How can a doctor be both in-network and out-of-network at the same time? I found myself asking this around a dozen years ago when I received a health insurance statement showing the doctor who read my mammogram was considered “in” for parts of this procedure and “out” for others.
I made multiple calls to customer service seeking an explanation but they gave me the runaround. Only a full year later when, in frustration, I contacted the CEO, did I get satisfactory resolution. The CEO assigned the case to a vice president, who found errors not only for the mammogram billing but for multiple other doctor appointments. I was refunded hundreds of dollars.
After that, my husband and I switched companies several times but I continued being overcharged because of so-called billing “errors.” It doesn’t happen with every bill, but it happens often enough. Right now I’m dealing with a billing “error” for a blood test. Two years ago I was overcharged for a vaccination. Before that, I went for a routine eye exam and was charged for a much more expensive procedure. Those are just a few examples.
I was 7 when I first wrote a letter to bring attention to a problem. I sent it to the U.S. Department of the Interior. I was concerned about the welfare and treatment of Native Americans after reading many books in the children’s section of our library. The department sent back a big envelope of printed information, but it was way above my reading level.
That was over 60 years ago. When I think of it now, it makes me smile, but I see it as the beginning of the thread that led to my work on these medical billing “errors.”
First, I asked for explanations
I have always felt I must act when I am hurt by an injustice or unfair treatment. I would be a hypocrite if all I did was talk about my values without acting upon them, especially when I’m the victim. But it’s not just about me. If billing practices harm me, they harm plenty of other people, too. I have stood up for friends and family who were too upset or simply didn’t know how to respond to unfair treatment.
My starting point is what I personally can do with my own two hands. I can write a letter to a CEO, the person who is ultimately in charge. And I can take it higher if necessary. Never doubt the power of persistence.
How does a billing “error” come to light? Before the mammogram billing problem, I accepted incomprehensible bills without thinking they should be otherwise. I simply paid them. After that episode, I began examining all medical bills and health insurance statements carefully.
Sometimes they just look odd, like the mammogram that had the doctor both in- and out-of-network at the same time. In the case of a bill for my father’s care there were charges for services after the date of his death. But being able to detect a billing error because it looks odd is the exception. Most are undetectable because bills and insurance statements are written in codes and abbreviations that most patients can’t read or understand.
I started calling to get a clear explanation of every code, abbreviation and charge that I couldn’t understand on a bill. When I couldn’t get it, I wrote the CEO. Eventually I was contacted by a high-up administrator. Now I call her whenever I have questions. But what about all the patients who haven’t been assigned this kind of special help?
Second, I questioned the whole system
The companies explain away the problems as “billing errors.” But they’re more than that: They are a systemic problem. According to my husband who teaches statistics, when errors always favor one party over another, they are not random.
I resent the time it takes to make calls and write letters about systemic problems that shouldn’t exist. Indeed they wouldn’t exist if management decided to take steps to correct them. Company management has told me about their quality control and audits of billing, but these clearly aren’t working. Why not? What needs to be done to fix their procedure so they prevent repeated billing errors? What will make this a management priority?
My tips for writing to CEOs
- I write postal letters because they are usually delivered to the CEO’s office, while emails and social media posts are typically handled by someone lower down the ranks. You can usually get the name and address of the CEO at the company’s website. It’s often under “Corporate Information” at the bottom of the webpage.
- My letters are always polite. You get more bees with honey than with vinegar. I do not let anger drip into the letter. I focus on the problem I want fixed.
- The letter is less than one page. It is a summary that states the problem concisely, for example: How can a doctor be in- and out-of-network at the same time? If there are details that are important, like copies of bills or a chronology of events, I put that in an attachment. A CEO is unlikely to wade through details. They’ll read the cover letter, consider the issue and then assign it to someone.
- If I can get a CEO to take an interest in me, if I can connect with their humanity, I’m more likely to get help. Across the top of my typed letter, I write by hand in a contrasting color of ink, usually red, something like “I don’t know whom else in your company to turn to about this. I hope you can help me.” I have written to CEOs for years about all kinds of problems — defective products, utility bills, servicing printers and more. It works.
Health care is the only thing we consume without a clue what it will cost. It doesn’t have to be this way. Who would accept a bill they couldn’t understand from a mechanic or a builder? But that is exactly the setup we have in health care. My healthcare network sends out “summary” bills. I can’t get an itemized bill unless I call and request it. They don’t provide a way to sign up to always get itemized bills. Every additional hurdle like this means that fewer people will make the enormous effort it takes to check bills, correct errors and reconcile bills with insurance statements.
It’s bad enough that health care is the only thing we consume without knowing its cost — but not being able to understand bills and reconcile them with insurance coverage makes a bad situation worse. Patients need to be able to check that billing codes are correct. Bills and insurance statements should use complete words and sentences that people can understand. Changing this deplorable situation is a fundamental consumer protection matter that would empower patients to identify errors and fraudulent charges.
Third, I invoked the fight against Medicare fraud
When I turned 65 and went on Medicare, I found a whole new angle for publicizing these problems and advocating for change. I started receiving warnings to be on the lookout for Medicare fraud and report it. How can seniors detect Medicare fraud if their bills and insurance statements are incomprehensible? That was my new angle: making bills and insurance statements understandable is in your own self interest if you want to reduce Medicare fraud, I urged.
Last summer I wrote to the CEO of the insurance company that sent me the warning about fraud. I wrote to elected representatives and the head of the American Association of Retired Persons. I sent copies of the letters to the media. I wrote to high-level federal government officials I see quoted concerning Medicare fraud. I wrote the head of Medicare.
Medicare has a lot of clout within the health care sector so I hope they can apply some pressure. Medicare uses complete sentences and words in its summary statements so why can’t others? Medicare customer service has been marvelous. They have contacted health care providers to straighten out billing problems when those providers haven’t responded to me.
I don’t get much feedback on my efforts. So what keeps me going? I do this because I hate to see people manipulated and taken advantage of. I think of all the people who don’t do what I do because they are too sick or too busy working and looking after loved ones. I think about all the people who are like me before the mammogram bill, people who are overcharged without knowing it and never considered that medical bills and insurance could be anything but incomprehensible.
Juliet Zavon lives in Squirrel Hill North, often advocates for electoral transparency and can be reached through firstperson@publicsource.org.
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