Caitlyn Mai thought she did every little thing proper. She known as forward to verify her insurer would cowl her cochlear implant surgical procedure. She thought every little thing went in line with plan however she nonetheless acquired 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 mentioned 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 “Bill of the Month” sequence, created in partnership with NPR.
Dan Weissmann
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.
Credit
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 all the time did when she wakened.
Caitlyn Mai: Music has all the time 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 observed 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 virtually 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 wonderful. 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 stability — that really depends on a mechanism inside our ears. Later, medical doctors discovered she had misplaced 87 % of her listening to on the fitting aspect.
Caitlyn: They assume I simply had some type of virus that settled in my ear, and it broken my ear. However I went to mattress fully wholesome the night time earlier than. Wakened, couldn’t hear out of my ear.
Dan: She needed to learn to stroll another time.
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 way of highschool, in Tulsa the place she grew up with out a whole lot of lodging.
Caitlyn: Trigger in center college, early highschool, you don’t need to convey consideration to your incapacity. At the least I actually didn’t need 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 device that helps restore listening to for many folks: Cochlear implants — small gadgets 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 acquired her insurance coverage to approve one for her. She had surgical procedure in December to insert the implant. And in January, an audiologist connected an exterior element to change on Caitlin’s right-side listening to.
Caitlyn: She mentioned, okay, sooner or later, you’re gonna begin listening to some beeps, simply say sure when you possibly can hear them. And my husband mentioned my face simply, out of nowhere, lit up, and I am going, sure! It was streaming on to my cochlear implant. And I positively began tearing up.
Dan: Then, two weeks later, Caitlin acquired an alert from the hospital on her cellphone.
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 sequence they do with our buddies at KFF Well being Information.
NPR HOST: Time now for the newest installment in our invoice of the month sequence, 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 scenario — properly, it was a very good story. And it made me interested by 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 vital colleague and trainer. And the underside line to Caitlyn’s story? Rise 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 are able to perhaps 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 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 a whole lot of time — and some huge cash — within the months earlier than surgical procedure. As an illustration …
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 verify 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 one in all 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 known as co-insurance — the place you pay a share of any invoice from a hospital.
Which meant Caitlyn was chipping away at what’s known as her out-of-pocket most: Essentially the most she may very well be on the hook for in a given calendar 12 months. The surgical procedure acquired scheduled for December — the identical calendar 12 months as all these checks — and he or she checked to see what she may 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 known as the insurance coverage firm to substantiate that estimate. After which she cranked up her due diligence.
Caitlyn: I known 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 known as insurance coverage and I mentioned, I need to make sure that all of those physicians are going to be in community on this date.
Dan: Caitlyn had finished her homework. In all probability greater than a whole lot of us would have thought to do. I requested her: How’d you get so diligent? And first, like a whole lot of of us I’ve talked with, she mentioned: Having a serious well being subject as a child — shedding 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 keep in mind her operating into points with that.
Can: And he or she’s acquired some consultants in her life now. Her brother and her sister in regulation work in well being care. Certainly one of her greatest pals is a healthcare lawyer and had some suggestions.
Caitlyn: However actually, I feel a whole lot 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 connected, 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 keep 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 little thing, it was simply the breakdown of the completely different pitches. They usually additionally had been simply a lot greater than they need to be.
Dan: So attention-grabbing. Radiolab might have already finished this story — [but] I’m similar to, let’s discover out what that’s about.
Caitlyn: I like Radiolab.
Dan: Me too! Anyway, two weeks after she begins getting used to her new listening to scenario, Caitlyn will get that alert on her cellphone.
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 keep in mind, Caitlyn mentioned she had a panic assault. That was literal: Coronary heart palpitations, hyperventilating.
It took her 20 or half-hour to get calm sufficient to begin making calls. And he or she says her insurance coverage instructed her they hadn’t paid as a result of the hospital had uncared for to ship one thing vital.
Caitlyn: The itemized invoice. Which has all of the codes and every little 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 per week later. However her cellphone stored 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 have got that itemized invoice but? They didn’t. So she known as the hospital once more.
Caitlyn: The lady I spoke with mentioned she was placing in a request to have it faxed to my insurance coverage and that might take two to a few weeks. And I mentioned, 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 mentioned, “late.” She tried one thing new: So she known 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 acquired extra notices labeled late. She fought her technique to a direct dialog with a supervisor.
Caitlyn: They stored saying,‘properly, a supervisor’s not obtainable proper now.’ I mentioned, No, you’re discovering a supervisor. I don’t care in the event that they’re chopping their lunch quick. 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: Finally, Caitlyn acquired a supervisor on the road and acquired 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, virtually two months after that first invoice gave Caitlyn that panic assault. Additionally by this time, Caitlyn had despatched her invoice to the oldsters at NPR and KFF Well being Information for that Invoice of the Month characteristic they do.
Caitlyn: I used to be like, I simply have to 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 acquired a name from a regional Affected person Service Heart supervisor.
Caitlyn: And he or she was tremendous good and tried to be actually apologetic, however by no means truly accepting any blame. Or outright saying,‘we’re so sorry.’ Simply mentioned, ‘I’m sorry to your frustration, that sounds terrible.’
Dan: She DID inform Caitlyn that the hospital had obtained cost from her insurance coverage. And that Caitlyn might anticipate a closing invoice inside per 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 mentioned,‘yep, that really matches what my insurance coverage mentioned,’ and he or she mentioned,‘oh, you realize what was left in your out-of-pocket, most individuals don’t,’ and I mentioned,‘I’m very properly versed in each greenback signal at this level on this complete case.’
Dan: Caitlyn says she acquired that invoice 4 days later and paid it instantly.
Caitlyn: And I saved the receipt of that, I’ve saved every little 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 beloved the way in which she stored combating, and finally took management of the scenario. And I hated how she acquired trapped between these two large entities and the way a lot time and stress the entire thing price her.
As a result of, you realize, the hospital might’ve resolved this so shortly by simply sending that itemized invoice to Caitlyn’s insurance coverage firm.
Caitlyn: And the hospital didn’t try this. They only circled and billed me. Which was a silly concept, because the insurance coverage firm is extra prone to have the cash. Not the authorized assistant in Oklahoma.
Dan: Caitlyn’s story raised just a few questions, and introduced again a whole lot of themes we’ve touched on earlier than. We dug in additionally discovered some new suggestions, and a few recollections I need to share. That’s coming proper up.
This episode of An Arm and a Leg is a co-production of Public Highway 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 ebook about U.S. healthcare. It’s known as “An American Illness,” and it was an inspiration for this present.
One query we ask typically on this present after 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 simply preserve billing you whereas they’re apparently not even taking part in ball along with your insurance coverage? And: Do we have now any authorized weapons to battle again with?
We requested a bunch of authorized consultants, and so they just about all mentioned: Sure, they most likely can try this, and no, we most likely don’t have any straightforward authorized weapons we are able to battle with. However then I talked with Berneta Haynes. She’s a senior lawyer with the Nationwide Shopper Legislation Heart.
And he or she had some sensible ideas which might be super-worth sharing. She used to work for a nonprofit known as Georgia Watch — that’s a state-level shopper safety group. They operated a hotline folks might name for assist.
Berneta Haynes: Customers and sufferers would name us with every kind of hospital billing points and medical debt points. And we’ve had these sorts of bizarre questions the place actually, there wasn’t a specific lever on the authorized stage to truly assist them. But when they really feel like they’re experiencing what may very well be thought-about doubtlessly an unfair enterprise follow, it’s completely inside their proper to file a criticism inside their state A. G.’s workplace.
Dan: The A.G. The state lawyer common. Whoever’s doing you mistaken, you possibly can file a criticism.
Berneta: Whether or not or not there’s any actual hook that your AG might use to carry them accountable is all the time a query that’s up within the air. However even simply the act of submitting a criticism could be very prone to get that entity, that firm, to behave appropriately.
Dan: Principally, 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 beloved the specifics that Berneta Haynes shared with me about her personal experiences.
Berneta: I’ll inform you, 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 every kind of points associated to insurance coverage firms not eager to do proper by us. And so forth.
Dan: In order that was enjoyable. Now, I do need to speak somewhat bit about what Caitlyn did, and what allowed her to do it. Caitlyn figures she made at the least a dozen cellphone calls. And he or she says she’s fortunate — privileged — to have a job the place she might try this. Right here’s the very first thing she says she did as soon as she acquired over that panic assault when the invoice arrived.
Caitlyn: I simply went to my boss’s workplace and I mentioned, I’m going to must make some cellphone calls. There’s an issue with my hospital invoice. She’s like, don’t fear about it. Do what you could.
Dan: And he or she had folks in her nook, just like the pal who’s a healthcare lawyer. And authorized recommendation wasn’t the massive factor that pal gave Caitlyn.
Caitlyn: More often than not I used to be simply venting to her, and he or she was like,‘you could preserve pushing, like, preserve going at them. Don’t allow them to win. Don’t roll over. Simply preserve 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 ultimately he wrote a ebook, giving recommendation to folks. And the title of the ebook 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 ebook — By no means Pay the First Invoice — that’s precisely how Caitlyn performed issues. She wasn’t going to consider paying something till she acquired her questions answered. And it’s price remembering.
Once we had been speaking with authorized consultants, one factor just a few of them mentioned was: In the event you pay one thing that insurance coverage was alleged to cowl, after which insurance coverage comes by way of, you’re alleged to get a refund. However who desires 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 very good time to memorialize Marshall Allen somewhat 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 ebook 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 ebook to equip and empower folks to face as much as the bullies.
And I feel it’s tremendously empowering, nevertheless it’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 strive, 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 mistaken.
And to me, it looks as if there was a component of ministry– not simply evangelism — to what he did after his ebook 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 speak it by way of, let me assist you to with this. Let’s work by way of this collectively.’ And now I’m serving to folks work by way of their payments, work by way of these conditions the place they’re being cheated. It’s tremendous satisfying and gratifying, so it’s my new interest.
Dan: He stored 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 publication — it was free, however he inspired folks to pay if they may, and he used the cash to rent medical-bill advocates to assist folks with particularly tough instances.
And Marshall was humorous. I need 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 once I was 16 years outdated, um, I labored for this dinner theater in Golden, Colorado, the place I grew up. Sooner or later 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 mentioned,‘there’s no cash. We shut down the enterprise. We are able to’t afford to pay you. You’re out of luck.’ Nicely, we had been all fairly offended about that. We had been actually offended as a result of that they had opened a sister dinner theater below the identical firm umbrella throughout city. And all of us knew that. And we had been like, properly, if you happen to can afford to maintain your different place open, you possibly can afford to pay us. They usually mentioned,‘sorry, children, you’re out of luck.’
Dan: Marshall goes dwelling, tells his mother what’s occurring.
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 am going down, I fill out the paperwork.
It’s just a few 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 one in all 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 large Perry Mason second.
Dan: Perry Mason was a lawyer on this tremendous outdated 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 lawyer 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 seems over on the proprietor and he goes,‘is what this child saying true?’And the proprietor’s like, ‘properly, yeah.’ And the choose is like,‘give this child his cash.’ And I used to be like, That is wonderful. You realize what? Possibly the courtroom system does truly work once in a while perhaps once in a while the little man can win.
Dan: Marshall and I each stayed all in favour of how folks can use the authorized system to get our rights. I discovered loads from Marshall, and like lots of people, I simply beloved 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 acquired to the purpose the place I used to be like, it’s my battle. I’ve acquired gasoline within the hearth. I’m, I’m going for it.
Dan: We’ll be again with a brand new episode in just a few weeks. Until then, maintain 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 College of Legislation, Wendy Epstein of the Faculty of Legislation at DePaul College, Sabrina Corlette at Georgetown College’s Heart on Well being Insurance coverage Reforms, and Elisabeth Benjamin from the Group 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 because of the Institute for Nonprofit Information for serving as our fiscal sponsor. They permit us to simply accept tax-exempt donations. You may study extra about INN at INN.org. Lastly, thanks to all people who helps this present financially. You may take part any time at https://armandalegshow.com/support/. Thanks a lot for pitching in if you happen to can — and, thanks for listening.
“An Arm and a Leg” is a co-production of KFF Well being Information and Public Highway Productions.
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