The Texas Triple-step: Savvy Mom Saves Big on Medical Bills – Three Times!
Jenni Sisson used my book as a guide to contest upcoding and apply for financial assistance. “Armed with just a little bit of knowledge you can save a lot of money," she said.
Jenni Sisson’s family had a doozy of a year for medical bills in 2021. The Texas mother of four had hernia surgery in March. Then one of her sons got a concussion, followed by another son getting whacked in the eye at a summer camp.
The hernia surgery resulted in a billing dispute because of a mix-up with her insurance plan’s prior authorization. Her insurance plan rejected her physician’s charges of $2,500 and she was fighting the denial. Frustrated, she reached out for help in some online forums and heard about my book, “Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win.”
Jenni writes about personal finance so she took an immediate interest in my how-to guide, which helps people navigate the financial pitfalls of our predatory health care system. Patients can save hundreds or even thousands of dollars – per health care encounter – if they know a few important principles and tactics and have the courage to apply them.
In September, when her 10-year-old daughter Eliza had a bout with appendicitis, Jenni was ready.
Jenni’s married to a wildlife biologist, and the family lives in the Texas panhandle. “We have cows for neighbors,” she told me. When Eliza complained of a painful and relentless stomachache, Jenni took her to a small rural hospital about 30 miles away. The clinicians performed an examination and ran a CT scan to confirm the appendicitis. The appendix had not ruptured, and they didn’t do appendectomies at the facility. Eliza was transferred to Covenant Children’s Hospital in Lubbock, a larger facility, where she underwent a successful appendectomy.
Then came the bills.
I talk a lot about upcoding in my book and my health literacy videos, The Never Pay Pathway, which are based on the book.
Here’s how upcoding works. Medical billers use billing codes to translate the medical records into a claim that can be submitted to an insurance company. In many cases the billing department can choose from a variety of codes to depict the severity and complexity of the case. An emergency room examination, for example, can be coded from level 1, for a straightforward case, to a level 5, for a comprehensive and highly complex case.
The hospital or clinician gets paid more if the case is comprehensive and complicated. Thus, it’s sadly common, whether by accident or on purpose, for billing codes to get goosed, so the code exaggerates the complexity of the case. That’s fraud if it’s done on purpose. It happens all the time and it costs patients and their health plans a lot of money that they should not be paying.
To protect yourself from upcoding, you need to get an itemized bill, with the billing codes. Then you can look up the billing codes to see if they accurately depict the complexity of the case and the level of care received by the patient. (If your hospital or doctor or insurance company won’t give you an itemized bill, I have a solution for you.)
Jenni’s itemized bill from Eliza’s visit to the rural hospital included the code 99285 – that’s for a Level 5 emergency room visit, the most complex. She looked up the code online and saw it was only appropriate in cases where clinicians performed a comprehensive medical history, a comprehensive examination and made medical decisions of high complexity. Level 5 codes are for cases that pose an immediate and severe threat to life or function.
The total tab for the bill came to $4,208. Jenni’s insurance covered $3,742, leaving her on the hook for $465.
Eliza’s case didn’t require complicated medical decision making at the rural hospital. It also wasn’t life threatening. There had been plenty of time to transfer her to Covenant Children’s. It looked like upcoding to Jenni, so she left a message with the billing department. “I’m sure this was unintentional,” Jenni said on the recording.
The next day, someone from the billing department called her back. This doesn’t seem like a Level 5 to me, Jenni said. Level 5 seems like a car crash where someone is missing a limb, she said, or something more severe. In this case it was a full 24 hours from the time of the diagnosis to the operation, she said. Jenni felt a Level 3 would be more appropriate. After some discussion, the billing representative said she would confer with a colleague. A day or so later the billing representative called back, saying they would waive the entire $465.
Jenni was thrilled. “I paid $20 for a book, and I made back $465!” Jenni said to me.
It pays to equip patients to stand up to bogus medical bills. “There’s some homework to be done,” she said of challenging the upcoding. “But if someone were to pay me $465 for those two hours of my time, I would absolutely do it.”
Some people might have quit with the win after the upcoding victory, but Jenni doubled down.
I also teach patients about hospital financial assistance policies in my book and health literacy videos. Nonprofit hospitals are required to provide financial assistance to patients, depending on their income. Many for-profit medical providers also have financial assistance policies. The terms can be generous, so patients should always check to see if they qualify.
Jenni took this tip to heart when the bill came in at $5,034 for Eliza’s surgery at Covenant Children’s. She described her family as middle income, but they do have six in the household and other medical bills. Those extenuating circumstances get considered on financial assistance applications. Jenni applied and weeks later a letter came in the mail from the hospital. It contained good news – $4,279 of the bill had been waived!
So, combined with the waived $465, that’s $4,744 saved on a single health care event! Incredible!
To top it off, months after the financial assistance victory, her disputed hernia surgery bill got cleared by the physician who had been charging her $2,500. She owed nothing.
That’s three Victory Stories for one person. Amazing.
I asked Jenni what advice she would have for others.
“Buy Marshall Allen’s book,” she said. “I tell everybody about it. There are so many different ways to save.”
“Invest in your knowledge,” Jenni added. “If I didn’t know to apply for financial aid it would have cost me more than $4,000. If I didn’t know about medical coding, I wouldn’t have saved $465.”
“Armed with just a little bit of knowledge you can save a lot of money.”
Takeaways
1. Be on the lookout for upcoding. Get your itemized bill, with the billing codes, and check for upcoding. Challenge codes that do not accurately depict the care that was provided.
2. Apply for financial assistance. Don’t count yourself out of financial aid before they do, Jenni said. “I especially encourage big families to apply even if you don’t meet the income threshold,” Jenni said.
3. Try and find the person who will fix your problem. “One thing that kept me going is that there’s a human on the other side of every decision,” Jenni said. “You have to get to the human that can help you.”
Hey employers and brokers!
The employees on your health plan need help navigating the health care system. You could equip them with my engaging health literacy videos, so they’re prepped to save like Jenni Sisson. Check out The Never Pay Pathway at www.allenhealthacademy.com. Let’s get in touch!