When patient advocate Jim Sliney, Jr. needed an emergency appendectomy, his health insurance company refused the charges and told him he'd be responsible for the costs.
The first time I ever really needed my insurance for an emergency surgery, my health insurance company told me I would get a letter saying they were refusing the charges and that I would be responsible for the costs.
But, I was told, don’t worry about that.
I had an emergency appendectomy. “Pretty straightforward for major surgery” was how my surgeon described it. My health insurance company called me while I was in the hospital, but I missed the call. They also called the next day after I was discharged.
The good news was that I had been assigned a case manager as a benefit of my employer-sponsored insurance plan. My case manager was a registered nurse, she asked how I was doing, if I had a follow-up appointment, and if I had any questions. Because I have a medical background, we were able to speak freely.
She explained that I shouldn’t worry. She also explained that I was going to get a letter saying, “something to the effect” that the company has not approved my admission and that I’m responsible for those charges.
She also said that Utilization Management (UM) had concluded that I could have been cared for “under observation” rather than as an “admitted” patient. I asked how I could be operated on and not be admitted to the hospital. She said not to worry. These things get sorted out.
But I was worried. There was absolutely no way I could cover the cost of a hospital admission, and I asked if other people expressed concern when they were told the same news I was. Did they get a letter that said, “don’t worry” on it?
I asked if other people end up paying because they are worried about things like losing their insurance or being reported to collection agencies. “That’s very rare,” she said, “and even when it does happen, usually UM and the hospital sort things out and the patient will get their money back.”
Rare. Usually. This told me that there were cases where people did pay and didn’t get their money back after being pressured to pay in the first place for all the wrong reasons.
The truth is, insurance companies and hospitals love when a patient pays. Let’s say the fee for the anesthesiologist is $4000. As a provider in the network, the anesthesiologist accepts considerably less than $4000 from the health insurance company. However, when that $4,000 bill goes to a patient, it doesn’t say “just pay part of this.”
I was told it was because I’m in the medical profession and I would understand. Which told me that people who aren’t in the medical profession get no explanation, just a letter in the mail that turns their blood cold and sets their lives on a new course.
And they get sicker from all the stress.
Prolonged stress from worry reduces the body’s immune response – literally the last thing any patient needs. When you’re sick, your physical, behavioral and mood responses to stress are all worsened. What’s next? The conditions related to bad health continue and, inevitably, get worse.
So, here’s some advice to my insurer: Don’t just tell me not to worry. Don’t send an insincere letter (that looks as serious as a heart attack) and tell me to ignore it.
That doesn’t reassure. Instead, it terrifies about the ability to pay. I’d like to trust my insurer’s word that “everything will be sorted out between you and the provider.” But the credibility necessary for that is pretty well shot by advising me to ignore the clear stated wording of your letters.
When I am already at my most vulnerable, this clear and present contradiction isn’t helping. Instead, of having my back, my health insurance company is making me even more sick.
Jim Sliney, Jr. is a freelance writer and patient advocate at Patients Rising, a national patient advocacy non-profit organization.
Get notified about new stories and resources to empower patients and caregivers.