Post-Stroke: Fractured Healthcare



This is an advisory piece that I hope influences many people regarding their healthcare and power you hold. This may or may not impact you and you might not agree with my statement, but if you don’t, I suspect you understand my problem.


In the United States we have private insurance (company provided, or privately paid), Medicare (65 and older or people with disabilities) and Medicaid (limited income) that is run by state and federal programs, under the guidance of Centers for Medicare and Medicaid Services. The private insurance companies (what little is left) adhere to the same guidelines qualified healthcare professionals must abide and for most, follow the same payment structure.


Every year, if you are employed, you select a tier that fits your medical needs. The healthier you are, the less you pay in. The more problems you have, the higher you pay in. There are generous companies in the United States that don’t require employee contribution (I call those unicorn companies). Makes sense, right? Well, being unhealthy, is two-fold. One, you are unhealthy because you choose an unhealthy lifestyle such as overeating, not eating, smoking, drinking, drugs etc. Second, you are unhealthy because of diseases or conditions that are out of your hands. Yet, these two are lumped together that drive healthcare cost up every year.


With the cost of insurance on the rise, along with the cost of living, people struggle to pay sky-rocketed medical bills. Especially the unexpected medical emergency. People begin to drown in medical debt and when you need to make that choice to pay for living expenses or medical bills, generally living expenses win. This impacts the medical facility because they aren’t getting paid. For years, these facilities factored in this loss of revenue in their yearly costs. After time, they sold your medical debt to a debt collector. This still didn’t cause a shift, as many people opted to file for bankruptcy because the debt was too much, and the amount of collection calls was borderline harassment.


Administrators had to rethink their finance structure to ensure revenue was coming in. So, many facilities opted for the pay up-front model after they check with your insurance company regarding your deductible, co-insurance, HRA (if you have one) and out-of-pocket max (if the procedure even makes it to that amount). They collect the money before the procedure or office visit and file the claim after services are rendered. They reimburse patients if the money paid at the time of service is over the actual cost. It’s a win for them because they have the money and it’s easier to refund patient’s than collect monthly payment arrangements. Reimbursements, if caught by a savvy person looking at an explanation of benefits, or a billing specialist looking at refunds usually come within 30 days. Sort of funny you are expected to pay upfront, but you must wait 30 days for monies owed. As a business, I understand how this model works protecting their revenue. As qualified healthcare professionals, this is a thorn because they are seeing patients backing out of critical procedures because they don’t have the money. The QHP does not have a say, because they are employees. Private healthcare plans are equally frustrated because the contract does not state that the insurer should pay up front. Yet, the administrators have the control with their policies.


Let’s examine population health. It’s a model that collects data from areas to see if that population has a high-risk of developing conditions or diseases. For example, let’s say there is an area in California that is prone to diabetes. The purpose collecting this date is to tackle those higher risk areas to promote healthier lifestyles to reduce these conditions or disease from sky-rocketing. Well, that’s great- however, money speaks. The areas identified as high-risk with diabetes and heart disease might be low-income families, that can’t afford care. It’s also hitting the middle-class now because the cost of living along with paying into health insurance is on the rise and raises are declining.

This is a flawed and fractured system.


Why am I bringing this up?

I was scheduled for my one-year angiogram on the 11th. This has been on the books for almost a year. On the 8th, I received a phone call from the radiology department telling me that my out-of-pocket max is $3,500, They asked if I would like to pay in full now or wait until I check-in on Thursday. I was shocked. Why are you asking for my out-of-pocket max, if my deductible hasn’t been tackled yet, nor my HRA funds? Anger boiled and I lost it because I had a three-day notice. Thankfully, I decided to release my anger in the privacy of my home without the person on the phone. After a moment of cooling down, I called my insurance company and explained my situation and they told me that they can’t do that. They told me when I speak to the radiology department, they need to contact them. For a moment, I felt vindicated with relief. Since business hours were down, I had to wait until the following day, which was the day I was scheduled to get labs and COVID testing for my procedure. First, I called my neurosurgeon office, and they were not happy with the radiology department. Of course, this is out of their hands. So, I call the radiology department again and spoke to another person. I explained to her that I don’t owe money up front and told her to call my insurance company. She took the number and perhaps two minutes later called me back (strange how quick that that went with all the prompts) and said that I still owed the out-of-pocket max and they would refund me if I overpaid after the claim processed. I had two choices 1) Be reactive with anger or 2) negotiate. I decided to go with option 2.


First, I told the employee, that I’m going to make a statement that has no bearing on her, nor am I personally upset with her since she is doing her job. I said I’m upset with the administrators. I had to do this because 1) she was ready to rumble 2) I didn’t want to be the reason she had a bad morning and 3) I didn’t want to be that patient. Well, despite my initial comments she still didn’t budge. I played the card that I dreaded but it was necessary. I said, “okay, go ahead and cancel my appointment. I will get an angiogram if I have another rupture and this occurrence is possible”. This comment was a trigger for the billing department of the potential negligence that could result in negative consequences and litigious impact on them. She immediately said she would call her manager and call me back. Five minutes later, she told me that her manger agreed to $340 up front. I thanked her profusely for reaching out to her manger. At the end of the call, she sympathized with me and said no one has that type of money up front. So, my angiogram is set for March 11th, and I am alleviated because lately I have been overwhelmed causing massive headaches and migraines that echo how I felt last year before my stroke. So, I’m trying to be proactive.


With my personal experience, I want to offer points that can help you:

  1. Expect to pay the full amount after the new Calendar year for your plan at the time of service.

  2. They will call to collect the full payment cognizant that you will be scared that if you don’t pay the procedure will not be done. If you can, it’s a win-win situation. If not, they will give you the perception that there is not an alternative.

  3. They can do a deposit, but won’t offer that until you say no.

  4. The deposit will be high, but that doesn’t mean you have to agree to that deposit.

  5. Learn to negotiate the price, and if needed, play the card of how serious this is and if God forbid something happens, it would suck because money was the wall between you and healthcare.

  6. You will get angry at first but take a deep breath and call the next day.

  7. Speak to the employee with respect because they are doing their job, and if you play your cards right along with a good attitude, you will get far.

  8. Use a patient advocate to investigate and negotiate pricing. There are plenty of groups available, to help people like us in this situation.

  9. If you have time, ask for the CPT procedure codes and price transparency a couple months before your procedure. Call your insurance company and see what the write-off is for the code. Make sure the codes they give you are not a bundled package, meaning they can’t use a certain CPT code to bill because it’s included with another.

  10. Check to make sure the anesthesiologist is in-network. Generally, it’s a team that works together, however for some reason anesthesiologists are not contracted the same as the QHP. This is the element of shock when you receive a bill. Get their tax identification number and ask your insurance company if they are in-network. If not, ask the hospital the cost. At least you will know how much to expect. Of course, this applies if you do your homework ahead of time.

  11. If you are brand new to the stroke world and know that you will have an angiogram in a year, look at your out-of-pocket max and start saving money little by little through the months so you are prepared when the new Calendar year begins money has been reserved. Of course, that’s if the out-of-pocket hasn’t gone up. However, at least you have a good chunk of a deposit. This is something I normally do myself, but I was in battle mode trying to survive and learn the new me so saving for an angiogram the following year was the last thing I thought of. Lesson learned. That’s why I hope publishing this will assist people.

  12. If you feel that insurance or the facility is wrong, you can always submit a claim to the Insurance commissioner to investigate.

Now, you might be advised to find a different place that won’t request the money up front. This sounds favorable, but let’s be honest, many of us want our neurosurgeon to do the procedure because they know our history. Since many of these places are under an umbrella, the physicians stick to the places that fall under the same policy. So, if you are comfortable seeking your procedure somewhere with the chance of someone else doing your procedure then go for it. For me, I am not comfortable, and I feel like I hit the jackpot with my neurosurgeon.


My frustration:

I have worked in the healthcare system going on 18 years on all fronts. I left what I call “boots on the ground” and opted for a career in healthcare technology sector so I could be a part of a company that strives to come up with technology for better outcomes. I made this decision because I was frustrated with the amount of control QHP were under and the patient’s care suffers because of it. Believe me, I loved the QHP that I worked for and I stand that they are some of the bests in the nation- but I could be part of a flawed system anymore and see the frustration on QHP and the patient’s faces. All QHP take a Hippocratic oath to “do no harm” and treat and hold patient’s well-being with integrity. Finances have been the crux for many years.

So, I call us a fractured healthcare system because no one wins. Hospital systems want their money, insurance companies have constraints and the QHP and patients both suffer. I don’t know if you ever catch commercials from healthcare system on TV stating that their bottom line is to serve. I chuckle because I know the truth. Again, I will state from a business model, I understand the financial aspect. There is one hospital system, which I won’t name that has been awarded for being one of the best healthcare systems in the country (not one that I use anymore). They are granted an exorbitant amount of money for research. I admit, they are good for research. Yet, if you have ever been to their hospital or ambulatory facilities, their cost is extreme, and they give you a short time period to pay. I always wonder where all that money goes since, they are given grants to continue their research. Well, the proof is in the constant building they do to expand their hospital. It’s kind of like churches that ask for donations that you believe assist the needy, however five years later they have built a mega church. Fact, we do have one of those up the street from where I live.

The conversation has been brought up if we should follow the rest of the world with Universal Healthcare. It doesn’t hold up because we are capitalist at heart and that takes away competition from private insurers and people making their own decision with a plan the fits them. It seems ideal that we receive the healthcare without worrying about cost. Yet, the pendulum does change because now you have the entire population with healthcare. Here a few takeaways from https://www.thebalance.com/universal-health-care-4156211

Pros:

  • Lowers healthcare costs- which is determined by the government (which scare me).

  • Physicians deal with one agency rather than several insurance companies and their rules.

  • Standard cost means that hospitals and providers are obligated to provide services at a low cost.

  • The government can impose penalties for lifestyle choices such as smoking, drinking and the list can go on. (I personally don’t agree with this because the United States is free will)

Disadvantage:

  • People that are healthy end up paying for the sick population.

  • Removing the worry of medical bills, people may be discouraged from living a healthy lifestyle.

  • This is a big one- if you need an elective procedure, such as knee replacement, you will be waiting in a long line.

  • QHP may remove in-house lab tests and opt to send a basic CBC or UA to an outside lab. These are critical in-house labs because if someone’s RBC and WBC is not WNL, then there is a sign of an infection or something else. Waiting for labs to come back can effectively make or break the outcome of a patient’s care.

Of course, there are several different types of Universal Healthcare Coverage. Many people are passionate that we need to go in that direction, and many are not. Personally, I am against it, especially hearing from other stroke survivors in the UK and the hoops they must jump. I like that I can bypass my primary physician and go to a specialist without their referral.


What the United States needs to do and has attempted several times with failure is to sit down and come up with a comprehensive healthcare enforcement that allows competition with insurance companies, but drive down costs, and give patient’s better price transparency. I’m not sure how this would look, but I have ideas of how it could work, but I’m not able to be heard. The only position that I can do is make people aware of what to expect in our current state.


I want you to know that you do have rights under “Hold patients harmless”.

Here are some links to investigate if you find yourself in jam

https://www.healthsystemtracker.org/brief/an-examination-of-surprise-medical-bills-and-proposals-to-protect-consumers-from-them-3/

https://www.npr.org/sections/health-shots/2020/10/27/926851809/hit-with-an-unexpectedly-high-medical-bill-heres-how-a-savvy-patient-fought-back

Understanding:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495228/

Advocate:

https://patientsrising.org/advocacy-articles/getting-help-with-access-to-treatment/?gclid=CjwKCAiAjp6BBhAIEiwAkO9Wuh65JfzuJEIOYZNQ0JZZMQGkiO85vGyc2dvCZoowFl4a7mn0hC0IYRoCHAwQAvD_BwE

Why patients are more afraid of a healthcare bill than the illness itself:

https://www.cnbc.com/2018/04/22/why-health-care-costs-are-making-consumers-more-afraid-of-medical-bills-than-an-actual-illness.html

Hopefully this article gives some insight with “what to expect”. It’s a slippery slope to write something like this because I know it’s 50/50 on how healthcare should run. I also know that I am in the healthcare industry, but as stated, I moved to the technology side. Full disclosure: not all hospital systems function with these policies. Also, this hospital system that I use is top notch and I have nothing but respect for them. In fact, I don’t really stray away from them. We all have different journeys with medical bills. This is my journey, and I hope if someone is in my same position, this will help you know that you DO have power.

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