How I Won an Appeal of $229,000 in Medical Claims

Having surgery is a big deal. It’s scary. It’s not a fun thing to deal with by any means, but if you’re reading this you’ve probably already determined it to be necessary and it’s an event that will probably happen to all of us (hopefully only) a few times in our lives. While you are probably mostly concerned right now with the logistics of the procedure and aftermath, there are some very important financial aspects to be aware of prior to going under the knife so that hopefully you never need to dispute a medical bill, the way I had to.

This post is long, so if you just want my tips on what to do pre or post surgery to avoid being overcharged or disputing a medical bill, use the hyperlink below to go to the end.

My Surgery

I had a surgery back in 2016 on my neck for a cyst that developed as some remnant of humans once having gills – I know, that raises other questions like why the heck do we have gill structures in our necks? But regardless of our fishy past biology, the long and short of it is that the surgery went well, and I no longer have a (giant) lump in my neck, just a minimal scar fairly hidden by my neck crease.

In general, I pretty much avoid doctors like the plague, so the whole experience including the total bill for my portion was all very foreign to me. I was so hesitant to have surgery that I went to three different doctors over the course of five years before coming to the realization that my neck-ball was developing its own identity and would soon consume my real noggin if I didn’t do something. One of my friends called it “gallon of goit”… yes, it was huge and goiter-y.

After seeing this thing grow continuously larger and no home-made remedy was getting rid of it, I was determined to say goodbye to good ol’ goity once and for all.

The doctor I ultimately chose had great reviews on HealthGrades and seemed to know what he was doing. He gave me a very thorough explanation of the entire procedure; how long it would take, how long it would take to heal, and all the gory details of what the end to end experience entailed. I listened very attentively to all of it, after all, my neck is kind of important to me.

I consulted with the surgeon’s billing assistant who had assembled all my information for the cost of the surgery: the overall bill, what I would need to pay the surgeon, the hospital, anesthesiologist, etc. The total price tag after my insurance was consulted was estimated at around $1200.00.

This might seem high or low (I don’t really know what the average surgery rates are), but to me it sounded reasonable and fair. I was expecting it to be higher, so I was quite relieved with the quote. I knew there might be additional charges for whatever miscellaneous expenses weren’t being figured into that equation – like the $100.00 you might get billed for something like a $.20 cent band-aid.

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Surprise Medical Costs Need to STOP

It’s my belief that medical billing companies are the modern-day equivalent of highway robbers. My view on that certainly hasn’t changed after this experience. My most helpful advice after dealing with what I did, is to SCRUTINIZE EVERY CHARGE THOROUGHLY. It’s painful and tedious and takes a lot of time that most of us don’t have excess of, but in the end, it’s worth it. I know it’s disheartening that you can’t trust companies (which you SHOULD be able to) who are involved in people’s health and well-being for a living, but the truth is, you can’t.

Be your own best advocate as no one else is going to be as concerned about you not getting screwed as much as you are. While it’s a nice thought to believe people in the medical industry are in that line of work to help people, it’s as much of a business as any other industry and crooks exist in every industry. If there is a way to take advantage of people, unfortunately, it will happen.

I decided to write this because there are a lot of people out there who don’t know what their options are when it comes to their medical bills or didn’t even realize they had any. It’s a helpless, horrible feeling to be facing an unexplained bill and have no direction on what you can do to fight it. I completely sympathize with anyone dealing with this, but especially people who are less saavy on the fact that there ARE things you can do.

Know this – you can and should fight back.

After telling my story to others I learned that a lot of my friends have dealt with similar situations, some still fighting legal wars or dealing with credit issues from medical bill collection agencies who have permanently damaged their credit, all due to fraudulent or mis-configured medical charges. Most people don’t have the time or stamina to go through the daily research and calls that I ended up going through for over 3 months.

The medical industry is in desperate need of a change. No other business operates as shadily and as finger-in-the-air-determine-the-price-you-think-you-can-get-away-with-charging after the service has happened already like medical services do. Imagine if you went to a restaurant and they wouldn’t tell you the price of the food? There might be some fancy places out there that do this, but in general, you know the range of what you will be paying when the bill shows up. You wouldn’t buy a shirt and go to the register and pay and then see random bills for random costs after the fact related to the shirt purchase. For the most part in life, we know what we will have to pay before we pay it.

With doctors and hospitals that isn’t the case. There are SO many steps, billing codes and miscellaneous charges from each participant involved, all ripe for human and machine error, and then numerous 3rd party interjections adjusting and negotiating rates, that I’m amazed any medical bills are ever accurate. I’ve seen this first hand as a friend of mine did medical billing for a company that reviewed billing codes and prices and negotiated them down on behalf of the insurance companies – i.e., “you put $1000.00 for this needle but we’ll give you $10.00” and then that has to be agreed upon by both parties. WHAT A WASTE OF TIME!! Why not have an amount/range that is determined “appropriate”? Someone will change this industry at some point like they are doing with banking and bitcoin but for now, it falls on us to check that our bills aren’t being overinflated. But I digress…

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Surgery, a Year, then “Surprise!”

Back to my surgery. The day of, I sat in the hospital billing room and paid almost the exact amount determined by my surgeon’s billing assistant which I was happily surprised by. The total, including a $200.00 anesthesiologist bill which came a few weeks after my surgery was about $100.00 LESS than the estimated total, so I paid roughly $1100.00 out of pocket, whereas I had been told it would be $1200.00 –  score, baby gets a new pair of shoes. I was so relieved when no extra bills showed up in the months following and my trust in the medical billing system went up a few notches. I had gotten used to a trickle of bills coming in after anything to do with a doctor for weeks and months after the fact, but to my shock, that actually didn’t happen this time – at least nothing showed up until 12 months later.

While I was in the hospital billing office I had asked about any out-of-network charges and was assured that there would be none as everything had been approved as in-network. This is a REALLY important thing to always ask prior to any medical procedure and I knew this tip from other incidents where my friends had been surprised by large out-of-network charges approved by the surgeon or hospital that they didn’t expect or know about. I felt like I had done everything right to avoid surprise bills and the whole experience went about as good as it possibly could have (except for the singer Prince dying during my surgery – bummer, I loved Prince). Well, I was wrong; I never saw the next part coming.

Fast forward exactly a year from the date of my surgery. My surgery was on 4/21/2016 and on 4/20/2017 a letter from my insurance company is in my husband’s hand, received that day. He asks me if I had any outstanding bills from the surgery the year prior. Skeptically, I said, “noooo”, and raised an eyebrow regarding why he was asking. He shows me a check from our health insurance company for $10,766 dollars. Confused, I looked at the check then looked at the Explanation of Benefits (EOB) which accompanied it. More confused, I looked at the codes and names next to the codes not understanding what I was looking at. There were several line items for “Neurological Testing” listed, some priced at around $22,000 apiece. Some of these had the exact same codes and repeated. “This is a mistake, it was meant for someone else obviously” I told my husband, “I didn’t have any neurological services”. From the prices and severity of what this appeared to be I’m thinking at this point that some poor soul had a brain surgery and somehow, they mis-billed it to my account.

We looked closer at the copy of the bill sent to the insurance company which states, “This is not a bill”, and determined the date of the services was the date I had my neck surgery. We pulled out all my records from the surgery and looked at all the itemized bills. I had no outstanding charges and the entire surgery including the surgeon’s portion and hospital had billed at $29,000 total (billed to my insurance company, not my portion). So why was I holding this letter which contained a $76,850.00 (Not a) Bill and a check?

I immediately called my insurance company to clear up what I thought had to be a mistake. Speaking to the after-hours barely understandable representative and after going through the normal (feels like) 200 pieces of identification I explained that we didn’t understand why we were receiving this check and that it was most likely a mistake. She said, “this is an out of network charge and that’s why we won’t cover the whole thing”, then repeated all the information that was already on the paper we were looking at (not helpful) and said, “we will cover the $10,000 which is what the check is for, and you will be responsible for the remaining $54,116 dollars”. Panic washed over me, and my blood pressure immediately skyrocketed. WHAT????? —- wait, WHAT?????????? I told her that I didn’t believe this was a legitimate charge, that I wasn’t going to cash the check, and asked what recourse I had. She explained that I could file an appeal which was in the paperwork that accompanied the information in the letter and had to be mailed in, that it couldn’t be done online – turns out, it can, the agent just has to do it for you and know how to do their job which was apparently too much to ask for.

First Bill

That night my husband and I talked about the possibility of getting a lawyer to deal with this and we resolved to start researching it during business hours. At that point I was literally having heart palpitations from thinking I might have to pay this bill.

The next day I was still mystified on what these charges were even for, so I looked up the codes and found an extremely helpful site which will give you the description of the medical billing code in more detail and tells you the average cost of what the range of the service typically is in- and out-of-network. I learned that the codes were related to the technicians who had put a needle in my face to monitor nerves while I was in the operating room – this is called Intraoperative Neuromonitoring (and there are tons of stories online of seemingly illegitimate charges attached to these types of services). The average price for each code listed on my Not a Bill when put through the FairHealthConsumer site sat at around $300.00 each for the usual cost to the insurance company. If my portion was only a few hundred dollars I would probably have paid it and not even questioned the cost, but it still should have been charged as an in-network service. Everything was supposedly in-network as per my inquiry to the hospital’s billing associate.

When I looked up the person’s name associated with the EOB he was shown as in-network and has an office IN the hospital where I had the surgery. The company name however, I could not find one record on and the insurance rep from the night before had given me the number for that company but when I called it, it was out of service. Once I had this information on what these charges might have been related to, I called my insurance again and this time spoke to someone who actually genuinely wanted to HELP – what a relief. We spent about 2 hours together on the phone while she tried to contact the bogus numbers on file for the provider, and together we reached numerous people and told our story but no one could help us – we kept getting redirected to 3rd party billing companies who no longer had any records on my surgery information or never had any records on it, but definitely couldn’t tell us anything about the bills we had received. This helpful rep and I then proceeded to file my first appeal, explaining in the appeal that the charges seemed astronomically high, that the provider should have been an in-network provider, and that there was no good contact who could explain what these charges were really for or who had authorized them. I was asking my insurance to reject these bills and take their own money back as these services were not accurately charged.

(FYI: You typically have a 90-day window that you must file your appeal within after receiving the EOB.)

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An Even Worse Letter

A week went by and I received something in the mail from my insurance company. I thought it would be the approval of the appeal – ha! that is laughable to think back to now. What I went through after the fact leads me to believe that the insurance companies do not pay attention to their customers or care in any way. It’s only when someone with perceived “authority” intervenes that they will actually listen – which leads me to believe your best bet is to obtain a lawyer or a medical advocate, if you can afford one.

I opened the letter and looked at an EOB that appeared to be similar in nature to the first, but this time it was accompanied by a $343.00 check and a remainder for me of ~$97,000. I went into some hysterical laughter and put my head in my hands for a bit. At this point I had racked up what was a total of ~$229,000 dollars in total charges, and I was potentially on the hook to pay ~$151,000 – the amount not covered by my insurance? How was this possible, how were these charges not considered fraudulent and not immediately rejected by my insurance company? The second bill was basically a repeat of the first one but had a different name for the provider (same services though and some of the same, and some different codes) and the TAX IDs were actually the same ID, but different company names, tell me that’s not suspect? Going forward I doubled down my efforts to get this whole situation resolved.

Second Bill

The next 3 months I spent probably an hour or so (if not longer) every day working towards a resolution. Frustrating is a complete understatement and it seemed NO ONE could or was willing to help me figure this out. I would have paid a lawyer as it was worth it based on the principal of the issue to not let these a-holes get one cent. However, I’m sure that would have cost me many thousands in legal fees and I was determined to figure this out as an average Joe patient who deserved an answer for these questionable charges.

I wanted to learn this so that I could use my learnings to help others who like me felt completely helpless and at the mercy of crooks. It seemed crazy to me to be billed for something you are basically unaware of and without your consent – out-of-network bills that just show up randomly a year later for a service you don’t even understand for a LUDICROUS amount approved by the idiots running the health insurance circus. It felt and continues to feel wrong in every way and enrages me – enough to write a blog article about it. I couldn’t fathom the idea that someone can just send a bill for an amount and the insurance company will just pay it and not question it, shouldn’t there be some proof that this service was actually provided and matches a reasonable range for the typical cost? It made me question if the insurance company was somehow benefiting from these overcharges because they had zero interest in questioning their validity. I honestly think they just don’t care.

Over the months of my research I found there is surprisingly very little information on line to help people in situations like the one I encountered and sadly, most of the people I spoke to had little understanding of who to tell me to speak with or advise me on what I could do, and these were people IN the medical industry or medical billing world. In the thick of this I did get contacted by the culprit company – one of the hundreds of numbers I had contacted actually turned out to be that place (although they never called me back again after the one phone call even though I requested another call back numerous times) – and the lady had told me that “I would never be billed and that they just have to bill really high but usually only get a small amount from the insurance company and were never going to be sending me a bill.” Uh, can I get that in writing? No, I didn’t think so.

I was actually so thrown off by this and was dealing with my actual job at the time she called that I didn’t even know how to respond to her and just said “thank you”. I still needed this fought through the insurance company, not just a lady telling me “don’t worry”.

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Doesn’t Anyone Care But Me?

I escalated my issue by writing a letter to the insurance company’s CEO which was followed up by me being contacted by a new “expert analyst” who took over my appeal. She proved to be worthless and not in any way as helpful as the lady who had worked with me previously. When I explained the situation and the outrageous amounts of the charges she said she wasn’t familiar enough with the codes, so they could be reasonable and that there was no way the system would incorrectly process the bills. A needle in my neck costing 6 times the amount of the entire surgery sounded reasonable? A system never making a mistake? This lady was CLUELESS. I failed to understand what she was actually getting paid to do as it was clearly not the role she was titled with. After working with her for hours on/off over the next few weeks I received a rejection for my appeal in the mail and she followed it up with this email:

1st Appeal Rejection Email

I immediately called her and asked her to file a secondary appeal, which I had been told by the first person (helpful person) was an option if the first appeal was rejected, but this analyst said, “you have exhausted all of your options at this point”. Really? Did this woman know anything? – NOPE. Pressing on, I attacked it from another angle realizing that this woman was not going to help me at all.

Since this was under my husband’s insurance that I was on, he contacted his HR department and they put me in touch with someone who actually knew what she was doing and stated that everything I dealt with to date was handled extremely poorly. She worked for the insurance company I was dealing with but was a representative FOR the company so acted on the company’s behalf and its members, not the insurance company’s. She was determined to get to the bottom of it and actually investigate the provider(s) that were sending these outrageous bills in for collection. She said she was going to use this example as a “coaching opportunity” for the lady I had worked with who did NOTHING to help me. Working with her for a while she had found out the insurance company had actually put a stop on the checks they gave me even though they had approved the charges, which means if I would have cashed them they would have bounced. So many things were done wrong here, and she stated that.

Upon my request, she filed the secondary appeal and collected all the information that I had documented painstakingly since the day I received the first EOB and check.

Hallelujah, I finally received a letter from my insurance company a few weeks later which stated that they were sorry and that my appeal was approved, and the charges sent by the providers were denied. This is ALL I wanted the whole time. Take your money back and don’t approve these false charges. Crazy I had to fight this hard for THAT – to save them their own money. This letter was so anti-climactic for me, after the months I spent in anguish – I half wanted some kind of apology from a person who could actually explain what had happened.

Coincidentally enough, and I don’t know if it had anything to do with my incident, the lady who fixed everything no longer works there as of right after this incident (which was weird). I never received a full explanation for what really happened because I received an email response when I reached out shortly after the appeal was approved that read, “I am no longer with X company, please contact Y with questions.” I have tried reaching out to her replacement but received no response from them.

I can only hope these crooks billing me/my insurance were investigated (and maybe were convicted) – since this experience we have been in touch with 9news, who has exposed the SAME COMPANY involved in my bills for seemingly “fraudulent” billing of others for the same simple procedures.

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If You Are About To Have a Surgery or Received Bills You Didn’t Expect

So, here is what I have learned.

Ever since my awful experience I have used the following process ANY time I go to the doctor, even if it is just for a checkup. It is a few extra steps to follow, but in my opinion, well spent energy – it’s the old adage that, “an ounce of prevention is worth a pound of cure”. I hope this helps a few people not have to go through what I did or might help someone who is dealing with a similar issue now.

The following steps are my recommendations to avoid surprise medical bills:

Disclaimer: This is my personal opinion and does not take the place of legal advice. Consult with a lawyer or medical professional for actual legal representation and information.

  1.  Get Your Codes Before Surgery: Speak with the billing associate from your surgeon’s office about the exact codes that will be used. These are called CPT or HCPCS codes. Get this list in writing if possible and make sure there are no additional codes which will be used. Don’t be afraid to question the billing rep to make sure there isn’t something being left out. Specifically ask about how they work with the Intraoperative Neuromonitoring team and who they will be using. Ask if this service is billed separately or will be included in the surgery charges. If it is included as part of the surgeon’s bill, ask for the exact codes that will be used. If not contact that company and get your estimated codes and charges associated to these codes in writing.
  2. Know Who Will Be in The Operating Room: Ask your surgeon’s billing associate for a list of ALL the participants who will be involved in your surgery or procedure and their contact info. This includes the hospital, anesthesiologist, and any outside technicians that the surgeon will bring in to assist during the operation. They can sometimes bring specialists and other people into your Operating Room while you are under anesthesia and can charge you for these extra people being present without your consent.
  3.  Find Your Advocate Info Before You Even Need Them: Call the hospital and get their patient advocate’s information. An associate of mine used the hospital patient advocate to fight a huge hospital overcharge and all his fees were dropped after engaging with this person to fight the charges on his behalf. Contact the patient advocate prior to the surgery to review the codes you will be charged for and get their advice on if these are all reasonable, or at a minimum get this person’s information up front in case you have questions on what you were billed for later.
  4. Get Your Codes from Everyone (not just your Surgeon): Contact the participants from step 2 including the hospital to receive the exact codes that they will be billing for at the time of your surgery.
  5. Check Code Average Prices: Review all the codes at FairHealthConsumer.org for the average prices of each and write these down.
  6. Call Your Insurance Company: Speak with your insurance company about all the codes that will be used and the participants who will be involved in your surgery. Have the insurance company verify that all participants are in-network and have them explain what you can expect your portion of the total bill to be.
  7. In-Network Status: Confirm with the hospital on the day of your surgery or procedure that all the members in the operating room will be in-network. Get this in writing if possible and explain (or put in writing) that you do not consent to any out-of-network providers being involved, even when you are under anesthesia.
  8. Get Your Bill Afterwards (itemized and detail versions which you have to ask for): Obtain a copy of your surgery records post-surgery/procedure. This was harder than it should be considering these are your records (basically your receipt for services), it took me filling out a lot of paperwork and online forms and didn’t show up for about a week. However, this is an important document to have as it should reflect the codes that you were or will be billed for and these should match the codes you were provided in the previous steps. If they do not, speak to the party responsible for the unexpected codes to understand what these are and why they are showing up.
  9. Match Your Before and After Codes and Prices: Examine your EOB statements once these come in post-surgery and match the codes to the surgery records (from step 8). Your bills should be close to the amounts the insurance representative quoted you – they may be off a small amount which is probably ok. If they do not match, call your insurance company. See the Steps to Appeal an Insurance Claim below if you decide to file an appeal.

The following steps are my recommendations to appeal an insurance claim which was either unexpected or is vastly different from your expected medical bill:

Disclaimer: This is my personal opinion and does not take the place of legal advice. Consult with a lawyer or medical professional for actual legal representation and information.

  1. Examine Your Codes: Review your EOB to understand what the codes were for. Look up the codes up on FairHealthConsumer.org to understand the typical price range these fall in for the original bill. IF you were provided with a check from the insurance company and you feel any of the charges/codes are inaccurate, DO NOT CASH THE CHECK. Cashing the check provided by the insurance company is basically you agreeing that the EOB is legitimate.
  2. Get Your Appeal Information: Speak with your insurance company right away and ask them what their “Appeal” process is. Ask about a secondary appeal if the first one is denied. Write the steps down and understand the deadlines around them. Get any information about the provider listed on the EOB such as contact information and address.
  3. Find your advocate: This is either someone representing your company’s insurance, or could be someone working for the hospital, or a 3rd party medical advocate if you can afford to pay for this. OR, contact a lawyer if this is feasible – but this will most likely cost you money. The key is to find that right person who can truly help represent your best interest. I learned that this was NOT the insurance analyst, but each circumstance might be different and perhaps I just had someone new or unknowledgeable on my particular case.
  4. Contact the Company Charging You: Try to contact the provider themselves and get the actual amount they will be billing you for. This is where it gets shady, in the case of the experiences reported through 9news by the same company that was billing my insurance, they would only bill the exact amount the insurance company had provided payment to the insured, so there was no overage/out-of-pocket fees to the insured party. This made it difficult to dispute; when the insured parties cashed the checks it was with the explicit purpose of making a payment to the provider. This provider also followed up with threatening phone calls to the patient(s) when they tried to understand the charges before making the payment.
  5. Bring in the Law: Contact the Department of Labor for the state where the insurance company resides if the insurance company is not acknowledging your reasons for appeal as legitimate or concerning, as well as the Department of Labor in the state the provider works out of. In my case, I had contacted the California Department of Labor and was going through the procedure of filing a claim when I received help from the insurance representative, and since she was handling it and getting it resolved I never finished filing the claim (per recommendation from the lady at the Department of Labor). However, if I wouldn’t have received any resolution I would have taken that as my next action.
  6. Get in Touch with a Medical Board: Check your state’s regulatory board representing patient’s rights. We have one here in Colorado named DORA and this is a panel of medical professionals who investigate claims for medical injustices. This process is also fairly daunting to go through but might be a good option (I can’t personally vouch for it since I didn’t get that far). If my outcome wasn’t favorable I would have eventually done this as well.
  7. Publicize the Issue: If you are up to it, contact your local news channels to see if they are interested in your story. I am not one to enjoy the spotlight, so this was not a very appealing option, but my husband and I have discussed it and are still willing to do this if it will help others to understand their options in scenarios such as these. It certainly helps your fight if your story becomes widely publicized.

I really hope that in the future laws are changed to prevent any of these types of horrible medical situations. Unfortunately, I don’t believe this is terribly uncommon, and yet most of us don’t have any idea on what to do about it after we’ve been a victim of incorrect medical charges – whether or not these are done intentionally or not (I want to believe these are usually unintentional mistakes).

If you are fighting a medical bill, you feel violated and alone, like no one can help and no one cares, and that you might have to pay bills you simply can’t afford to pay. It’s awful.

Please do what you can to safeguard yourself before a surgery – I hope this advice can help others avoid the pitfalls I went through.

Have you gone through something like this? Share your story below if you’ve dealt with something similar!

 

What are your thoughts?

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