Smart Patient

By HanhLinh HT

Did you know that 95 percent of people surveyed by the Kaiser Family Foundation don't have basic health insurance knowledge? This important information isn't taught in school, and the trivial amount of training from employers is not enough. It's no wonder that 57 percent of Americans cited medical debt as

• Language: English
• Publisher: New Degree Press
• Release date: Dec 9, 2020
• ISBN: 9781636761350

Book preview

Introduction

I’m sorry ma’am, your claim has been denied. It looks like there has been a…

No, that’s wrong! yelled the patient, cutting off Fay, the front desk specialist, as she was trying to explain. Not insurance’s fault. I am poor. I have Medicaid. Never been denied. The patient continued with a flushed face and an angry voice that kept getting louder, never mind there were other patients in the same small waiting room.

I quickly went toward the front desk after overhearing the disgruntled customer to see if Fay needed support. The first thought that entered my head was, how could someone be so rude toward our front desk staff? Having been to other medical offices and being a patient myself, I have to say we have a professional and caring team.

I see there was a gap in your insurance coverage, ma’am, said Fay as she tried to inform the patient of what the computer system was showing. I can try emailing our billing department for further explanation.

Fine, said the patient reluctantly, obviously still annoyed. She seemed to be okay with us taking action to ease the situation while stern on not doing anything herself.

I stood behind the service window this entire time, hidden from the patient’s sight, to see how everything would progress. I could see the helpless look in Fay’s eyes as she knew that even if she emailed the billing department, they would give her the same answer the electronic health record (EHR) system did. Nevertheless, Fay knew the patient would feel better if she showed she cared.

After the situation seemed under control, I walked back to my office to keep working on a new design, aimed to make the clinic a safer and more comfortable space. At Fairfax Clinic, I managed the office’s operations, including processing medical claims and optimizing processes. At the time, we were going to hire a new nurse practitioner, which means we needed more room for two providers to work in the same clinic. Despite trying to focus on the unfinished task, I kept thinking about the patient, who looked to be around my mom’s age. I wished she knew only Medicaid, her health insurer, could answer her questions. As a clinic, we didn’t have any decision-making power in determining her effective date.

My first instinct was to judge, thinking the patient probably yelled because she knew we would still be professional to her. A funny thing happens whenever I start judging someone. My mom’s voice always pops in my head. Put yourself in the other person’s shoes, she often said. My internal voice of reason brought me back to the times I was the patient standing on the other side of the counter.

I remembered looking for an optometrist when I was eight months pregnant. My vision had gotten blurry and my eyes became much dryer due to hormonal changes. This caused the shape of my cornea to alter and my tear production to decrease. With that in mind, I was hoping the optometrist could give me some treatment plans or good suggestions to ease the discomfort.

First, I tried looking on ZocDoc, an app that allows patients to book appointments and read reviews, but there were only out-of-network providers. Then, I tried searching on the insurance page, which I had to toggle back and forth between the different sites to look up reviews. Since there was a severe lack of reviews, I finally just gave up and picked a random in-network optometrist close by my house. I called to make an appointment and gave them my vision insurance information to verify eligibility.

When I got to the office, I confirmed my eligibility one more time, verifying whether my eye exam would be covered. After I got a firm yes, I proceeded with the eye exam, which went well. The optometrist concluded that I have about -1 degree in each eye, which could improve after pregnancy. He mentioned that I could pay $100 to measure dry eye severity using this new fancy machine he had. The optometrist insisted the insurance company would reimburse me after I filled out a form at his office. To me, paying up front and hoping for a reimbursement didn’t sound safe. Since I work at a medical clinic, I knew these special diagnosis might not be covered by my insurance. When I insisted I would call the insurance company to check first, I could see the optometrist wasn’t so happy and looked a little annoyed.

May I have the CPT code for the dry eye exam? I asked.

Oh. Sure, said the optometrist with a surprised tone of voice. He proceeded to the front desk and started looking on the computer. It took at least ten minutes to get the code, as if no one had ever asked him that before. Well, no one probably had. I didn’t know there was such a thing as a CPT code until I worked in insurance a few years ago. I will explain those coding and billing nuances later.

There I was, eight months pregnant, feeling heavy and sweating even though it was in the middle of winter. On one hand, I felt tired enough to take a chance and see if I would get reimbursed. On the other hand, I had a baby coming. That $100 could be two months-worth of diapers! I decided to call insurance. I spent the next ten minutes on the phone with customer service, which felt extremely long. The voice-command auto attendant kept saying, I didn’t get that. Please tell us the reason for your call, followed by the pound key. When I finally got to a representative after consistently pressing zero, I was told the dry eye exam would not be covered under my vision insurance. I opted to try lubricant eye drops first before getting the exam.

It’s not only the lack of transparent information about the providers or insurance coverage but also the lack of cooperation between these parties that left me paralyzed in the middle. These gaps were broken bridges that made getting care difficult. If I didn’t question the optometrist’s claim that insurance would reimburse me, I would have been $100 out. That is not a small amount, but it’s not large compared to many stories you will hear about later in the book. If that ten minutes can save me $100, imagine the clarity you can get if you put in time to demand information by knowing where to look and asking the right questions. The business of healthcare is like a minefield where patients can easily fall into traps if they don’t know how to spot potential dangers.

Our healthcare system is fragmented. Just like any industry, there are different players and customer-facing processes as well as back-office administrative works. Those workflows and players interact with their own interests in mind, resulting in the complex system we have today. While it might not be a big deal that other industries are fragmented, healthcare impacts people’s lives, and the lack of integration can mean life and death.

Just in my office, we have an EHR (electronic health record) system, a website for prior authorizations, separate databases for tracing patients’ controlled medication prescriptions in each state, and insurance websites for referring patients. Outside of the clinic, patients deal with a slew of other standalone and disconnected systems, like the pharmacy, health insurance companies, and hospitals. If a patient is hospitalized, bills can come from multiple different providers instead of just one bill from the hospital. To top that off, there are in-network, out-of-network, and all the other insurance mumbo jumbo that makes everything more confusing. Like a torn-up shirt patched up again and again, it’s difficult to trace the source of the problem.

To filter out noise and understand how things work in the simplest way, I follow the money. According to Professor Gary Branning of Rutgers Graduate School of Business, The United States is the only profit-motivated healthcare system in the world.¹ In a profit-motivated system, money represents motivation. As patients, we are in a vulnerable position. We trust our doctors’ expertise and rarely question medical facilities’ charges. Many of us think those in the medical field must be thinking in the patients’ best interest, honoring to do no harm. However, the reality is that the business of healthcare is ugly because business often means profit, and profit can mean outrageous charges and surprise bills. Only through understanding how money changes hands in the system do we know how it works. Once we understand that, we will know what we need to do to navigate through.

The difference between me and the patient in the previous story is I had knowledge about the gaps in our system that she didn’t. I was able to anticipate the problems and confirmed coverage with my insurance before getting care. I did my due diligence to fill the holes before falling into the traps. As patients, it’s important to set our expectations low and put our guards up high. If I didn’t know to ask for CPT codes, I wouldn’t have gotten the answers. Unlike me, some patients might not be able to forgo certain medical treatments even if they are not covered. While there is no magic bullet when it comes to managing healthcare finances, there are techniques and tactics to position yourself well and claim what is rightfully yours.

SO, HOW DID I GET HERE?

It all circles back to about a year and a half ago when I found out I was pregnant. I was uninsured. Yes, you read that right. Uninsured.

I had been working at my husband’s medical clinic, Fairfax Clinic, and decided I didn’t need to have a health insurance plan since I was relatively healthy. I wanted to save the company some money since the clinic runs on a tight margin and everything gets reinvested into the business. Healthy, I was. But in hindsight, it’s always when you think Oh, I don’t need it when you need it the most, like not bringing the umbrella on a rainy day even though it was in your bag for the last three weeks. Something unexpected is bound to happen. The universe works in a funny way.

If you are laughing, I know something similar probably happened to you.

Being uninsured in the US during pregnancy is like knowing a tsunami is coming, trying to run away, but then realizing no matter how fast you are, the tsunami is going to get you. The tsunami of debt could be $10,000, $50,000, or even $100,000. One never knows.

The solution was obvious—get a health insurance plan so at least you get some negotiation power and some coverage!

So I got one for $500 a month on the Marketplace. The plan’s deductible was $2,000, and I can’t remember the rest. All I can tell you is it wasn’t a good insurance plan because it had a high deductible (yes, $2,000 is high for an individual) and didn’t have many in-network obstetrician-gynecologists. I don’t remember other details because, at that time, I didn’t realize how important it was to know them.

My husband is a physician. Naturally, I asked him for good OB-GYN referrals. Every single person he recommended was out-of-network. That’s a pretty telling sign that things were going to be…interesting, for lack of a better word.

Eventually, I was able to get on his health insurance plan, which was far better than my previous. I went from being uninsured, to underinsured, to insured within a span of four months. The formal definition of being underinsured is that the out-of-pocket expenses equals 5 percent to 10 percent or more of income, according to the Commonwealth Fund.² Frankly, that percentage concept doesn’t mean much to me. Let me translate.

For example, if you earn $50,000 a year, paying $2,500 or more from your own pocket for copays, deductible, and other cost-sharing expenses (excluding premiums) would classify you as being underinsured. The insurance would act more like a catastrophic insurance, where one ends up paying a large chunk of cash before getting the coverage.

That was me.

The combination of having that head-spinning experience and seeing the convoluted healthcare system firsthand while working at Fairfax Clinic was enough for me to see two sides of the same coin. As a patient, I felt like I was constantly facing blind spots left and right. As a healthcare administrator, I understood where the blind spots were and why they existed. There were constant aha moments that left me wondering, if people know this is what happens on the other side, they would understand why things are the way they are.

Having experienced different scenarios throughout my pregnancy taught me powerful lessons I hope no one else has to learn. For that, I set out to collect stories from other people’s experiences and put them together in a real, honest, and entertaining book to share with you.

This book is for anyone who has ever felt lost navigating the US healthcare system. You will love this book if you are someone who manages your own or your family’s healthcare finances, whether you are in your teens, twenties, thirties, or sixties. Affording the care you need is as important as making the right clinical decisions for your health. With more than 95 percent of the general population not knowing the basic information about health insurance, you can become the top 5 percent by applying the knowledge shared in this book.³

Remember, you are not alone. By holding this book in your hands you are now part of a powerful community that supports one another, shows each other how to spot questionable practices, avoid traps, and detect inaccuracies to take back what belongs to you.

In the process of writing, I interviewed many patients, industry experts, doctors, and entrepreneurs who told powerful anecdotes about their own experiences in healthcare. They talk about the hidden processes, the things they wish people knew, the struggles they have gone through, and the lessons they want to pass on to others. While not everyone agrees with what American healthcare should be, there is one common diagnosis: the people who took that extra step of due diligence got better care and better deals. Persistence and perseverance pay off. It’s up to us to educate ourselves. What are you waiting for?

The beautiful thing about learning is that nobody can take it away from you.

—B.B. King⁴

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1 Gary Branning and Martha Vater, Healthcare Spending: Plenty of Blame to Go Around, American Health and Drug Benefits 9, no. 8 (2016): 445-447.

2 Sara R. Collins, Herman K. Bhupal, and Michelle M. Doty, Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured, Commonwealth Fund (2019).

3 Health Insurance Quiz, Kaiser Family Foundation, accessed August 22, 2020.

4 Quotable Quote, Goodreads, Inc., accessed October 9, 2020.

Part 1:

The Why

Chapter 1

Stupid Fees

Like the majority of the US population, I didn’t learn how to navigate the healthcare system until I got hit with a dose of reality. My formal education taught me critical thinking and allowed me to build lasting friendships, but never once in those twenty-something years of schooling did I learn about how the US healthcare system