Caitlyn Mai thought she did every part proper. She known as forward to ensure her insurer would cowl her cochlear implant surgical procedure. She thought every part went based on plan however she nonetheless received a invoice for the complete value 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 it’s best 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 of, Market, the BBC, 99 P.c Invisible, and Reveal, from the Middle for Investigative Reporting.
Credit
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 wakened.
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 nearly all on the right-hand aspect, and he or she couldn’t hear them.
Caitlyn: I used to be like, that’s type of bizarre. So I switched the earbuds and it labored superb. 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 stability — that truly depends on a mechanism inside our ears. Later, docs discovered she had misplaced 87 % of her listening to on the correct aspect.
Caitlyn: They assume I simply had some type of virus that settled in my ear, and it broken my ear. However I went to mattress utterly wholesome the night time earlier than. Awoke, couldn’t hear out of my ear.
Dan: She needed to discover ways to stroll another time.
Caitlyn: I’ve to depend on my eyes. My buddies nonetheless discover it hilarious if I shut my eyes, I fall over.
Dan: That was eighth grade. Caitlyn made it by way of highschool, in Tulsa the place she grew up with out lots of lodging.
Caitlyn: Trigger in center college, early highschool, you don’t wish to deliver 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 plenty of folks: Cochlear implants — small units 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 12 months, Caitlin received her insurance coverage to approve one for her. She had surgical procedure in December to insert the implant. And in January, an audiologist hooked up an exterior part to modify on Caitlin’s right-side listening to.
Caitlyn: She mentioned, okay, sooner or later, 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’m going, sure! It was streaming on to my cochlear implant. And I undoubtedly began tearing up.
Dan: Then, two weeks later, Caitlin received 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, on condition that Caitlyn had gotten her insurance coverage firm’s OK for the process prematurely, was a reasonably large shock. NPR featured Caitlyn’s story lately for a collection they do with our buddies 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 scenario — properly, it was a superb story. And it made me interested by 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 essential colleague and trainer. And the underside line to Caitlyn’s story? Rise up for your self. Don’t cave. Make the following name.
That is An Arm and a Leg — a present about why well being care prices so freaking a lot, and what we are able to 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. For example …
Caitlyn: To show to insurance coverage {that a} listening to support wouldn’t work needed to be fitted for a listening to support after which do a pair hours of testing to show, yep, it doesn’t assist.
Dan: There have been opinions with audiologists, together with her surgeon, and an MRI to ensure 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 one more 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 value cash, and he or she needed to wrangle together with her insurance coverage to get their OK.
However after all 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 proportion 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 may very well be on the hook for in a given calendar 12 months. The surgical procedure received scheduled for December — the identical calendar 12 months as all these checks — and he or she checked to see what she might 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 12 months is round 2,000, give or take, 200 {dollars}.
Dan: She known as the insurance coverage firm to verify 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 the entire particulars of who’s presumably going to be on my case. After which I rotated and I known as insurance coverage and I mentioned, I wish to be certain that all of those physicians are going to be in community on this date.
Dan: Caitlyn had performed her homework. Most likely greater than lots of us would have thought to do. I requested her: How’d you get so diligent? And first, like lots of of us I’ve talked with, she mentioned: Having a serious well being situation 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 keep in mind her operating into points with that.
Can: And she or he’s received some consultants in her life now. Her brother and her sister in regulation work in well being care. Certainly one of her finest buddies is a healthcare lawyer and had some suggestions.
Caitlyn: However actually, I believe 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 hooked up, and listening to on her proper aspect for the primary time in 15 years. Caitlyn says all of it took some getting used to.
Caitlyn: I keep 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 completely different pitches. I wasn’t listening to the phrases and every part, it was simply the breakdown of the completely different pitches. And so they additionally have been simply a lot increased than they need to be.
Dan: So fascinating. Radiolab might have already performed this story — [but] I’m similar 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 scenario, 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 pressured in any respect, I did my due diligence. I do know it’s gonna be costly, however inexpensive.
Dan: Besides, proper: It’s 100 and thirty-nine thousand {dollars}! Six figures. The complete quantity for her surgical procedure. You would possibly keep 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 begin making calls. And she or he says her insurance coverage instructed her they hadn’t paid as a result of the hospital had uncared for to ship one thing essential.
Caitlyn: The itemized invoice. Which has all of the codes and every part,
Dan: Caitlyn says she instantly requested the hospital, in writing to ship her insurance coverage the itemized invoice, and he or she says despatched a follow-up every 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 could have that itemized invoice but? They didn’t. So she known as the hospital once more.
Caitlyn: The woman I spoke with mentioned she was placing in a request to have it faxed to my insurance coverage and that will take two to a few weeks. And I mentioned, maintain on, it takes you two to a few 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, “late.” 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 received extra notices labeled late. She fought her strategy to a direct dialog with a supervisor.
Caitlyn: They saved saying,‘properly, a supervisor’s not out there 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 an extended, lengthy 12 months already.
Dan: Ultimately, Caitlyn received a supervisor on the road and received 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, nearly 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 characteristic they do.
Caitlyn: I used to be like, I simply must vent. And so I submitted it simply to vent it out. By no means anticipating anybody to succeed in out.
Dan: However they did. And on April ninth, Caitlyn received a name from a regional Affected person Service Middle supervisor.
Caitlyn: And she or he was tremendous good and tried to be actually apologetic, however by no means really 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 obtained fee from her insurance coverage. And that Caitlyn may anticipate a remaining invoice inside every 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 truly matches what my insurance coverage mentioned,’ and he or she mentioned,‘oh, you understand 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 complete case.’
Dan: Caitlyn says she received that invoice 4 days later and paid it instantly.
Caitlyn: And I saved the receipt of that, I’ve saved every part. 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 liked the way in which she saved preventing, and in the end took management of the scenario. And I hated how she received trapped between these two massive entities and the way a lot time and stress the entire thing value her.
As a result of, you understand, 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 try this. They simply rotated and billed me. Which was a silly thought, 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 a couple of 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 overlaying healthcare in America. Their senior contributing editor, Elisabeth Rosenthal, reported Caitlyn’s story for KFF and NPR. She wrote a e-book 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 once 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 maintain billing you whereas they’re apparently not even enjoying ball together with your insurance coverage? And: Do we now have any authorized weapons to battle again with?
We requested a bunch of authorized consultants, they usually just about all mentioned: Sure, they in all probability can try this, and no, we in all probability don’t have any simple authorized weapons we are able to battle with. However then I talked with Berneta Haynes. She’s a senior lawyer with the Nationwide Shopper Regulation Middle.
And she or he had some sensible ideas which might be super-worth sharing. She used to work for a nonprofit known as Georgia Watch — that’s a state-level shopper safety group. They operated a hotline folks may name for assist.
Berneta Haynes: Shoppers and sufferers would name us with all types of hospital billing points and medical debt points. And we’ve had these sorts of bizarre questions the place actually, there wasn’t a specific lever on the authorized degree to truly assist them. But when they really feel like they’re experiencing what may very well be thought-about probably an unfair enterprise apply, it’s completely inside their proper to file a criticism inside their state A. G.’s workplace.
Dan: The A.G. The state lawyer basic. Whoever’s doing you unsuitable, you possibly can file a criticism.
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 criticism may be very prone to get that entity, that firm, to behave accurately.
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 liked the specifics that Berneta Haynes shared with me about her personal experiences.
Berneta: I’ll let you know, 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 succeed in out or threaten to succeed in 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 straight.
Dan: Ooh, that’s good!
Berneta: That has been the way in which we’ve gotten decision on all types of points associated to insurance coverage firms not desirous to do proper by us. And so forth.
Dan: In order that was enjoyable. Now, I do wish to speak a bit of bit about what Caitlyn did, and what allowed her to do it. Caitlyn figures she made at the very least a dozen cellphone calls. And she or he says she’s fortunate — privileged — to have a job the place she may try this. Right here’s the very first thing she says she did as soon as she received over that panic assault when the invoice arrived.
Caitlyn: I simply went to my boss’s workplace and I mentioned, I’m going to need to make some cellphone calls. There’s an issue with my hospital invoice. She’s like, don’t fear about it. Do what you must.
Dan: And she or he had folks in her nook, just like the good friend who’s a healthcare lawyer. And authorized recommendation wasn’t the massive factor that good friend gave Caitlyn.
Caitlyn: More often than not I used to be simply venting to her, and he or she was like,‘you must maintain pushing, like, maintain going at them. Don’t allow them to win. Don’t roll over. Simply maintain 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 e-book, giving recommendation to folks. And the title of the e-book 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 children.
Caitlyn: So unhappy.
Dan: Tremendous, tremendous, tremendous unhappy.
Dan: And naturally the title of Marshall’s e-book — By no means Pay the First Invoice — that’s precisely how Caitlyn performed issues. She wasn’t going to consider paying something till she received her questions answered. And it’s value remembering.
After we have been speaking with authorized consultants, one factor a couple of of them mentioned was: If you happen to pay one thing that insurance coverage was imagined to cowl, after which insurance coverage comes by way of, you’re imagined to get a refund. However who needs to chase that?
Yeah. Don’t pay that first invoice till you’ve made certain that is cash you actually owe. So, this looks as if a superb time to memorialize Marshall Allen a bit of 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 e-book had simply come out.
Marshall Allen: What I believe we have to do is stand as much as the bully. We have to cease being afraid. We have to cease pondering another person goes to stay up for us. And I wrote the e-book to equip and empower folks to face as much as the bullies.
And I believe it’s tremendously empowering, but it surely’s onerous, and standing as much as a bully takes unimaginable braveness. It takes fortitude. It takes persistence. You would possibly get beat up within the course of. There’s no assure of victory. It’s dangerous, proper? But when we don’t strive, we don’t have an opportunity.
Dan: Marshall was a Christian minister earlier than he turned 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 folks and exploiting them is unsuitable.
And to me, it looks as if there was a component of ministry– not simply evangelism — to what he did after his e-book 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 folks and I’m saying,‘name me, let’s speak it by way of, let me enable you with this. Let’s work by way of this collectively.’ And now I’m serving to folks work by way of their payments, work by way of these conditions the place they’re being cheated. It’s tremendous satisfying and gratifying, so it’s my new pastime.
Dan: He saved at it. He left ProPublica and took a job with the Workplace of the Inspector Common on the federal division of Well being and Human Companies. And he revealed a publication — it was free, however he inspired folks to pay if they may, and he used the cash to rent medical-bill advocates to assist folks with particularly difficult circumstances.
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 are able to’t afford to pay you. You’re out of luck.’ Nicely, we have been all fairly offended about that. We have been actually offended as a result of they’d opened a sister dinner theater beneath the identical firm umbrella throughout city. And all of us knew that. And we have been like, properly, if you happen to can afford to maintain your different place open, you possibly can afford to pay us. And so they mentioned,‘sorry, children, you’re out of luck.’
Dan: Marshall goes house, tells his mother what’s occurring.
Marshall: And my mother tells me it’s best to sue him. I’m like, mother, what do you imply? I can barely drive. How can I sue the man? She goes,‘it’s best to take him to small claims courtroom.’ So lo and behold, I’m going down, I fill out the paperwork.
It’s a couple of paragraphs. It’s simple to fill out the paperwork in small claims courtroom. 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 circumstances. And I get a discover within the mail like six weeks later. And I’ve a courtroom 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 choose in there. And lo and behold, the proprietor of the corporate and his lawyer needed to present up in courtroom there with me.
And I believed we’d have an enormous argument all the executive choose did is he learn my few paragraphs on the little factor I’d written up and he appears over on the proprietor and he goes,‘is what this child saying true?’And the proprietor’s like, ‘properly, yeah.’ And the choose is like,‘give this child his cash.’ And I used to be like, That is wonderful. You realize what? Perhaps the courtroom system does really work once in a while perhaps once in a while the little man can win.
Dan: Marshall and I each stayed thinking about how folks can use the authorized system to get our rights. I discovered so much from Marshall, and like lots of people, I simply liked his spirit. Marshall Allen, thanks. And right here’s the tip of my dialog with Caitlyn.
Dan: Marshall Allen would have been extraordinarily happy with you.
Caitlyn: Yeah.
Dan: Caitlyn has the ultimate phrase right here.
Caitlyn: I received to the purpose the place I used to be like, it’s my battle. I’ve received gasoline within the hearth. I’m, I’m going for it.
Dan: We’ll be again with a brand new episode in a couple of weeks. Until then, care for 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 due to Christopher Robertson at Boston College’s Faculty of Regulation, Wendy Epstein of the Faculty of Regulation at DePaul College, Sabrina Corlette at Georgetown College’s Middle on Well being Insurance coverage Reforms, and Elisabeth Benjamin from the Neighborhood 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 Periods. 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 unbiased 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 due to the Institute for Nonprofit Information for serving as our fiscal sponsor. They permit us to simply accept tax-exempt donations. You possibly can study extra about INN at INN.org. Lastly, thanks to all people who helps this present financially. You possibly can take part any time at https://armandalegshow.com/help/. Thanks a lot for pitching in if you happen to 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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