For the past three years, I’ve written about rural healthcare issues for the Daily Yonder. From mental health issues to surprise billing to suicide, I’ve tried to tell the stories of rural health as accurately and thoroughly as possible.

Now, for the first time, I am part of the story.

I recently had hip replacement surgery. It was the first of three total joint replacements that I have planned to have before the end of this year. I’m looking forward to it all being over, but getting there — let’s just say it has been eye-opening.

I’ve listened to a lot of stories about other’s experiences with the healthcare system. I thought they were the outliers. But now, as I’m in the middle of it, I realize those horror stories are more the norm than the exception.

Facing Surgery

After being diagnosed in March, my doctor and I agreed we should do all of the surgeries this year. Aside from freeing me from pain, it was the best use of my high-deductible insurance and would save me thousands of dollars.  

From the onset, I was thrilled at how my doctor’s office took charge of everything. I received a packet filled with information, including the times and dates of every pre- and post-operative appointment I needed. Every step was taken care of. And every person I talked to wanted me to rate their quality of service. I was overjoyed that they were taking my needs seriously and making everything so easy.

Anything that was part of my surgery was explained to me. When I had questions, they were happy to answer them. I talked to nurses. I talked to physical therapists. I talked to my friends who’d gone through their own joint replacements.

On the financial side of things, I talked to my financial advisor and my health insurance agent to make sure I had all my ducks in a row. As a self-employed writer, I had to make sure that I not only had the time to do it, but the money to do it as well. We came up with a budget for out-of-pocket expenses and a nest egg in case I couldn’t work. I set up a health savings account (HSA) and started saving. As June rolled around, I was sitting pretty and ready to go – physically, emotionally and financially.

But one of the things that I was advised to do was to make sure that my anesthesiologist was covered by my insurance. I talked to the surgery coordinator and she felt sure that the anesthesiologist would be covered because the hospital is covered. I talked to the hospital’s pre-admissions nurse and she felt sure that the anesthesiologist would be covered because the surgeon was covered.

I should say here that I’ve been a reporter for more than 20 years. I have a degree in communications from a college they call the Harvard of the Midwest. Between pregnancies, sick kids, and a prior hip replacement, I’ve navigated healthcare waters before. I am not unfamiliar with how the system works, how to get answers, or who to ask to get them.

Figuring out what a procedure costs may be difficult, but there’s little doubt about who will be responsible for the final bill if there’s an unexpected expense. “Patients are responsible for assuming the financial obligations for health care rendered are paid in a timely manner,” reads at statement of patient responsibilities. (Photo by Liz Carey)

But as a reporter, if I don’t get a definite “yes” or “no,” I keep asking until I do. There’s an old saying in journalism – “If your mother says she loves you, check it out.” In other words, just because someone says something, doesn’t mean it’s true. I needed to make sure the anesthesiologist was going to be covered by my health insurance so I wouldn’t get any surprise bills down the road.

And this is a big deal because anesthesiologists bill for their services separately from the hospital and the surgeon. Those bills can range from $50 to $5,000, depending on the procedure, the provider, the time the patient is under and the drugs used. So, for me, the implications were more than just one bill. I could be facing as much as $15,000 in surprise bills if the anesthesiologist wasn’t covered by my insurance.

Getting Answers

I figured the most logical place to start asking questions was the hospital. I called, spoke to the front desk and explained my situation. They transferred me to the surgery department. I spoke to a surgical nurse who gave me the name of the third-party group that handles anesthesia for the hospital and told me to call them.

I called the anesthesia group and got a third-party answering service. They took my information and transferred me to a patient specialist. With as understanding a voice as possible, she said “Unfortunately, we are out of network for your insurance provider, but we’re willing to work with you on setting up a payment plan.”

According to a 2016 survey from the Kaiser Family Foundation, the cost of healthcare is wreaking havoc on the budgets of Americans, even those who have health insurance.

“Overall, about a quarter (26%) of U.S. adults ages 18-64 say they or someone in their household had problems paying or an inability to pay medical bills in the past 12 months,” the survey found. “People from all walks of life can and do experience difficulty paying medical bills.”

I’m used to tracking down information – it’s what I do for a living. … If I’m having trouble finding answers, how hard would this be for others?

About two thirds of those bills come from a one-time medical event, the survey found. For insured households, more than three quarters (77%) postpone vacations or major purchases to pay those bills, while 63% use all or part of their savings and 31% tap their retirement accounts. One in 10 patients, the organization found, simply go without the care because they can’t afford it. 

Krutika Amin, Ph.D, associate director for the Program on the ACA with Kaiser Family Foundation said surprise bills are common, even for patients who work to find answers.

“The research we’ve done has shown that one in five patients to the ER and one in six patients with inpatient visits receive surprise bills,” Amin said. “Sometimes patients don’t have the full information they need until after the fact, and even those that do sometimes end up with bills they didn’t expect.”  

Fifteen thousand dollars in surprise bills would have wiped out my savings.

As a result, I asked the patient specialist what exactly I could do to get their services covered. She recommended having the hospital pre-authorize the anesthesiologists services with the insurance company.

Phone Tag: You’re It

I called the hospital. Again, I got the front desk and explained the situation. And again, I was sent to the surgery department. When I explained what I wanted, the surgery nurse told me that’s not what they do there, they only handle surgery. She recommended I call billing.

So I called the hospital back, got the front desk and asked for billing. After a brief hold, I was asked for my billing number, which I didn’t have because I hadn’t been billed yet. A few phone prompts later and I was connected to a billing specialist, who very politely told me he couldn’t help me because they were a third-party vendor for the hospital and they only handled bills after the insurance claim was paid. He said I should call admissions.

Again, I called the hospital, got the front desk and this time asked for admissions. The front desk woman told me that she was admissions, so I asked her if she could pre-authorize the anesthesiology group for my upcoming surgery. She said she didn’t do that, recommended I talk to registration and transferred me to a voicemail box.

Carey received a lot of information about procedures and appointments, but when it came time to figure out what her anesthesiologist would cost, there wasn’t much to go on. (Photo by Liz Carey)

After a bit of stewing and trying to figure out what to do, I called the hospital back and asked for the administration office. I thought, you know, if anyone knew who I needed to talk to, it would be the people who run the hospital.

After listening to my request, the administration office’s executive assistant said she couldn’t answer my questions and transferred me to a patient access specialist. Once connected, I explained to them what I needed. She said she couldn’t help me because, as a third-party vendor to the hospital, she only handles billing questions and pre-authorizations for the hospital facilities, not any of the third-party vendors who perform work there.

You can probably imagine my growing level of frustration here.

Advocating on Your Own Behalf

Over and over again, we’re told to ask questions about healthcare. To be proactive about our healthcare billing. To make sure that we use in-network providers. To shop around for the best price. To be good stewards of our own financial well-being.

Kaiser Family Foundation’s Amin said even with hospitals that are transparent about how much they bill for services, getting an idea about how much something will cost is still difficult.

As a careful consumer, I was trying to do what the healthcare profession was telling me to do to avoid a surprise bill. But no one in the healthcare field seemed to know how to help me accomplish the tasks.

“The way hospital contracts are set-up, nurses are the only ones employed by the hospital; all the other service providers usually will be contracted,” she said. “We’ve tried to get more insight into how much hospitals charge for different things, but hospitals are only required to provide the facility charges and not what the physicians charge or what different insurance companies will pay for. Since only the facility fees are made available, it is hard, even for patients who are trying to shop around, to find the right information.”

As a careful consumer, I was trying to do what the healthcare profession was telling me to do to avoid a surprise bill. But no one in the healthcare field seemed to know how to help me accomplish the tasks they were telling me to do.

I called the anesthesia group back and asked them to get their own pre-authorization. They said the hospital had to do it, because as an out-of-network provider, they couldn’t access the insurance company’s system.

So I called the hospital back and asked to speak to the administrative office again. This time I connected with the chief nursing officer. He reiterated that the hospital only billed for the facilities, not for their third party vendors. I asked who else I might have to worry about getting a bill from.

His response? It depends. I could get a bill from a pathologist if I had something that needed to be tested. I could get a bill from radiology if they needed to take x-rays. I could get a bill from a surgical assistant if they weren’t covered by my surgeon’s practice. And until I had the surgery, it would be hard to know whether one or several of them would be a part of my care.

He recommended that I call my surgeon and get them to pre-authorize the anesthesiologist.

Which, of course, I did. The third-party billing specialist I talked to there said they don’t handle pre-authorizations for other providers, only their own group.

I might add at this point, none of these people asked me to fill out a survey about my thoughts on their customer service. Probably a good idea on their part.

I’m used to tracking down information – it’s what I do for a living. I’m used to planning out how I’m going to pay for things – as a small business, I have to. I’m used to getting people to answer tough questions. But, as I sit here, after more than three hours of making 16 phone calls to seven different healthcare entities, I still don’t have any answers.

Which, of course, begs the question – if I’m having trouble finding answers, how hard would this be for others?

It scares me to think what a single mother with little formal education who lives paycheck-to-paycheck in rural Kentucky would do if faced with these hurdles. Or how an elderly man living in the rural Midwest caring for his ailing wife would navigate through the system. How does a tenant farmer living in south Georgia, where some counties don’t even have doctors let alone hospitals, know who to call, what to ask, or where to go for help?

Even when you’re doing everything you’re supposed to do, it’s not enough.

It shouldn’t be this hard.

My own mom told me she would have given up after the third or fourth call and likely just paid the bills.

I knew what to ask and I had the time to ask it. But what would have happened if my son had been in an automobile accident and needed surgery instead? Should I stop the physician and say “HEY! Wait,… before you wheel him in there, I need to know whether or not the anesthesiologist is in-network,” then grab my phone to shop for in-network providers online while my kid bleeds out and struggles to breathe?

And what about rural residents who may be near death and are air-lifted to urban hospitals? Do insurance companies and hospitals expect patients to have the wherewithal to stop the EMTs and ask whether or not the helicopter hovering over them is in-network so they won’t face a $39,000 bill from the air ambulance company? 

And how is anyone supposed to get answers and be their own best advocate, if even the hospital can’t tell you who you’re going to get a bill from? Short of having someone sit by your bedside and stop every healthcare professional who walks into your room to ask whether or not they are covered by your insurance, how are you supposed to protect yourself from surprise bills when, apparently, anyone and everyone is a third party vendor?

Even when you’re doing everything you’re supposed to do, it’s not enough.

It shouldn’t be this hard. Making people already facing health crises jump through hoops so they don’t face economic ruin should not be a thing. And not being able to answer questions like “How do I make sure that someone who is going to be providing me with care is covered by my insurance, especially when I have no control over who it is or what services they decide to provide?” is unacceptable. 

Hospitals are in the business of helping people be healthier. But without addressing the needs of patients when it comes to billing, they’re ignoring the fact that the stress, anxiety, fear and depression that comes from navigating the healthcare and health insurance system is, I would argue, as destructive to a patient’s health as not getting care at all.

Liz Carey lives in Kentucky and is a freelance journalist who covers healthcare and other topics for the Daily Yonder.

Do You Have a Healthcare Billing Story? We Want to Hear it.

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