Bill me

Via Gross Anatomy (a super medical blog on its own) comes this story about nightmarish medical billing:

So it took a bit more than 90 minutes of my time this morning to get paid on a $59 balance from 15 months ago. Our billing specialist spends her days like this. We have thousands and thousands of dollars of write-offs every months … for things that we just don’t have the energy to follow-up on. The system is simply broken.

Jacob’s story illustrates how hard it is even for a physician to penetrate the insurance machine; patients, far less powerful or authoritative than their physicians, have an even harder time. One of the things that I have trouble communicating with my students in medical sociology is just how difficult it is to navigate the world of health care bureaucracy. Most of my students are young enough that they’re covered by parents’ insurance and have never needed to find an in-network physician or appeal a payment denial.

I have dental insurance through my wife’s employer. (The outright scam that is dental insurance is a topic for later discussion.) A year ago, my wife and I saw the dentist for regular cleanings; she had a cavity filled. Two weeks ago we got bills for the cleanings. Why the delay? Despite sending us plenty of other information and various account statements in the intervening year, the insurance company never “confirmed” our address, whatever that means (our paying of all the previous bills didn’t do it for them?), which somehow prevented them from actually billing us. So we have unexpected bills from a year ago to sort out. The confusing communication between doctors, patients, and insurers get even harder to follow when hospitals outsource their billing: In another situation, we started receiving bills for a previously-paid office visit, and offered to go on down to the hospital with the receipt that reads “paid in full.” The catch? The hospital has outsourced its billing, so that the people sending us polite-but-threatening bills are located in Florida and they don’t have a copy of the original account statement. A situation that should be resolved by walking into a records room and opening a chart becomes three weeks of phone calls, explaining the story to four different account managers, writing letters.

Everybody has a story like this. My parents had the same procedure performed, on the same day, based on the same referral by their family doc. One was paid by the insurance company and one was denied, not on any medical basis but for some obscure bureaucratic reason. In the medical sociology literature, the obstacles to patient care put up by insurance companies and hospital bureaucracies are sometimes called systems barriers, and they have differing effects on patients: Dealing with insurance companies and hospital systems takes time, an understanding of how large systems work, and a significant level of confidence and comfort to be able to navigate that system. Many patients—the elderly, the very sick, those with little education or a lack of familiarity with complex organizations—are unable to confront the system. At worst, inability to navigate the health care system means that these patients simply drop out, failing to get health care at all. At best, it means that we all dread the system that is supposed to keep us healthy.