Caitlyn Mai thought she did every thing proper. She known as forward to verify her insurer would cowl her cochlear implant surgical procedure. She thought every thing went based on 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 you need 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 “Invoice of the Month” collection, 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 Middle for Investigative Reporting.
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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 awakened.
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 away from bed and prepare. And I seen 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 facet, and she or he couldn’t hear them.
Caitlyn: I used to be like, that’s type of bizarre. So I switched the earbuds and it labored tremendous. 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 away from 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 may barely stroll in any respect. She had no sense of steadiness — that really depends on a mechanism inside our ears. Later, docs discovered she had misplaced 87 p.c of her listening to on the proper facet.
Caitlyn: They suppose I simply had some form of virus that settled in my ear, and it broken my ear. However I went to mattress fully wholesome the evening earlier than. Wakened, couldn’t hear out of my ear.
Dan: She needed to learn to stroll over again.
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 highschool, in Tulsa the place she grew up with out lots of lodging.
Caitlyn: Trigger in center faculty, early highschool, you don’t wish to carry consideration to your incapacity. At the very least I actually didn’t wish 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 software that helps restore listening to for many individuals: 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 yr, 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 part to change on Caitlin’s right-side listening to.
Caitlyn: She mentioned, okay, in some unspecified time in the future, 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 just lately for a collection they do with our friends at KFF Well being Information.
NPR HOST: Time now for the newest installment in our invoice of the month collection, 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 state of affairs — properly, it was a very good story. And it made me interested in 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 necessary colleague and trainer. And the underside line to Caitlyn’s story? Get 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 will 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 crucial 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 lots 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 critiques with audiologists, together 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 an additional 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 considered one of these preliminary steps price cash, and she or he needed to wrangle together with her insurance coverage to get their OK.
However in fact even together 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 might be on the hook for in a given calendar yr. The surgical procedure acquired scheduled for December — the identical calendar yr as all these exams — and she or he 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 yr 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 probably going to be on my case. After which I rotated and I known as insurance coverage and I mentioned, I wish to be sure all of those physicians are going to be in community on this date.
Dan: Caitlyn had achieved her homework. In all probability greater than lots of us would have thought to do. I requested her: How’d you get so diligent? And first, like lots of people I’ve talked with, she mentioned: Having a serious well being challenge as a child — shedding her listening to — gave her an early heads-up to be careful.
Caitlyn: Slightly bit was, uh, expertise of my mother coping with insurance coverage battles with me rising up. I bear in mind her operating into points with that.
Can: And he or she’s acquired some specialists in her life now. Her brother and her sister in legislation work in well being care. Considered one of her greatest pals is a healthcare lawyer and had some suggestions.
Caitlyn: However actually, I feel lots of it’s I’ve nervousness, 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 part connected, and listening to on her proper facet for the primary time in 15 years. Caitlyn says all of it took some getting used to.
Caitlyn: I bear in mind these, like, first few days particularly, it wasn’t actually like I used to be listening to full sounds. It was type of simply totally different pitches. I wasn’t listening to the phrases and every thing, it was simply the breakdown of the totally different pitches. And so they additionally have been simply a lot larger than they need to be.
Dan: So fascinating. Radiolab might have already achieved this story — [but] I’m identical to, let’s discover out what that’s about.
Caitlyn: I really like Radiolab.
Dan: Me too! Anyway, two weeks after she begins getting used to her new listening to state of affairs, 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 burdened in any respect, I did my due diligence. I do know it’s gonna be costly, however reasonably priced.
Dan: Besides, proper: It’s 100 and thirty-nine thousand {dollars}! Six figures. The complete quantity for her surgical procedure. You may bear 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 start out 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 necessary.
Caitlyn: The itemized invoice. Which has all of the codes and every thing,
Dan: Caitlyn says she instantly requested the hospital, in writing to ship her insurance coverage the itemized invoice, and she or he says despatched a follow-up per week later. However her cellphone saved pinging with alerts about owing the hospital 100 and thirty-nine thousand {dollars}.
Caitlyn: The app so conveniently instructed me that I may 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 may have 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 3 weeks. And I mentioned, maintain on, it takes you two to 3 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, “overdue.” 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 rotated and faxed it to my insurance coverage.
Dan: Yeah however, this didn’t finish issues, not but. Caitlyn says she acquired extra notices labeled overdue. She fought her method to a direct dialog with a supervisor.
Caitlyn: They saved 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 brief. I’m speaking to a supervisor proper now. I don’t care if I sound like a Karen. It’s been a protracted, lengthy yr already.
Dan: Ultimately, 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 function 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 Middle 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 in your frustration, that sounds terrible.’
Dan: She DID inform Caitlyn that the hospital had acquired fee from her insurance coverage. And that Caitlyn may anticipate a remaining 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 she or he 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 whole 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 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 saved combating, and finally took management of the state of affairs. And I hated how she acquired trapped between these two massive entities and the way a lot time and stress the entire thing price her.
As a result of, you realize, the hospital may’ve resolved this so shortly by simply sending that itemized invoice to Caitlyn’s insurance coverage firm.
Caitlyn: And the hospital didn’t do this. They simply rotated and billed me. Which was a silly concept, for the reason that 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 lots of themes we’ve touched on earlier than. We dug in additionally discovered some new suggestions, and a few reminiscences I wish to share. That’s coming proper up.
This episode of An Arm and a Leg is a co-production of Public Street Productions and KFF Well being Information, a nonprofit newsroom protecting healthcare in America. Their senior contributing editor, Elisabeth Rosenthal, reported Caitlyn’s story for KFF and NPR. She wrote a guide 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 hold billing you whereas they’re apparently not even taking part in ball along with your insurance coverage? And: Do we’ve any authorized weapons to struggle again with?
We requested a bunch of authorized specialists, they usually just about all mentioned: Sure, they most likely can do this, and no, we most likely don’t have any straightforward authorized weapons we will struggle with. However then I talked with Berneta Haynes. She’s a senior legal professional with the Nationwide Client Legislation Middle.
And he or she had some sensible ideas which can be super-worth sharing. She used to work for a nonprofit known as Georgia Watch — that’s a state-level client safety group. They operated a hotline individuals may name for assist.
Berneta Haynes: Shoppers 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 selected lever on the authorized degree to really assist them. But when they really feel like they’re experiencing what might be thought of probably an unfair enterprise observe, it’s completely inside their proper to file a grievance inside their state A. G.’s workplace.
Dan: The A.G. The state legal professional common. Whoever’s doing you unsuitable, you possibly can file a grievance.
Berneta: Whether or not or not there’s any actual hook that your AG may 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 grievance 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 numerous 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 wish to discuss slightly bit about what Caitlyn did, and what allowed her to do it. Caitlyn figures she made not less than a dozen cellphone calls. And he or she says she’s fortunate — privileged — to have a job the place she may do 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 it’s essential.
Dan: And he or she had individuals in her nook, just like the buddy who’s a healthcare lawyer. And authorized recommendation wasn’t the large factor that buddy gave Caitlyn.
Caitlyn: More often than not I used to be simply venting to her, and she or he was like,‘it’s essential hold pushing, like, hold going at them. Don’t allow them to win. Don’t roll over. Simply hold pushing. They need to be paying.’
Dan: And at that time, I instructed Caitlyn, she and her story have 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 guide, giving recommendation to individuals. And the title of the guide 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 youngsters.
Caitlyn: So unhappy.
Dan: Tremendous, tremendous, tremendous unhappy.
Dan: And naturally the title of Marshall’s guide — 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 have been speaking with authorized specialists, one factor just a few of them mentioned was: Should you pay one thing that insurance coverage was purported to cowl, after which insurance coverage comes by, you’re purported 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 like a very good time to memorialize Marshall Allen slightly bit. He appreciated to check the healthcare system to a schoolyard bully. Right here’s what he instructed me when he was on this present in 2021 when his guide 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 guide to equip and empower individuals to face as much as the bullies.
And I feel it’s tremendously empowering, but it surely’s arduous, 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 attempt, 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 along with his religion. The gist was: The Bible is fairly clear that dishonest individuals and exploiting them is unsuitable.
And to me, it looks like there was a component of ministry– not simply evangelism — to what he did after his guide 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 individuals and I’m saying,‘name me, let’s discuss it by, let me assist you to with this. Let’s work by this collectively.’ And now I’m serving to individuals work by their payments, work by these conditions the place they’re being cheated. It’s tremendous satisfying and gratifying, so it’s my new interest.
Dan: He saved at it. He left ProPublica and took a job with the Workplace of the Inspector Normal on the federal division of Well being and Human Providers. And he revealed a publication — it was free, however he inspired individuals to pay if they might, and he used the cash to rent medical-bill advocates to assist individuals with particularly tough instances.
And Marshall was humorous. I wish to shut out this episode with a narrative he instructed me the primary time we talked, in 2019. It’s type 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, they usually’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 will’t afford to pay you. You’re out of luck.’ Properly, we have been all fairly offended about that. We have been actually offended as a result of that they had opened a sister dinner theater beneath the identical firm umbrella throughout city. And all of us knew that. And we have been like, properly, for those who can afford to maintain your different place open, you possibly can afford to pay us. And so they mentioned,‘sorry, youngsters, you’re out of luck.’
Dan: Marshall goes dwelling, tells his mother what’s happening.
Marshall: And my mother tells me you need to sue him. I’m like, mother, what do you imply? I can barely drive. How can I sue the man? She goes,‘you need to take him to small claims court docket.’ 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 court docket. 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 considered one of these instances. And I get a discover within the mail like six weeks later. And I’ve a court docket date, and I’m like equipped for this massive 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 decide in there. And lo and behold, the proprietor of the corporate and his legal professional needed to present up in court docket there with me.
And I assumed we’d have an enormous argument all the executive decide did is he learn my few paragraphs on the little factor I’d written up and he appears to be like over on the proprietor and he goes,‘is what this child saying true?’And the proprietor’s like, ‘properly, yeah.’ And the decide is like,‘give this child his cash.’ And I used to be like, That is superb. what? Possibly the court docket system does truly work now and again perhaps now and again the little man can win.
Dan: Marshall and I each stayed thinking about how individuals can use the authorized system to get our rights. I realized so much from Marshall, and like lots of people, I simply beloved his spirit. Marshall Allen, thanks. And right here’s the top 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 struggle. I’ve acquired gasoline within the fireplace. 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 because of Christopher Robertson at Boston College’s College of Legislation, Wendy Epstein of the School of Legislation at DePaul College, Sabrina Corlette at Georgetown College’s Middle 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 Classes. 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 impartial 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 just accept tax-exempt donations. You may be taught extra about INN at INN.org. Lastly, thanks to everyone who helps this present financially. You may take part any time at https://armandalegshow.com/help/. Thanks a lot for pitching in for those who can — and, thanks for listening.
“An Arm and a Leg” is a co-production of KFF Well being Information and Public Street Productions.
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