Caitlyn Mai thought she did every thing proper. She referred to as forward to ensure her insurer would cowl her cochlear implant surgical procedure. She thought every thing went in line with plan however she nonetheless obtained a invoice for the total price of the surgical procedure: greater than $139,000.
What Caitlyn did subsequent is a reminder of why a beloved former visitor as soon as stated it’s best to “by no means pay the primary invoice.” This episode of “An Arm and a Leg” is an prolonged model of the July installment of the “Invoice of the Month” collection, created in partnership with NPR.
Dan Weissmann
@danweissmann
Host and producer of “An Arm and a Leg.” Beforehand, Dan was a workers reporter for Market and Chicago’s WBEZ. His work additionally seems on All Issues Thought-about, Market, the BBC, 99 P.c Invisible, and Reveal, from the Heart for Investigative Reporting.
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Emily Pisacreta
Producer
Claire Davenport
Producer
Adam Raymonda
Audio wizard
Ellen Weiss
Editor
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Don’t Get ‘Bullied’ Into Paying What You Don’t Owe
Dan: Hey there —
One morning when she was in eighth grade, Caitlin Mai did what she at all times did when she wakened.
Caitlyn Mai: Music has at all times been an enormous a part of my life. And so I instantly put in my headphones and began placing on music as I used to be about to get off the bed and prepare. And I seen my earbud in my proper ear wasn’t working.
Dan: It was apparent, as a result of on this Beatles tune she’d cued up, Eleanor Rigby, the vocals are nearly all on the right-hand aspect, and he or she couldn’t hear them.
Caitlyn: I used to be like, that’s sort of bizarre. So I switched the earbuds and it labored tremendous. However then it was, the opposite one wasn’t working in my proper ear. And I used to be like, what?
Dan: Yeah, complicated. After which she tried getting off the bed.
Caitlyn: I used to be so dizzy. It was my first time experiencing vertigo, and it was so extreme, I couldn’t stroll throughout the room with out getting severely movement sick.
Dan: With that vertigo, Caitlin might barely stroll in any respect. She had no sense of steadiness — that really depends on a mechanism inside our ears. Later, docs discovered she had misplaced 87 p.c of her listening to on the correct aspect.
Caitlyn: They suppose I simply had some kind of virus that settled in my ear, and it broken my ear. However I went to mattress utterly wholesome the evening earlier than. Awakened, couldn’t hear out of my ear.
Dan: She needed to discover ways to stroll over again.
Caitlyn: I’ve to depend on my eyes. My pals nonetheless discover it hilarious if I shut my eyes, I fall over.
Dan: That was eighth grade. Caitlyn made it by highschool, in Tulsa the place she grew up with out plenty of lodging.
Caitlyn: Trigger in center faculty, early highschool, you don’t wish to deliver consideration to your incapacity. No less than I actually didn’t wish to on the time. I used to be tremendous anxious about that.
Dan: Catilyn’s 27 now, she works as a authorized assistant in Oklahoma Metropolis. Her husband’s a lawyer. And for the longest time, she couldn’t entry a instrument that helps restore listening to for many folks: Cochlear implants — small units that stimulate nerves contained in the ear.
The FDA didn’t approve them for only one ear till a few years in the past. Final 12 months, Caitlin obtained her insurance coverage to approve one for her. She had surgical procedure in December to insert the implant. And in January, an audiologist hooked up an exterior element to change on Caitlin’s right-side listening to.
Caitlyn: She stated, okay, in some unspecified time in the future, you’re gonna begin listening to some beeps, simply say sure when you’ll be able to hear them. And my husband stated my face simply, out of nowhere, lit up, and I’m going, sure! It was streaming on to my cochlear implant. And I positively began tearing up.
Dan: Then, two weeks later, Caitlin obtained an alert from the hospital on her telephone.
Caitlyn: And I open it up, and I instantly began having a panic assault.
Dan: It was a invoice for 100 and thirty-nine thousand {dollars}. The complete quantity for Caitlin’s surgical procedure.
Which, provided that Caitlyn had gotten her insurance coverage firm’s OK for the process upfront, was a fairly large shock. NPR featured Caitlyn’s story not too long ago for a collection they do with our friends at KFF Well being Information.
NPR HOST: Time now for the newest installment in our invoice of the month collection, the place we dissect and clarify complicated or outrageous medical payments.
Dan: I interviewed Caitlyn for that story. And we’re bringing you an expanded model right here as a result of Caitlin’s state of affairs — nicely, it was a superb story. And it made me inquisitive about a pair issues.
It additionally jogged my memory of some good recommendation we’ve heard right here earlier than — and it jogged my memory of an necessary colleague and trainer. And the underside line to Caitlyn’s story? Get up for your self. Don’t cave. Make the subsequent name.
That is An Arm and a Leg — a present about why well being care prices so freaking a lot, and what we will possibly do about it. I’m Dan Weissmann. I’m a reporter, and I like a problem — so our job on this present is to take one of the vital enraging, terrifying, miserable elements of American life, and produce you one thing entertaining, empowering, and helpful.
To get her insurance coverage firm’s approval, Caitlyn had already spent plenty of time — and some huge cash — within the months earlier than surgical procedure. For example …
Caitlyn: To show to insurance coverage {that a} listening to assist wouldn’t work needed to be fitted for a listening to assist after which do a pair hours of testing to show, yep, it doesn’t assist.
Dan: There have been evaluations with audiologists, along with her surgeon, and an MRI to ensure there wasn’t an excessive amount of scar tissue for an implant to take.
Caitlyn: That took a very long time to get scheduled, get insurance coverage to approve, pay for, then get again for one more appointment. I counted up at one level — it’s like round eight or ten appointments that I had earlier than the ultimate, okay, let’s schedule surgical procedure.
Dan: And — you caught that, proper? The place she talked about she needed to get her insurance coverage to approve paying for the MRI? Each certainly one of these preliminary steps price cash, and he or she needed to wrangle along with her insurance coverage to get their OK.
However in fact even along with her insurance coverage saying sure, there have been nonetheless copays, and deductibles, and what’s referred to as co-insurance — the place you pay a proportion of any invoice from a hospital.
Which meant Caitlyn was chipping away at what’s referred to as her out-of-pocket most: Probably the most she could possibly be on the hook for in a given calendar 12 months. The surgical procedure obtained scheduled for December — the identical calendar 12 months as all these exams — and he or she checked to see what she might need to pay.
Caitlyn: I checked out my little portal for insurance coverage, I’m exhibiting what’s left on my out-of-pocket max for the 12 months is round 2,000, give or take, 200 {dollars}.
Dan: She referred to as the insurance coverage firm to substantiate that estimate. After which she cranked up her due diligence.
Caitlyn: I referred to as the hospital, and I requested for the names of the anesthesiologist, the radiologist. I requested for all the particulars of who’s presumably going to be on my case. After which I circled and I referred to as insurance coverage and I stated, I wish to be certain all of those physicians are going to be in community on this date.
Dan: Caitlyn had finished her homework. Most likely greater than plenty of us would have thought to do. I requested her: How’d you get so diligent? And first, like plenty of of us I’ve talked with, she stated: Having a serious well being situation as a child — dropping her listening to — gave her an early heads-up to be careful.
Caitlyn: Just a little bit was, uh, expertise of my mother coping with insurance coverage battles with me rising up. I bear in mind her operating into points with that.
Can: And she or he’s obtained some specialists in her life now. Her brother and her sister in legislation work in well being care. Considered one of her greatest pals is a healthcare lawyer and had some ideas.
Caitlyn: However truthfully, I feel plenty of it’s I’ve anxiousness, and so I used to be simply actually paranoid.
Dan: The surgical procedure went nice. And some weeks later, Caitlyn was within the audiologist’s workplace, getting that exterior element hooked up, and listening to on her proper aspect for the primary time in 15 years. Caitlyn says all of it took some getting used to.
Caitlyn: I bear in mind these, like, first few days particularly, it wasn’t actually like I used to be listening to full sounds. It was sort of simply completely different pitches. I wasn’t listening to the phrases and every thing, it was simply the breakdown of the completely different pitches. They usually additionally had been simply a lot larger than they need to be.
Dan: So attention-grabbing. Radiolab might have already finished this story — [but] I’m identical to, let’s discover out what that’s about.
Caitlyn: I really like Radiolab.
Dan: Me too! Anyway, two weeks after she begins getting used to her new listening to state of affairs, Caitlyn will get that alert on her telephone.
Caitlyn: And it tells me I’ve a brand new bill. And I used to be like, oh, superior! I’m not harassed in any respect, I did my due diligence. I do know it’s gonna be costly, however inexpensive.
Dan: Besides, proper: It’s 100 and thirty-nine thousand {dollars}! Six figures. The complete quantity for her surgical procedure. You may bear in mind, Caitlyn stated she had a panic assault. That was literal: Coronary heart palpitations, hyperventilating.
It took her 20 or half-hour to get calm sufficient to start out making calls. And she or he says her insurance coverage instructed her they hadn’t paid as a result of the hospital had uncared for to ship one thing necessary.
Caitlyn: The itemized invoice. Which has all of the codes and every thing,
Dan: Caitlyn says she instantly requested the hospital, in writing to ship her insurance coverage the itemized invoice, and he or she says despatched a follow-up every week later. However her telephone saved pinging with alerts about owing the hospital 100 and thirty-nine thousand {dollars}.
Caitlyn: The app so conveniently instructed me that I might join month-to-month funds of 11,000 {dollars} a month, which is simply so absurd.
Dan: After two weeks, she requested her insurance coverage: Do you might have that itemized invoice but? They didn’t. So she referred to as the hospital once more.
Caitlyn: The woman I spoke with stated she was placing in a request to have it faxed to my insurance coverage and that will take two to a few weeks. And I stated, maintain on, it takes you two to a few weeks to fax a doc?
Dan: Reply: Apparently sure? And Caitlyn says even three weeks later, her insurance coverage firm nonetheless hadn’t gotten that itemized invoice the hospital promised to fax.
And all this time Caitlyn was nonetheless getting notices from the hospital billing division. And the newest one stated, “late.” She tried one thing new: So she referred to as the hospital and demanded they ship the itemized invoice on to her, instantly. Which they did.
Caitlyn: So I circled and faxed it to my insurance coverage.
Dan: Yeah however, this didn’t finish issues, not but. Caitlyn says she obtained extra notices labeled late. She fought her strategy to a direct dialog with a supervisor.
Caitlyn: They saved saying,‘nicely, a supervisor’s not accessible proper now.’ I stated, No, you’re discovering a supervisor. I don’t care in the event that they’re reducing their lunch brief. I’m speaking to a supervisor proper now. I don’t care if I sound like a Karen. It’s been a protracted, lengthy 12 months already.
Dan: Ultimately, Caitlyn obtained a supervisor on the road and obtained the supervisor to get permission from a supervisor to cease sending her payments whereas the hospital waited for insurance coverage to pay.
By this time, it was late March, nearly two months after that first invoice gave Caitlyn that panic assault. Additionally by this time, Caitlyn had despatched her invoice to the parents at NPR and KFF Well being Information for that Invoice of the Month characteristic they do.
Caitlyn: I used to be like, I simply must vent. And so I submitted it simply to vent it out. By no means anticipating anybody to achieve out.
Dan: However they did. And on April ninth, Caitlyn obtained a name from a regional Affected person Service Heart supervisor.
Caitlyn: And she or he was tremendous good and tried to be actually apologetic, however by no means really accepting any blame. Or outright saying,‘we’re so sorry.’ Simply stated, ‘I’m sorry to your frustration, that sounds terrible.’
Dan: She DID inform Caitlyn that the hospital had obtained fee from her insurance coverage. And that Caitlyn might anticipate a closing invoice inside every week. And that as an alternative of 100 thirty 9 thousand, it was gonna be one thousand, 9 hundred eighty-two {dollars} and twenty-five cents.
Caitlyn: I stated,‘yep, that really matches what my insurance coverage stated,’ and he or she stated,‘oh, you understand what was left in your out-of-pocket, most individuals don’t,’ and I stated,‘I’m very nicely versed in each greenback signal at this level on this total case.’
Dan: Caitlyn says she obtained that invoice 4 days later and paid it instantly.
Caitlyn: And I saved the receipt of that, I’ve saved every thing. It feels prefer it’s resolved, however there’s a part of me that’s nonetheless ready for the opposite shoe to drop
Dan: So, Caitlyn’s story brings up a LOT. In fact, I liked the way in which she saved combating, and in the end took management of the state of affairs. And I hated how she obtained trapped between these two huge entities and the way a lot time and stress the entire thing price her.
As a result of, you understand, the hospital might’ve resolved this so rapidly by simply sending that itemized invoice to Caitlyn’s insurance coverage firm.
Caitlyn: And the hospital didn’t do this. They simply circled and billed me. Which was a silly thought, because the insurance coverage firm is extra prone to have the cash. Not the authorized assistant in Oklahoma.
Dan: Caitlyn’s story raised a couple of questions, and introduced again plenty of themes we’ve touched on earlier than. We dug in additionally discovered some new ideas, and a few recollections I wish to share. That’s coming proper up.
This episode of An Arm and a Leg is a co-production of Public Street Productions and KFF Well being Information, a nonprofit newsroom masking healthcare in America. Their senior contributing editor, Elisabeth Rosenthal, reported Caitlyn’s story for KFF and NPR. She wrote a e-book about U.S. healthcare. It’s referred to as “An American Illness,” and it was an inspiration for this present.
One query we ask typically on this present once we see a invoice that’s so wildly ridiculous and unfair is: Can they freaking DO that?!? Like, is that even authorized?
Like on this occasion, can they only hold billing you whereas they’re apparently not even taking part in ball together with your insurance coverage? And: Do we’ve got any authorized weapons to battle again with?
We requested a bunch of authorized specialists, and so they just about all stated: Sure, they most likely can do this, and no, we most likely don’t have any straightforward authorized weapons we will battle with. However then I talked with Berneta Haynes. She’s a senior legal professional with the Nationwide Client Regulation Heart.
And she or he had some sensible ideas which are super-worth sharing. She used to work for a nonprofit referred to as Georgia Watch — that’s a state-level client safety group. They operated a hotline folks might name for assist.
Berneta Haynes: Customers and sufferers would name us with all types of hospital billing points and medical debt points. And we’ve had these sorts of bizarre questions the place actually, there wasn’t a selected lever on the authorized stage to really assist them. But when they really feel like they’re experiencing what could possibly be thought-about doubtlessly an unfair enterprise follow, it’s completely inside their proper to file a grievance inside their state A. G.’s workplace.
Dan: The A.G. The state legal professional common. Whoever’s doing you fallacious, you’ll be able to file a grievance.
Berneta: Whether or not or not there’s any actual hook that your AG might use to carry them accountable is at all times a query that’s up within the air. However even simply the act of submitting a grievance could be very prone to get that entity, that firm, to behave accurately.
Dan: Mainly, go up the chain. Whether or not to a authorities watchdog, or within the group that’s bugging you. We’ve heard this earlier than, however I liked the specifics that Berneta Haynes shared with me about her personal experiences.
Berneta: I’ll let you know, one of many mechanisms my husband and I’ve needed to make the most of repeatedly, not in a hospital context, however in varied different service contexts is to achieve out or threaten to achieve out to the CEO or president. And it will get outcomes each time. It will get outcomes each time!
Dan: Oh, and right here’s the professional tip.
Berneta: My husband has repeatedly, when he’s needed to do it, arrange a LinkedIn premium account simply to search out the CEO and message them instantly.
Dan: Ooh, that’s good!
Berneta: That has been the way in which we’ve gotten decision on all types of points associated to insurance coverage corporations not eager to do proper by us. And so forth.
Dan: In order that was enjoyable. Now, I do wish to discuss a bit bit about what Caitlyn did, and what allowed her to do it. Caitlyn figures she made a minimum of a dozen telephone calls. And she or he says she’s fortunate — privileged — to have a job the place she might do this. Right here’s the very first thing she says she did as soon as she obtained over that panic assault when the invoice arrived.
Caitlyn: I simply went to my boss’s workplace and I stated, I’m going to need to make some telephone calls. There’s an issue with my hospital invoice. She’s like, don’t fear about it. Do what you must.
Dan: And she or he had folks in her nook, just like the good friend who’s a healthcare lawyer. And authorized recommendation wasn’t the massive factor that good friend gave Caitlyn.
Caitlyn: More often than not I used to be simply venting to her, and he or she was like,‘you must hold pushing, like, hold going at them. Don’t allow them to win. Don’t roll over. Simply hold pushing. They need to be paying.’
Dan: And at that time, I instructed Caitlyn, she and her story had been actually reminding me of somebody.
Dan: There’s a reporter named Marshall Allen. He labored for ProPublica for a very long time. He wrote on healthcare, and he wrote on stuff like this. And finally he wrote a e-book, giving recommendation to folks. And the title of the e-book was, By no means Pay the First Invoice.
Caitlyn: Oh!
Dan: And I instructed Caitlyn, Marshall was on my thoughts on the time as a result of when Caitlyn and I talked in Could, Marshall had simply died, like lower than two weeks earlier than. And he was younger — 52. He had three children.
Caitlyn: So unhappy.
Dan: Tremendous, tremendous, tremendous unhappy.
Dan: And naturally the title of Marshall’s e-book — By no means Pay the First Invoice — that’s precisely how Caitlyn performed issues. She wasn’t going to consider paying something till she obtained her questions answered. And it’s value remembering.
After we had been speaking with authorized specialists, one factor a couple of of them stated was: If you happen to pay one thing that insurance coverage was purported to cowl, after which insurance coverage comes by, you’re purported to get a refund. However who needs to chase that?
Yeah. Don’t pay that first invoice till you’ve made positive that is cash you actually owe. So, this looks as if a superb time to memorialize Marshall Allen a bit bit. He preferred to match the healthcare system to a schoolyard bully. Right here’s what he instructed me when he was on this present in 2021 when his e-book had simply come out.
Marshall Allen: What I feel we have to do is stand as much as the bully. We have to cease being afraid. We have to cease considering another person goes to stay up for us. And I wrote the e-book to equip and empower folks to face as much as the bullies.
And I feel it’s tremendously empowering, but it surely’s exhausting, and standing as much as a bully takes unimaginable braveness. It takes fortitude. It takes persistence. You may get beat up within the course of. There’s no assure of victory. It’s dangerous, proper? But when we don’t attempt, we don’t have an opportunity.
Dan: Marshall was a Christian minister earlier than he grew to become a reporter. He wrote a considerate essay about how his work as an investigative reporter match together with his religion. The gist was: The Bible is fairly clear that dishonest folks and exploiting them is fallacious.
And to me, it looks as if there was a component of ministry– not simply evangelism — to what he did after his e-book got here out. Right here’s what he instructed me in 2021:
Marshall: I’ve began taking calls, and I’m responding to emails that I get from folks and I’m saying,‘name me, let’s discuss it by, let me assist you to with this. Let’s work by this collectively.’ And now I’m serving to folks work by their payments, work by these conditions the place they’re being cheated. It’s tremendous satisfying and gratifying, so it’s my new pastime.
Dan: He saved at it. He left ProPublica and took a job with the Workplace of the Inspector Common on the federal division of Well being and Human Providers. And he printed a e-newsletter — it was free, however he inspired folks to pay if they might, and he used the cash to rent medical-bill advocates to assist folks with particularly difficult instances.
And Marshall was humorous. I wish to shut out this episode with a narrative he instructed me the primary time we talked, in 2019. It’s sort of an origin story.
Marshall: So after I was 16 years previous, um, I labored for this dinner theater in Golden, Colorado, the place I grew up. Someday I present up for work, and so they’ve closed down the enterprise. They owed me like three weeks of pay.
The man had closed the place with out paying us and stated,‘there’s no cash. We shut down the enterprise. We will’t afford to pay you. You’re out of luck.’ Nicely, we had been all fairly indignant about that. We had been actually indignant as a result of they’d opened a sister dinner theater below the identical firm umbrella throughout city. And all of us knew that. And we had been like, nicely, for those who can afford to maintain your different place open, you’ll be able to afford to pay us. They usually stated,‘sorry, children, you’re out of luck.’
Dan: Marshall goes dwelling, tells his mother what’s happening.
Marshall: And my mother tells me it’s best to sue him. I’m like, mother, what do you imply? I can barely drive. How can I sue the man? She goes,‘it’s best to take him to small claims courtroom.’ So lo and behold, I’m going down, I fill out the paperwork.
It’s a couple of paragraphs. It’s straightforward to fill out the paperwork in small claims courtroom. I fill out the paperwork and switch in like 10 bucks on the time or no matter it prices. It’s not that costly to file certainly one of these instances. And I get a discover within the mail like six weeks later. And I’ve a courtroom date, and I’m like equipped for this huge Perry Mason second.
Dan: Perry Mason was a lawyer on this tremendous previous TV present — courtroom drama. However this wasn’t a courtroom.
Marshall: It’s extra like a convention room and there’s some administrative listening to choose in there. And lo and behold, the proprietor of the corporate and his legal professional needed to present up in courtroom there with me.
And I believed we’d have an enormous argument all the executive choose did is he learn my few paragraphs on the little factor I’d written up and he appears to be like over on the proprietor and he goes,‘is what this child saying true?’And the proprietor’s like, ‘nicely, yeah.’ And the choose is like,‘give this child his cash.’ And I used to be like, That is wonderful. You already know what? Possibly the courtroom system does really work now and again possibly now and again the little man can win.
Dan: Marshall and I each stayed concerned with how folks can use the authorized system to get our rights. I discovered quite a bit from Marshall, and like lots of people, I simply liked his spirit. Marshall Allen, thanks. And right here’s the tip of my dialog with Caitlyn.
Dan: Marshall Allen would have been extraordinarily pleased with you.
Caitlyn: Yeah.
Dan: Caitlyn has the ultimate phrase right here.
Caitlyn: I obtained to the purpose the place I used to be like, it’s my battle. I’ve obtained gasoline within the fireplace. I’m, I’m going for it.
Dan: We’ll be again with a brand new episode in a couple of weeks. Until then, deal with your self.
This episode of An Arm and a Leg was produced by me, Dan Weissmann, with assist from Emily Pisacreta and Claire Davenport — and edited by Ellen Weiss.
KFF senior contributing editor Elisabeth Rosenthal reported Caitlyn’s story for KFF and NPR. She was editor in chief there when she invited me to collaborate with KFF to make this present’s second season, and we’ve been colleagues ever since. I’ve by no means felt so fortunate or so grateful.
Particular due to Christopher Robertson at Boston College’s Faculty of Regulation, Wendy Epstein of the Faculty of Regulation at DePaul College, Sabrina Corlette at Georgetown College’s Heart on Well being Insurance coverage Reforms, and Elisabeth Benjamin from the Neighborhood Service Society of New York for pitching in with authorized experience right here.
Adam Raymonda is our audio wizard. Our music is by Dave Weiner and Blue Dot Periods. Gabrielle Healy is our managing editor for viewers. Bea Bosco is our consulting director of operations. Sarah Ballama is our operations supervisor.
An Arm and a Leg is produced in partnership with KFF Well being Information. That’s a nationwide newsroom producing in-depth journalism about healthcare in America and a core program at KFF, an unbiased supply of well being coverage analysis, polling, and journalism.
Zach Dyer is senior audio producer at KFF Well being Information. He’s editorial liaison to this present. And due to the Institute for Nonprofit Information for serving as our fiscal sponsor. They permit us to just accept tax-exempt donations. You possibly can study extra about INN at INN.org. Lastly, thanks to all people who helps this present financially. You possibly can take part any time at https://armandalegshow.com/assist/. Thanks a lot for pitching in for those who can — and, thanks for listening.
“An Arm and a Leg” is a co-production of KFF Well being Information and Public Street Productions.
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