Your Cheat Sheet for Medical Billing and Insurance Challenges

For the past few months, I have been in at least weekly and sometimes daily contact with either my insurance company, various medical providers, Medicare or all of the above. While I’ve dealt with what I often call “paperwork hell” since my de novo Metastatic Breast Cancer (MBC) diagnosis since 2017, this fresh experience has reminded me of a litany of things that I often incorporated into my routine when it came to billing and insurance issues. Sad to say, I got a little lazy and hadn’t been as careful for a bit and am regretting that as I worked to get things corrected recently.

For anyone who has to engage with the medical and insurance system here in the US, here’s my cheat sheet of remedies that I’ll be more adherent to in the future:

First, know your insurance policy(ies) as much as possible. It is my opinion that every person should know the following parts of coverage available to them: 1) The deductible amount and a log of payments that apply to the deductible; 2) What co-insurance amounts apply and when; 3) The different co-pay amounts and why; 4) The out of pocket maximum and a log of payments that apply (this will sometimes overlap, be subsumed, or run concurrently with the deductible); 5) the differences (if any) of 1-4 for an out of network or in network provider. There are many more provisions of most policies, but these are the 5 amounts/categories that come up the most for me. I have the customer service number to my insurance policy saved in my phone and will often call just to double check or refresh my recollection.

Second, while paperless billing is an attractive option, I find that having the paper in hand is often a bit easier to keep track for me. When a bill arrives, I’ll typically wait until the Explanation of Benefits (EOB) arrives from my insurance company and ensure that everything on the bill matches the EOB before paying. A spreadsheet or other chart electronically would likely work just as well and save a few trees, but I find I miss things when I’ve tried that. And if the EOB is slow in coming or there is additional processing time, I always call the provider and ask that the bill be frozen or put in “disputed status” so that I don’t get the collection calls or have the bill sent out to an outside collection agency.

Third, whenever the estimate arrives (most of my providers do this automatically), I review the estimate before the appointment to ensure that nothing odd shows up. It has been my experience that the estimates are rarely correct and often wildly incorrect, so a little bit of legwork up front can help. The estimates usually have CPT codes or procedure codes and that’s the information that my insurance company needs to provide an estimated allowed amount for that specific code. It has been my experience that what I’m quoted over the phone as an estimated allowed amount from my insurance company is nearly always correct or very close. I then communicate this information ahead of time to the office and ask for a new estimate. Sometimes providers insist on some amount up front for a variety of reasons, so ensuring that the payment up front is as correct as possible can save a lot of headaches later.

Fourth, don’t pay up front unless you absolutely have to. Outside of regular co-pays, which are usually easy to remember, sometimes providers will ask for a larger amount up front (that’s usually in the estimate), which may represent a coinsurance or service that may not be covered. In my experience, this often happens with imaging or services outside of meeting with a provider. Most of the time when a provider wants funds up front, they won’t allow you to proceed with the appointment unless you pay so that legwork up front can pay dividends.

Fifth, whenever you receive correspondence or a bill or a phone call, etc., don’t ignore it. Ask questions until you understand and ask for supervisors if needed to get to someone who can help you understand. It has been my experience that the front line people answering the phone in a billing office are often the least experienced and so asking for supervisors is usually necessary outside of simple issues. I often call multiple times just to see if I get the same answers when something feels off to me and usually discover some nuance that affects the result.

Sixth and finally, if you fuss enough and escalate your concerns, you might get to a different department, sometimes called patient advocates. Now I won’t quibble too much here, but I do object to this label generally because these people still work for the organization attempting to collect money, so they aren’t neutral or even fully on the patient’s side. What they do offer typically is a bit more personal attention, a willingness to dig a little deeper, and direct phone lines and emails. Just remember that they aren’t truly there for you, but are there to ensure that their employer gets paid.

Everyone has different ways of organizing medical treatment, bills, etc., but I did want to shout out a few resources so if you find yourself in these sort of “paperwork hell,” you’d have some options:

• Triage Cancer (https://triagecancer.org) has a legal and financial navigation programs, which are excellent and staffed by lawyers. Yes, I’m biased here, but I do think getting input from the right expert is key. If the staff lawyers can’t answer all the questions, callers are then offered someone from the various councils of experts that have agreed to assist.
• Your medical system may have a patient experience or patient advocacy or risk managers or ombudsmen or some office named similarly — it is the role of this office to assist people who have encountered a situation and need assistance. I have these numbers and email addresses saved for easy access. As a patient, you might not always know what happens with a complaint or request, but you can ask to get a follow up after an investigation has occurred.
• Your medical provider is required to list on their website (or some other public facing communication) who inspects and certifies them to conduct business. If contacting your institution isn’t successful, then going to a state or federal agency can be helpful.
• Your state’s insurance commissioner’s office. If your insurance company isn’t helping you or aren’t living up to the contract, the office of your state’s insurance commissioner may be able to offer assistance.
• Legal Clinics for Cancer Patients. Many local bar associations or national ones like Triage Cancer offer clinics for people living with cancer and this can be a great way to start asking questions. Shameless personal plug — I run a monthly legal clinic at Project Life (www.ProjectLifeMBC.org) for those MBC patients and their families who are members.

Hopefully some of the items on this list might help you the next time you get into a discussion about payments with a medical provider and perhaps some of the resources I listed would be helpful too — now, it’s your turn, what would you add?