ve been studying your medical bills. I’ve talked to insurers, hospitals, economists and analysts about the problems you’ve experienced; and written about what I found out. Everyone seems to have a medical bill horror story, and although they’re each unique, there are some common themes. Here are some of the things I’ve learned:
We launched the Philly Health Costs project on the premise that prices for even basic services, such as blood tests and X-rays, vary widely among providers. As out-of-pocket costs continue to rise, it’s increasingly important for people to be able to know in advance what something will cost — but it’s virtually impossible to get answers. This turned out to be overwhelmingly true in the Philadelphia area. The examples are endless, but I offer up two as prime illustrations of the absurdity people encounter in our health system:
Prices are difficult to find out in advance and impossible for anyone to explain after the fact. Patients who call providers to inquire about cost are told that the information is proprietary or that they should check with the insurance company. Insurers also struggle to give exact numbers, because the amount you owe will depend on what exactly the provider bills for, how much of your plan’s deductible you’ve already paid, and whether there are other cost-sharing terms in your plan.
Online price estimator tools can sometimes give a ballpark figure, but even when people use this, they can end up with a bill that’s out of the stadium. That’s what happened to Michelle Smith, of Springfield, Delaware County: She used her insurer’s price tool to find a low-cost, in-network breast MRI provider and got an estimate of less than $1,375. Her bill was $3,237. Rubina Tahir, a chiropractor in Philadelphia, tried to price out how much the care she received during her pregnancy would cost, but even as a medical professional accustomed to dealing with insurance companies, she had trouble. She soared past her plan’s $2,000 deductible and hit the $5,000 out-of-pocket maximum when her daughter was born.
Analysts estimate that as many as one in five medical bills contains a mistake, yet it’s incredibly difficult for patients to get mistakes corrected. Judy Politzer, a retired midwife from Swarthmore, had a colonoscopy without anesthesia (uncommon in the U.S. but not unheard of) and was billed for it anyway. She spent months trying to get it removed from her bill. Too often, patients aren’t taken seriously when they question their bills. Instead of getting an explanation of the charge, they’re simply told, “No, that’s the right amount. You owe it.” As one patient billing expert explained, insurance companies routinely challenge medical bills with providers when the dispute is over the amount the plan owes. But a growing portion of medical bills is falling to patients — as is the responsibility of challenging a mistake. The difference is that patients don’t have the clout and know-how to go up against a hospital.
Routine procedures, such as colonoscopies and mammograms, are particularly susceptible to billing errors. Under the Affordable Care Act, certain preventive tests are supposed to be covered in full by insurance, without any additional co-pay or bill to the patient. A screening colonoscopy, for example, should be covered fully for adults age 50 and older who meet all other guidelines for a screening and are at average risk of colon cancer — even if a polyp is removed. But based on the many, many emails I’ve received from frustrated readers, providers routinely switch the procedure code to a diagnostic colonoscopy if they snip a polyp, and patients get billed accordingly.
Many of the people who have been featured in my articles brought their problem to me after getting nowhere on their own. And sometimes, a little publicity can help move things along. Liz Parlett Butcher wrote to me after months of trying to get the family’s Medicaid managed-care plan to pay for her 9-year-old son’s preferred insulin brand. The insurer wanted Shane, whose family lives in Egg Harbor Township, N.J., to first try an insulin that cost the plan less, but Shane wasn’t responding well to it — his mother said he almost went into a diabetic coma. After The Inquirer’s story, UnitedHealthcare issued the family a 20-year coverage guarantee for Shane’s preferred insulin.
Evan Acuna, a 27-year-old Collingswood resident, got his share of an ER bill reduced from $4,752 to $779 after he called the hospital in a panic to tell them he couldn’t afford to pay it. It’s frustrating and unfair because not everyone can get their story in front of a reporter and it shouldn’t take public shaming to resolve the types of problems I write about. (That much said, please don’t hesitate to contact me if you have an interesting billing problem, and are willing to have your name and photo in The Inquirer.)
Insurance companies and health systems need to do a better job of communicating with people. Typically people bring their bills to me once they believe that they’ve exhausted all their options — they’ve called their insurer and the hospital numerous times and been unable to get an answer to their question. When I talk to insurers and hospitals, they point to their online price tools, plan coverage descriptions on their websites, financial support departments that are there to answer questions, but it’s clear these resources aren’t enough. People are showing a deep interest in the cost of health care and these major players are missing an opportunity to meaningfully engage with their members in a way that could actually help reduce their overall health-care spending.
People are very concerned about medical debt affecting their credit rating. Often, they try to challenge a medical bill, but in the meantime they keep getting notices and end up paying it because they receive a “last reminder” notice telling them this is their final opportunity to pay before it’s sent to a collection agency. FICO, the most commonly used credit agency, has updated its formula to lessen the impact of medical debt on credit rating. But banks and lending institutions may be using older software versions that still count medical debt like any other delinquent bill.