A Seriously Hard Part of the US Healthcare System

Back in March, my husband had to visit the local Emergency Room at our local hospital for an infection that needed immediate attention. We are lucky enough to have healthcare provided by his employer, but it doesn’t cover everything. We waited to see what would get covered and what would not, and how the hospital’s charges to our insurance would be paid or not paid. We got the final bill from the hospital’s billing center just this week, and we owe several hundred dollars on top of what was paid out by the insurance company.

The thing here is that even with coverage, a person has to understand how insurance companies work. How they structure payments to various hospitals, individual providers, clinics and facilities that do things like test blood and other human samples for diseases, infections and the like. Knowing what the plan you have covers doesn’t give the full story. And this is where the title of this post comes in.

Yes, not having coverage is the hardest, and I would prefer everyone had coverage. Period. 

However, even having coverage means you have to be a hard-ass advocate and know how to deal with both the insurance company and your providers. You need to know how providers are set up to be paid by your insurance company and how much of any bill is likely to be covered and whether what’s left over will be on your head or not. You need to know whether payments will be direct to the provider or will you get a check that will need to be deposited by you and then the funds re-dispersed to the provider because the insurance company’s agreement with the provider doesn’t cover your services or there isn’t an agreement with this provider but the insurance company will pay on the grounds of emergency care, at a smaller percentage. Dealing with the stacks of paperwork that arrive from several sources for one incident is enough to drive any person a bit bonkers.

And it does. Many people just toss paperwork from insurance companies and healthcare providers in a file (sometimes in the circular file) and call it done until a bill arrives, months and months later, that looks like it should have been paid. Then they start calling. Whereupon they discover that paperwork sent to them months ago pertains to this bill and they need to get copies of that paperwork to understand what’s going on. Which takes more time. When they finally get an understanding of how they were billed, and can start negotiating for payment options, the bill might be in the pipeline for collections – which is a whole nother issue.

The point here is that being your own healthcare advocate is extremely hard, especially if you have chronic healthcare issues that need medical attention frequently.  Even a one-time issue, such as a broken bone, can have long-term repercussions if there’s need for physical therapy to help get back to a normal life. Every time you visit a healthcare provider and pony up an insurance card you are setting up for at least a small mound of paperwork that needs to be scrutinized and understood so that what you owe in the end is as minimal as you can make it.

A person with healthcare coverage through their employer is going to have issues making calls during working hours to the insurance company and their providers. Few companies provide any services to help with this aspect of healthcare. I’ve heard of people asking their company’s HR if they could help with advocacy, but the answer is mostly a firm no, since both insurance companies and healthcare providers want to be dealing with the covered person, not someone else. I can’t call on my husband’s behalf about his coverage, since he’s the person listed as the primary covered person. He can call on my behalf as the spouse covered under his insurance, but I still often have to get on the phone and allow it.

Someone who buys their own healthcare plan through one of the ACA networks? I shudder. It’s not that I don’t like the ACA, I do because it helps cover more people than would have coverage, but it leaves a lot to be desired as far as advocacy on behalf of those covered. Many people who run small businesses and have plans through the ACA now have to wade through minefields of paperwork and phone calls to figure out how a bill for services was generated, and what the breakdown of service costs looks like. Most final bills are a single number, with no breakdown as to how much is going to a doctor, how much for tests done, how much for nursing care or follow-up treatments, how much for medications, how much for every item that is billable by the provider.

I could sit for hours reading through the bills and statements from our insurer, trying to parse out and understand what’s covered and what isn’t. And then wind up with a huge headache.

Advocating for yourself with regard to healthcare isn’t something that’s taught in schools or in any other venue. It’s something you have to learn on your own. Most people don’t learn the ins and outs and wind up with anger, fear and frustration. Those who manage to learn enough to deal usually pay out of pocket costs that they just can’t figure out how to negate. A few learn enough to be able to negotiate payment plans for the out of pocket costs that aren’t able to be covered or zeroed out. Most just let the insurance company pay what they will then toss other bills aside, setting themselves up for the collections scenario (I’m not going into the issues with wages not keeping up with costs of living, that’s another post).

We need to start teaching people how to navigate through health insurance bills and claims. How to have meaningful phone conversations with providers and insurers. How to parse out what’s covered and not in their plans. How to get the breakdowns for bills from hospitals and clinics. If we are going to continue to be the only country in the developed world that insists on a capitalist, greedy healthcare system, we should teach people how to live with it.

2 thoughts on “A Seriously Hard Part of the US Healthcare System

  1. Would you mind if I shared this? Please let me know because I understand how these things can get lost to the author if they are shared sometimes.

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