Recently, there's been a lot of talk in the news about Daraprim, the medication that was initially set to see about a 5,000% price increase for reasons that sounded dubious at best. In case you missed it, a drug company bought the medication and raised the price from around $13 a pill to $750. The company in question has since backed down, and I have not heard what the new price will officially be as of yet.
Either way, this situation makes me instantaneously furious. The thing about our health and medications is that the person who is sick isn't really in a position to negotiate. If you tell me the medication cost $30, I will pay it. If you tell me the medication costs $3,000, I will find a way to pay it. My health and my life are effectively held for ransom. For a period of time, I was on a medication that cost $28,000 a dose, and, no, I did not put any extra zeroes in there. BUT, when I was studying for a semester in Scotland (where my medication schedule fell twice while I was over there), the medication itself was about a tenth of the price, AFTER the exchange rate and foreign transaction fees. This all meaning that it would be cheaper to take a weird vacation every eight weeks to receive my infusion than to pay for it out of pocket in the states. It is absolutely absurd that we don't have some kind of a cap on these pharmaceuticals.
Thank God for insurance, right?
Truly, with how many times I've been hospitalized, my fluxing and ongoing medications, and the sheer bad luck of it all, we would be a few levels of irreparably bankrupt were it not for insurance. If it hadn't been for the portion of the Affordable Care Act that allowed me to stay on my parents' insurance, I would have been in a whole lot of trouble, when I was too sick to find insurance through work and Andy and I were sorting things out as far as what we needed. That component, allowing us to stay on until I was 26 saved us a great deal of heartache and a ridiculous amount of money.
I was very content to let my father do the arguing with insurance for as long as possible, but it was inevitable that I would have to figure this out eventually. My first major surgery, the only real surgery we expected with my Crohn's in 2012, was under my parent's insurance. The emergency surgery a day later, the days between ICU and the hospital proper, the nurse visits at home, the ostomy supplies, etc. were originally under their insurance. And THEN, before the last surgery, we changed to Andy's insurance. This meant that I have made a lot of calls to insurance, providers, prescription coverage specific personnel, other billing departments, and a few other components in between to get to the bottom of some of the charges that were piled up on my dining room table. For a year, I was sorting out what needed to be argued to one insurance or another, let alone which facility/doctor/department.
For the past few months, Andy and I have had a couple thousand dollars tied up in medical expenses that we were disputing, so that in the meanwhile we were holding that money paid on credit cards until everything was sorted out--I am not in a position to refuse payment for certain services, so our fight isn't negotiating for a lower price but instead reimbursements.
As such, I hope to pass some of this experience on. Getting to the bottom of your medical bills and charges is a life skill and usually happens to be necessary at some rather inconvenient times in your life. I make no promises to your results, but here are a few suggestions.
***As an aside, I am quite satisfied with my particular medical insurance. No system is perfect, but they seem to get a lot right most of the time.
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1. Ask questions.
I tell you this truth--there are some charges that will stay on only if they are not contested. Sometimes, it is easiest to just pay it and make sure it goes away, but some charges will clear up as soon as you start asking questions. It is always worth asking where these charges come from, why they aren't covered, etc.
I was receiving bills for a long time from a specific company that checks all of my hospitals' tests, meaning that the test is done at the hospital, but it gets sent to this secondary company for quality assurance. I understand this concept, but my insurance thought they were paying for the same test twice. I hit a dead end arguing with my insurance, but I called the hospital to ask if there was any way I could be exempt from this practice, as much as I think it's necessary. Eventually, I was passed to the right person: she took down what my insurance company was and I only see the odd bill for this service anymore.
2. Be persistent.
There was a period of time where my insurance company recognized my voice. At that time, I was trying to get pre-approval situated with an upcoming surgery. I also needed to find out how to get my ostomy supplies reimbursed because that was about $200 a month and my supplier did not bill insurance first. I was asking a lot of questions. And when they told me they'd get back to me, I gave them about a week. If they didn't have anything then, I told them I would be calling back in a couple days. Then, every day if necessary. Then, twice a day if very necessary. I only got to the twice a day stage once, that I can recall. Once a day happened at least three times.
3. Spin it.
Your tone and how you approach what is going on can make a huge difference. I might be fuming, but I am polite. I approach my concerns with specific questions, building up to more difficult ones. I allow them to finish their explanation and listen to the explanation. "Can you help me understand this?" seems to go over much better than "What the hell is going on?"
In a recent concern, I was very certain that we had met our deductible, meaning that I should see the prices of my medications covered per the terms of the plan. Yet, I had an $800 bill from Walgreen's. Walgreen's ran it into their system again at my request and the same result popped up--problem wasn't on their end.
My first question to insurance was if I had met my deductible. And then if they knew roughly when it was met. I then explained that I was still being charged and asked if there was something I could do to help them to move this along; did they need a copy of the receipt or a list of my prescriptions through the year or any additional information? Do they need to hear something specifically from my doctor or the hospital that I could request on their behalf?
In short, my biggest spin is "What can I do to help you fix this [mess that you made]?" I don't say the last part, but I think it REALLY LOUDLY sometimes. Instead, I approach the conversation with a "How can I help you to help me?" And this also means following up with my doctor to make sure that they call my insurance or getting paperwork started, but I get things moving wherever I can and thereby also ensure that it's never information from me that they are waiting on--sometimes you don't know until you ask. This leads me to my next thought.
4. Don't hang up until you understand or you know who you're calling next.
I have had days where I spent two hours straight on the phone trying to sort out one issue. A chunk of that was on hold and getting through the automated menus, mind you, but it's still exhausting. When I get that conversation going--again, staying polite but firm, as unaccusatory as possible--I know that the person on the other end is trying to translate components into terms that they will understand. We have to do that at work all the time, translate the client's question into one that we know how to answer; the person on the other end answering calls has the same struggle.
And yet sometimes we still hit a wall. Somewhere along the way, we are misunderstanding each other. Make it clear that you are listening, but you are still confused. Better yet, ask for specific pieces of clarification--a generic "I don't get it" doesn't leave much of a starting point. Or what I have done more than once is ask if I can paraphrase what I'm understanding so far. "Let me see if I'm understanding this correctly" or "I'm going to try re-phrasing that to make sure I understand" makes any major discrepancies immediately clear to the other side as you repeat that understanding. I tend to check at least one more time at the end, with a "I just want to check one more time that I've got this right."
If you do not understand, do not let them go. Genuinely try to understand the reasoning for why a charge is still applied or something isn't covered. Once you have a reason, then you can fight it along those logical patterns. Perhaps your doctor/case manager can appeal your situation and an exception can be made. Perhaps that representative can give you some further ideas on where to else to start. Either way, if you don't know why the decision was made, there is nothing that can be done. It's like trying to make amends with someone when you don't know why they're angry.
So, while you're still keeping that cool head, make sure that you understand or know who you're calling next. Perhaps the next step to solve the issue is to start requesting records from you doctor--I have made more than one call to ensure that letters have been sent out, if only to immediately call back insurance and ask if there is another step I can start on for them.
5. Know where the problem is.
You might not intrinsically know where the problem is, but it's a waste of time and effort to scream at the Walgreen's clerk when it's your insurance company at fault or more specifically the division that handles prescriptions.
That being said, think through the problem.
When my prescriptions were showing up incorrectly at Walgreen's, I requested that they re-run them. Run back through insurance, it spat out the same answer. Somewhere along the chain, Walgreen's was repeating the answer it was receiving. Ergo, not their fault. I asked them to print out a list of all my prescriptions to date for this year in case I needed evidence; they totally do that for you, by the way, but are happier with you if you can choose a non-peak time.
I called my insurance immediately. They told me I had met my deductible. So it's not wrong on that component.
There is a specific other group that manages the prescriptions and another group off of that to manage specialty medications, such as when I was using an auto-injector pen. Having eliminated some of the other options, I knew better where to direct my concerns. Luckily, my insurance made some of those calls for me.
In some cases, though, it could be an error from the hospital or another billing agent. That's why that first tip, asking questions, is helpful--direct your energy to where the problem is at, instead of busting everyone's balls. I recognize very well that no one is very happy when it comes to working through these kinds of bills, but I would urge you to stay as calm as possible. Sometimes, too, a company can put a hold on the bill until you have things sorted out with one party or another, but you won't know until you call and ask.
6. Come prepared.
Have your prescriptions and costs-to-date handy. Highlight the day of service on your claim. Note where the account number is. Keep your insurance card close by. These small steps can make the call go much more smoothly for you and whomever you are speaking with. Keep things as simple as possible, too. They do not need to know the complete backstory of why you were in the hospital or what was done. Stick to the facts--dates and charges.
I would be remiss if I did not add this: know how your plan works.
I don't mean that you need to know it inside and out, but understand your generalities. Is it a high deductible plan or flex spending? What is the limit or the time limit? What percent of prescriptions are covered, before/after deductible? What is the difference for out-of-network providers vs in-network? How can you find whether someone is in-network?
These are some of the basic questions that it would be good to have a handle on.
One more question worth investigating is whether you need or qualify for a Health Savings Account (HSA). Money deposited directly in an HSA is all pre-tax and also earns interest, saving you money twice (thanks, former banker Andy). We needed one for our high deductible plan and it is definitely how we have been able to insulate ourselves and **gasp** start to actually pay down debt instead of accruing it.
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It's a daunting process, but I can tell you it is quite validating to hold a reimbursement check in your hand and FINALLY pay off that credit card where all medical fees had taken residence. Again, I cannot promise success, but this is one of those adult things that just has to be done. Suck it up, and do it. Take ownership of your bills and your care plan before things get too deep. Have someone that can advocate for you when necessary. Keep your chin up.
And if you don't have insurance, PLEASE consider getting some. Life happens and one bad day can mean a lifetime of unexpected debt. Comparing to a full hospital bill, it's better to be safe.
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