Your Money or Your Life
Insured patients are showing up for medical appointments and being told to pay the ENTIRE BILL up front or they won’t get treatment. What should they do?
Before you get into this *very* helpful piece, originally published in Marshall Allen’s Allen Health Academy newsletter, I would like to give a brief introduction to Allen and the incredible work he does to help patients, employers and even a former health insurance executive like me, when it comes to navigating the convoluted U.S. health care system.
Allen is the founder of Allen Health Academy, author of “Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win” and an investigative journalist with a decade-long stint at ProPublica.
I encourage you all to follow Allen’s work and subscribe to his newsletter.
- Wendell Potter
An insured cancer patient showed up for chemo and was told she would have to pony up $14,000 before they’d administer her life-saving medication.
An insured heart surgery patient got turned away when he couldn’t pay the entire cost in cash up front.
A cancer center told an insured brain cancer patient his family would have to pay in full for the initial treatment.
I’m hearing more and more about patients with health insurance arriving for appointments where they are told that they won't be treated until they have paid the full price out-of-pocket — including the insurance plan’s portion — before any claim has been sent to their insurance plan. In other words: pay up now or you don’t get the medical care you need.
“It’s a real ‘your money or your life’ scenario,” said Deb Ault, founder of Ault International Medical Management.
Deb – who is better known as “Nurse Deb” – said her company is hearing from several patients a day who are encountering this problem. The cases above were on her clients’ health plans. In each situation her team found alternatives so the patients could get the care they needed.
It’s happened to my family, too. My wife showed up for a dental appointment and the dentist required her to pay almost $500 – the entire estimated cost – before treatment. Then the dentist submitted the bill to our health plan.
The up front payment demands range in price depending on the service, Deb said. It may be hundreds of dollars for a typical doctor visit, or between $5,000 and $25,000 for a surgery. The medical providers typically don’t demand payment until the patient shows up for the appointment, Deb said, so the patient is under pressure to pay up.
I’ve long said that American health care has a moral problem: it exploits people’s sickness for profit. This is an egregious example. It’s unethical to wait until a patient shows up for an appointment to demand full payment. It’s unreasonable to make the patient front the insurance company’s cost. It’s predatory and blocks patients from getting the care they need.
What’s behind the trend? Dr. Eric Bricker, founder of A Healthcare Z, said the demands are likely motivated by clinicians who haven’t been getting paid by patients and insurers. I’m not surprised they’ve been getting stiffed. Health care is unaffordable to many working Americans. High premiums and deductibles - the amount patients pay before their health plan kicks in – have resulted in more patients being unable to pay. Insurance companies also make it a hassle for clinicians to get paid. I’m sympathetic to their struggles, but demanding insured patients pay the whole cost up front is not the way to go.
Deb said the practice creates extra administrative hassle for the medical providers. They must reconcile what the patient paid up front with the insurance reimbursement, and then repay any overpayment on the back end. She speculates that something sinister is behind the practice. “It almost feels like an adverse selection process,” she said. “As if the clinicians are saying, ‘If you can’t afford health care we don’t want you as a patient.’”
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Are billing departments allowed to do this? In most cases, yes. Clinicians are only required to provide emergency treatment to patients regardless of their ability to pay. If it’s a scheduled or elective appointment, the law doesn’t prohibit demanding payment up front. This is in the realm of fairness, or ethical and equitable business practices. And some providers are taking the low road.
What’s a patient to do in this situation? There’s no universal answer. It depends on the urgency of the treatment and the patient’s financial situation. In the case of my wife’s dental visit, we could afford to pay up front and I knew how to make sure I got reimbursed on the back end. But it became a medical billing battle and we never went to that dentist again. But many patients can’t afford to pay hundreds or thousands of dollars up front. Here are some tips.
How patients can protect themselves
Before your appointment:
Know your health insurance plan. Understand what your plan covers and what it does not. Be clear about your out-of-pocket obligations. Find out if your plan prohibits a billing department demanding full payment up front.
Call your nurse navigator, if you have one. Take advantage of your health plan’s navigation service, if it has one. Experts like Deb and her team protect patients from billing fiascos.
Share your complete health insurance information when you make the appointment. Deb suggests sending a photo of your insurance card so there’s no doubt. Ask whether you need to bring any money to the appointment.
Confirm the financial details in advance with your health plan. Call your health plan and make sure the services are in-network and covered. Know in advance whether you’ll be asked to pay anything up front.
Have a Plan B. Think in advance of alternative places to get the treatment you need, in case there’s a problem. Deb said patients need to be open to changing doctors, even if they’ve been going to the same doctor for a long time.
What to do if your medical provider demands payment in full when you show up:
Walk away (if you can). If it’s not urgent and you can get the care elsewhere, consider canceling the appointment and walking away. That’s the strongest rebuke we can make of these practices. We need to shun medical providers who don’t treat us fairly, and reward the fair ones with our business. This is obviously a hassle and may be impossible, Deb pointed out, because of physician shortages.
Don’t back down. If you’re having a standoff with the billing representative, don’t walk away, Deb said. Stay polite but persist in getting the problem settled. Monopolize as much of their time as possible so you don’t get ignored. Ask for a supervisor. Get your insurance plan on the phone and talk through the issue.
Call your HR person. If you’re on an employer-sponsored plan, call your HR person on the spot and see if they can help. They might be able to enlist your benefits broker for help, or get you connected to some other resource.
Be cautious about entering into a payment plan. If you agree to a payment arrangement it’s hard to get it corrected on the back end, if it’s something unfair, Deb warned.
Be wary of any credit card or loan arrangement offered by the clinician. Deb said more and more medical providers, typically hospitals, are offering credit cards and other loan arrangements. But those can come with exorbitant interest rates that will create more financial bondage in the long run.
Patients and employers should also get educated by reading my book, “Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win.” The book is a guide to protect yourself from the predatory financial practices that are undermining American health care. You may also be interested in The Never Pay Pathway, my health literacy video curriculum that’s based on the book.
Get educated to get empowered.