Afford Anything - How to Handle Medical Bills, with Dr. Virgie Bright Ellington

Episode Date: October 12, 2023

#466: The Consumer Financial Protection Bureau reported in 2022 that medical debt is the most common reason to get a debt collector call. A Census Bureau study in 2021 found nearly 1 in 5 households (19%) couldn’t pay for medical care when it was needed. These statistics underscore the fact that the potential for unforeseen medical expenses to negatively impact our lives is ENORMOUS. Dr. Virgie Bright Ellington, a medical billing expert and author of “What Your Doctor Wants You to Know to Crush Medical Debt,” joins us for today’s episode to discuss the thorny topic of medical expenses. The episode begins by acknowledging the widespread and detrimental impact that medical bills can cause, especially in a healthcare system as intricate as the one in the United States. Dr. Ellington emphasizes the importance of proactively addressing medical bills to prevent them from becoming a source of financial stress. She then shares a detailed roadmap that will empower listeners to navigate the complex world of medical bills with confidence, ultimately achieving financial peace of mind in healthcare. For more information, visit the show notes at https://affordanything.com/episode466 Learn more about your ad choices. Visit podcastchoices.com/adchoices

Have you ever received a medical bill that is a lot higher than you imagined? What do you do? Well, in today's episode, we are going to speak with a medical billing expert, Dr. Virgie Bright-Ellington, about how to handle unexpected or unexpectedly high medical bills. Welcome to the Afford Anything podcast, the show that understands you can afford anything, not everything, every choice carries a trade-off, and that applies to every limited resource, such as your money, your time, your time, your focus, your energy. So what matters most and how do we make decisions accordingly? That is what this podcast is here to explore and facilitate. My name is Paula Pant. I am the host of the show. And today we're speaking with Dr. Virgie Bright Ellington, a board certified internal

medicine physician, a former health insurance executive, and an expert in medical billing. She is a two-time cancer patient whose experience as a patient has led her to become the principal of crush medical debt financial wellness, an organization that helps companies and employees navigate medical bills. She is also the chief medical officer of Bright Ellington Medical Associates and a former medical director at Etna. Prior to that, she practiced internal medicine at New York University. She is an alum of the University of Michigan Medical School. Here she is Dr. Virgie Bright Ellington. Hi, Dr. Virgie. Hi, Paula.

So good to be here. I am so happy to have you here. You're very, very passionate about medical debt, specifically medical debt and medical financial literacy. How did you become so passionate about this topic? So, Paula, I've been a board-certified internal medicine physician for longer than I want to admit, like 20-plus years, and I was a health insurance executive for a decade. And so I was a medical billing expert.

I had a complete 360-degree view of how the U.S. healthcare system worked or so I thought until I became a patient and discovered my hospital roommate Mia had been tricked into signing an agreement to pay a bill that I was pretty sure Paula she didn't actually owe, but I was definitely sure was putting her and her entire family into debt for the rest of their lives. and I was just outraged. I mean, true story, I tell this all the time. Literally, I just saw the curtain dropped.

I saw pure red. I was just outraged because I knew she had been tricked into this and it was deliberate. And so I thought, you know what, Virgie, don't get angry. Don't get mad. Get to get and do something. And that's how crushed medical debt was born. There's 100 million meas in the United States. And it doesn't have to be this way.

So that's my mission. this is what we're going to do. Right. Tell us the story of Mia. So she was tricked into paying, it's called a balance bill. Yes, you got it, a balance bill. So Mia had been, she's a young lady. She's mom of two young toddlers. So she can't work outside the home right now because her kids aren't young enough to go to school.

And her husband works at a 24-hour diner. So very modest income, right? Okay. So she was telling me, we were talking and she says, you know, I'm really afraid about the bill that's going to come from this hospital stay. She said she had been in the hospital about a year prior for the same symptoms. And it's unfortunate she had been having symptoms that are concerned about her having like a rare cause of a stroke or something.

So they kept her in that year for like a week. And on her last day, the day she was being discharged, she said a hospital representative came into her hospital room and said, before you can leave, you have to. to sign this. And she said, I didn't know what it was. I have insurance. I don't know why they said I had to sign this, but she said it sounded like they said that I had to sign it because if what my insurance doesn't pay, that I'll pay it.

And that's when it hit me. I'm like, oh, my gosh, they deliberately tricked her into signing a balanced bill. So a balanced bill is when you have insurance and you're in-network provider. So in-network means that they've agreed to have accept whatever the insurance company pays for their services as payment in full. So, for example, I use just to keep the math simple. Let's say that the provider for a certain medical service charges $100. And the insurance company says, well, you know what, Dr. Provider, Dr. Physician, if you want access to millions of patients in your potential patient, for your practice panel, then you're going to accept what we're going to pay you as payment in full.

And that's a contract agreement between the physician or the provider hospitals usually do this, large medical centers, usually not single solo partitioners that we think of historically. But the medical center or the provider practice will say, okay, yeah, we'll agree to that. Balance billing is when they actually send out the bill to the patient and the Bill says, hey, you know, we charge $100 for this service. Your insurance only paid $10. So you are on the hook for the balance, the remaining $90. So these proportions sound really weird and outrageous, but Paula, they're not.

The insurance company only will pay a fraction of what the retail, what I call an MRSP, right? manufacture retail sticker price. It's just a total made-up number. And the higher the number of the provider quotes the insurance company is to try to get more of that fraction that they know they're only going to get. Right. So that's balanced billing. And the reason why patients don't know about it is because a balanced billing disagreement is between the provider and the insurance company. So the insurance company knows that there are providers that will still try to trick patients to believing they know they owe rather the balance, but because the patient isn't aware that they're in the middle of this contract and they are not contracting directly with the provider, and they don't know.

Wow. So what could a person do? Let's say you're in the, actually, I'll go through two potential scenarios. Scenario A, you're in Mia's position in which you're in the hospital, you've been there for a number of days, you've already had services provided, and someone tells you, hey, you can't leave before you sign this. What should a person in that situation do? We'll go over that. And then the next question I'm going to ask is, what do you do if you show up for an appointment? And as part of the intake forms, you see that.

But we'll start with what happens if it comes at the end? Well, if you really want to be snarky, a gentleman showed up for his wife was being discharged from some procedure. And when he arrives, he was told, like Mia was told, before you can leave, you have to sign this. agreement to pay, whatever financial document. And so the gentleman calmly walked to the lobby to the pay phone. So you know how long ago this was. Wow. And he called his sheriff and he said, you know, my wife is being held hostage by this hospital. I need help. Come right now. Wow. So true story. It actually happened. And of course, the sheriff shows up. And, you know, of course, the gentleman was just trying to make a point. Like, what the what? I haven't gotten a bill. I'm not going to

sign an agreement to pay anything. The not snarky answer, Paula, is, no, you don't have to sign anything before you can leave. I mean, if you walked into your grocery store and they said, you know what, Paula, before you can leave, you're going to have to pay for the services you received, okay, but you know what you're getting and you have the bill. They will show you what you're being charged for. They show you the itemized bill. Exactly. They will show you an itemized bill. Right. At a restaurant, they show you an itemized bill. They show you itemized bill. All of the services and or products you receive, right? At a retail store. They show you an itemized bill. Do not agree to pay anything until you get a bill. A real bill. And we'll talk about what a real bill is, a real itemized bill

is later. But yeah. All right. And so what happens, let's say you're going to a, we'll say it's a preventative appointment. You're going to your primary care or to a dermatologist or to an OBGYN. And as Part of the intake, you see a form that says that is essentially a balanced bill. What should a person do in that situation? So what I tell people is two things, two situations. In an emergency situation, you're going to the emergency room. You do not want to be there. You feel like it's life or limb at risk, right?

Life threatening. They cannot deny care if it's an emergency. Right. So when you tell people, if you're in a position where you can actually read something, you may be in pain, you may be fatigued. You know, you don't have to feel that. You have to read it. But if you feel like you want to scan it, meaning the document that they're asking you to sign two things, by the way.

Now, it used to be a piece of paper. Now, post-COVID, it's like they'll show you that sometimes I have a tablet that they hand you or they'll say, hey, just look at this screen and just sign this signature pad that's just connected to the customer service reps desk. No. Right. You don't care how much pain you're in, how tired you are, how many people are behind you, how nasty. how nasty the customer service rep gets, you're going to say, I need a printed copy. I can't sign this. I only sign printed copies. And often you'll get pushed back. They'll say, oh, well, this is just our privacy notices or HIPAA practices or our COVID hygiene practices. Okay, fine. Give me a piece of paper,

print it out, please. Then I'll look at it. When you look at it, you're going to scan through it. If you're not in a position to read it and fully understand it, much most of us aren't even when we're feeling well. You're going to look for a scan through and look for words like responsibility, financial, payment, exit out, and write in, I agree to pay Medicare rates. I agree to treatment and or to pay Medicare rates. Initial it and at the bottom, then sign it. But in an emergency situation, the point is they cannot refuse care. Now, to you, because you don't agree to sign a financial agreement or sign a form. Now, once they get you stabilized, then yes, they can ship you out someplace else, but you have

to get care in an emergency situation. Now, like you said, in the case of if it's routine care, then they absolutely have a right to say, yeah, we want our co-pay up front or if you don't have insurance, we want some kind of payment up front. They can demand that, sure, and you can decide if that's what you want to do. So it's not a balanced bill up front, except if they're saying in that document that you agree to pay fully of what the difference between what they charge and your insurance pays. So if you see something that says you agree to pay what your insurance doesn't, then you're going to have to X that out and write in, you know, initially after the X, initial, make your initials and say, I agree to pay Medicare rates or whatever you feel comfortable. Some people that do this work, Paula, say, well, you know, Medicare is really, really like the lowest retail rate that providers accept.

And, you know, they're saying they're going to go bankrupt if they just take Medicare rates from everyone. There's some data that shows us probably not true. Then I say, okay, fine. A lot of these folks, they'll say two times Medicare rates, they'll agree to pay. Okay. I start with Medicare. Why not start with Medicare rates? Let's go through because there's so much to cover.

We've talked about balance billing, but there's. There's, there is just a lot. Like, as I was reading this, I was terrified by the end. I was like, remind me never to leave this chair so I don't risk rolling an ankle and ending up in bankruptcy. Yes. It's a thing. It's a real thing. In terms of where to start, for those watching on YouTube, here's an itemized bill with CPT codes.

It's incredibly difficult to read. Yep. It's, you know, I mean. And they're accounting on UNAP. being able to read it. So let's talk about that. So let's just talk about it's overwhelming to think that we can check for mistakes. And you know what? We shouldn't have to check for mistakes. But there are things that we can do to make sure that, hey, you know what, either all this bill or I don't. And what you want to do is make sure that you apply three steps of the only right

way to pay every medical bill to any and every medical bill that you get for any medical service. Unfortunately, if you have to end up taking ambulance services, physical therapy, whatever it is, any kind of medical services, dental care, you want to make sure that you apply the three steps. And that step one is that you want to get a real bill, an itemized bill. You hear that all the time when folks are doing this work saying ask for an itemized bill. And this is the thing. Often they're very happy to give you an itemized bill, and that's still not a real bill. A real bill has CPT codes.

CPT codes are to medical services, what products are, or I should say bar codes are. to products in a store, in a retail store. So every medical service you can think of getting the United States, every test, every operation, every ER visit, every outpatient doctor visit, all has its own unique CPT code. And so when you get a bill, unfortunately, nine times out of ten, you're not going to get a bill with CPT codes. It's not a real bill. If it doesn't have CPT codes or if it doesn't say CPT or sometimes it'll say CPT-Sash-P-H-P-P-T-Sash-Pix

H-C-PCS, it's a subtype of CPT code. If it doesn't say that, it's not a real bill. I explain this also, Paula, to let folks know that it is not a mistake. I call it a mistake to be polite, but they're really not mistakes. There are my mistakes if we fall for it. If we pay them, it's a medical bill paying mistake. That is, often you'll see service codes and people think, well, that's the CPT code. No, it isn't. That's something internal to. the provider. We don't know what that represents. The reason why you need CPT codes is because that is currency for care in the United States and Canada, but basically we're talking about the United States. Okay, this is the thing. If insurance companies don't even think about getting a bill from a provider, paying a bill that they get from a provider that doesn't have CPT codes, they don't know what that is. They're like, well, you guys sent us communication, but we don't know what this thing is it doesn't have CPT codes on it, so it's not a claim. A claim is a bill from the provider to the insurance company. So this claim doesn't have CPT codes on it. We never received a claim from you.

If an insurance company doesn't pay for anything that is not a CPT code, you don't know if you're paying for an apple or a cow, right? A CPT code for a cow is different than a CPT code for an apple, right? Right. So an insurance company says if they get something that says, hey, we took care of your member and we provided the service. They're like, okay, and, but doesn't have CPT codes. So why would providers send patients different bills than they send insurance companies, payers? Because we file for it. It works 99% of the time because there is no basic medical financial literacy in the United States.

Wow. So that's the first step. All right. How do you recognize the CPT code? Is it five digits? It's always five digits. All right. So it is five digits.

Usually sometimes it'll be five digits dash two digits or it'll start off with a letter. The thing is also some rarely they will run it as seven digits. It'll be five digits. And instead of the dash in two digits, they'll run it as seven digits, which is why I say, don't worry about the number of digits. Just make sure it says CPT at the top. Okay. So I just want to keep it simple. for us.

Perfect. Perfect. Yeah. So that's the first step in identifying, okay, I'm making sure no mistakes are made.

Okay. So you're going to call or you're going to ask for, and when you look at this bill that you got in the snail mail, open it up, if it doesn't say CPT at the top or CPT slash Hicks

or something at the top, okay. And I don't care if it says service codes. That's still not an itemized bill. It's not an accurate bill. It's not a real bill. If an insurance company

is not going to pay it, then you're not going to pay it either, right? You're going to call up. You're going to call your billing providers or call your provider's billing office and ask for a real bill. Step two, once you get the bill, this is where the money is literally, no pun intended. You're going to take each of those CPT codes and do an internet search. Google what is the description for each of those codes just to make sure.

So like 99213, it represents a type of outpatient procedure or office visit rather. You're going to put that in, you know, just Google. CPT 9213 or CPT code 992.O.3, just CPT 99213 is fine. And you're looking for descriptions of the services that you had. So just make sure it sounds roughly like you had to make sure there's no upcharging like you're not charged for like a humoral fracture intervention as opposed to like an arm sling. Right. We had to go just make sure you're not getting upcharged. And, you know, making sure you're not getting duplicate billed, that kind of thing. You know, mistakes happen.

Also, while you're Googling, Paula, you're going to look for what Medicare pays for each of those services, each of those CPT codes, because Medicare rates are the actual very most fair, the least expensive retail price for services provided in the United States. So that's key. That's what you're actually looking for. So then you're going to take that to step three, and you're going to call back to the the provider because what happens is you're going to think, oh my gosh, you're going to call back the provider and say, yeah, you know, you guys really helped me with my emergency hernia surgery

I needed last month. And you sent me out. The original bill was $10,000 I have here. But in my case, I am willing and able to pay $3,000 because your research with what Medicare pays for that hernia surgery is $3,000 as opposed to $10,000. Now, $3,000 is still a lot of money. So you're going to say, you know what, accidents and emergencies never happen at a great time, right? So there's no way I can stretch my budget. I can't squeeze more than $50 extra out of my budget to pay towards this. Who can I speak with who can help me make a payment plan?

And that payment plan, $50 for $3,000. a lot of folks are thinking, oh my gosh, why would any, they're not going to accept that. It'll take forever literally years, like, yeah, five years to pay it off. And my response is, yeah, and, yes. The reason why it doesn't matter how long it takes. You're asking for an interest-free payment plan directly with the provider because they know that you're coming to them. You're being proactive. They don't have to chase you and maybe have to send it to collections and get only maybe,

at best, pennies on the dollar. And they know that that original number, I call it a fantasy number or wishing number. They're wishing and hoping and praying that you'll call for it. Right. Right. So those are the three steps of the only right way to pay any medical bill that you get. Asking for a CPT code and looking it up in step two, asking for it in step one, looking it up in step two, that takes care of a lot, a majority of the foolishness that are quote unquote mistakes. Right.

Okay. Step one, find the CPT code. Step two. Look it up and find out was it for the right type of service? And if so, what, yeah, does it sound like, yeah, does it sound like you got that service? Does it sound vaguely familiar? Right. And if so, what does Medicare pay for it?

And then call your provider and say, hey, are you willing to bill me at the medical? No, no, no. Great point. Always ask open-ended questions. ask closed-in-a-closed-in-a-closure is something that can be answered with yes or no. So you're going to say, who can I speak with who can help me make a payment plan? Right, but before the payment plan, we first have to get to the Medicare rate. Yeah, well, you don't have to tell them that you did the research.

You know, I don't tell them. I just say, hey, this is what I'm willing and able to pay. Some people do. They'll say, well, you know what? I did my research, and this is what Medicare pays for it, and this is what I can afford to pay. Then they'll say, who can I speak with? But, you know, Paul, I always say, ask, who can I speak with who can help me? If you can't help me, if they give you pushback, who can I help me to make a payment plan? Because, frankly, most of us want to help. And if not, it's because we're not trained, really. Don't give folks the opportunity to tell you no, is my point.

So don't say, can I make a payment plan? No, they will, they look something a payment plan. You just have to let them know that you can't get blood out of a stone and this is what you're able to do. and this is, it is what it is. Right. Right. Okay. That's good to always ask open-ended questions.

Please. Because if you ask the close-ended questions, then they could say no. Oh, exactly. And, you know, if they're having it, they just want to go home and drink their soda and play video games, folks in the front lines doing that. Unfortunately, you know, this is, they don't want to have to do something that's outside of their process. So, of course, the automatic response is no. Right. So every medical bill is negotiated.

Pala, for this reason, because the initial price you're given is just a made-up fantasy number. So, yeah, everything is negotiable. And you want to pay a reasonable rate for what you actually owe. And that's usually the Medicare rate. We'll come back to this episode after this word from our sponsors. The holidays are right around the corner. And if you're hosting, you're going to need to get prepared. Maybe you need bedding, sheets, linens.

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You talk about wrong quantities. It's getting charged for 100 tablets instead of 10. And then correct length of stay and right type of room for any. hospital care. On the surface, these might sound like obvious things to spot, but in the moment, sometimes, you know, double or multiple billing, for example, I mean, any one procedure can have so many subcomponents within it, and any one of those subcomponents might be multiple billed. It's less straightforward than it seems. So how can you really, how can you spot that? Great, great question. So the thing is, that's, that's what you're a lot of,

we need a CPP code. This is a CPT code describes a certain procedure. Like there's a CPT code for hernia surgery, right? There are different parts to some surgeries, but you're only going to pay for one code. You're not going to, that's a great way that providers will try to trick you into paying more. So instead of paying the flat rate, you're paying a la carte itemized. And like I say, you know, there are only mistakes if we fall for it. So I put mistakes, quote unquote, in parentheses, because they know what they're doing.

They're not mistakes. Like, you know, they're only mistakes if we fall for it. If we don't know any better. And that's what they're counting on. They're counting on the average American doesn't have basic medical financial literacy. Like I said, just doing the three steps. You don't have to know fancy anatomical terms or medical terminology. You don't have to be someone who's very quick with words and very assertive or not assertive.

Assertive is good, but not aggressive. People think they have to be aggressive or be in a certain way to be able to negotiate. And what you're doing with the three steps is you're automatically negotiating. Every medical bill is negotiable. And you want to make sure that you're paying the basic fare. And that's usually, that's always in this country, Medicare rates, what Medicare pays for the services. So, yeah, you can get rid of a lot of foolishness. Like I say, a lot of the games that are played.

by like you talked about the upcharge, there's a CPD code for incision and there's a separate CPT code for suturing. Under the umbrella of a CPT code for hernia, if you get a bill and you see, okay, I had hernia surgery, there's a CPT code for that. Okay, I had that surgery. And then you see another CPT code for incision and another CPT code for suture. Well, that's breaking out services. By definition, you can't do a surgery. Right? I can't have a hernia surgery if you don't do the incision and do the suture. That's why you need the three steps. You don't have to know fancy terms. You just have to know what happened. Right? Just generally, does it make sense? Does it make sense? If I had to explain this to my grandma or my five-year-old, you know, but this makes sense.

Oh. So there's a fancy name for that is called incidental. Insurance companies don't pay for that foolishness. Neither should you. Incidental. It is incidental. to the overall, overall procedure, basically integral to during the procedure. You can't do the hernia surgery without doing an incision and a suture. Right. Oh, okay. Yeah. Okay.

So incidental, like, you can kind of think of it then as almost necessary. Necessary to the procedure. Integral, necessary to the procedure. You're not going to bill me separate for something that you needed. If you're going to do, if I trust you to do my hernia surgeon, I'm going to pay you for it. I'm not going to pay you for, if I buy a car. Mm-hmm. I'm not going to pay you separate for.

okay, we're going to break out the seats. Right. You know, that's separate for the seats. It's really nice seats. Yeah. No, we're not going to do that. Right, right, right. Yeah, and if something's optional, like floor mats.

Exactly. Yeah, they'll throw in the... Optional, you know, but the car seats aren't optional to the car. Exactly. Floor seats, yeah. I mean, floor mats are rather. Yes. Yeah, but seats not so much.

Exactly. The seats are necessary. The wheel, the steering wheel is necessary. And I use a car analogy a lot, Paul, Because think about when you take your car to the car doctor, right? The car mechanic, you know, most of us don't know fancy terms, the car mechanic terms. And you don't have to to be able to understand what's in your budget. And if they say, okay, well, the carburetor needs to be fixed.

You know, you need a new carburetor. They'll be like, okay, well, how much is that going to cost? And they'll tell you, well, this and this. Well, this is all I have on my budget. What can we do? And they'll say, you know what? We can get a used carburetor. You know, like we get stuff from junkyards or things like that.

everything is negotiable when it comes to medical bills and you don't have to know fancy terms. If you don't have to know fancy terms to be able to afford your car and the repairs, you don't have to do it for your human body either. Right. Right. Now, what about, so there's a section in here where you talk about medical equipment billing. For somebody like me who is just not familiar with medical equipment, how do you even necessarily recognize the terms of some of these names? Even with the CPT code, you might not know, hey, I've got this stuff.

What's it called? Right. What I would do is call the provider and say, I don't know what this is. That's, frankly, that's what I would do. Never be afraid to ask questions. And you know, I find that the insurance companies, if you're fortunate to have insurance, insurance companies, you would think that they're trying to get you off the phone, you know, call the number of the back of your insurance card, but they're always very helpful, you know,

and say, you know what, I got this bill. I'm a member of your insurance company. And I got this bill from this provider. And it says this CPT code, the CPT code. But what did they send you? Did they send you and your claim? Does your claim with your CPT codes match to what I got? Ask questions.

Wow. So compare notes. Yes. Compare notes with the insurance company. Yeah. So the three step, first step, get a real bill. Second step, take all those CPT codes from the real bill. make sure you find out that, you know, that it sounds like what you got and what Medicare pays for it.

And then you call back and say, okay, this is what I can pay, total it up. While you're waiting for the first step, if you have insurance, I usually tell folks, while you're waiting for that, call your insurance company, say, hey, oh, by the way, did my provider send you a claim, a bill for this date of service? And if they say, no, you're like, okay, yeah, I bet. when you get the bill, the real bill, you're going to call them back and say, yeah, I talk to my insurance company. And this is before you build my insurance company. By law, if you have insurance, the insurance company has to be bill first before you can be expected to pay. Right. If they did say, yes, we got that.

Then you can say, okay, I haven't gotten an EOB or explanation of benefits. And they'll say, okay, they'll mail it to you if you prefer or often is online and they'll direct you online. and just keep them on the phone while you're looking for it. So I can't find it. Can you show me where on the site? And then just go through it with them. You'd be surprised with how help with the insurance companies are if you have insurance. For people who you've seen kind of go down this path, what are some of the places where they get tripped up or what are some of the mistakes they make once they're actively engaged in this process?

I really appreciate that question. People think that the hard part is when you call back the provider in the third step and say, hey, this is what I can. afford to pay. This is, this is what I got. Who can I speak with who can help me make a payment plan or who in your team can help me make a payment plan? But Paul is actually step one, because that's, again, no pun intended, or maybe pun intended, that's where the money is. I'm just shocked at the games that many providers, billing departments have been trained to play to keep you from getting a real bill. The thing is this, the insurance companies have already contracted with, this is what they're going to pay and not a penny more.

for services. And the providers know that if they're going to get the premium money, it's going to be from the patient, either who are cash paying or, or like most of us, we don't have basic medical financial literacy. So we're going to fall into thinking, oh, this is a real bill. This is what we owe. No, it's a balanced bill. No, you don't owe any of it. So do you remember I told you the story about Mia, you know, got me into this work and talking about this issues and this mission to crush medical debt, that very same hospital six months later tried to send me a balance bill for $90,000. Wow. $90,000, yes.

And that's, so my point is, this is a long answer to your question, Paula. They know what they're doing. They're not mistakes. They're only mistakes if we don't know better and we fall for it. I call them medical bill paying mistakes. So 80 to 90 percent of every medical bill in the United States have mistakes, but they're only mistakes we pay for them. They're not really mistakes in the providers part. They know what they're doing. So what did you do when you got the $90,000 balance bill? Great question. I call my best friend,

my lawyer best friend who always yells at me for calling, you know, out. Yeah, the contract lawyer. Yeah. Yeah. For fraud. The one who's always accusing you of asking you for a defamation case. I called her up and I was cracking up. I was dying laughing because I knew I didn't owe any of the money. And she said, you know what, Virchie? You're the only person. I know who's laughing when everybody else would be curled up in a fetal position and a ball crying. And so this is a thing. So I looked at it and I tell people the story because it was like broken up into three

lines. It was for emergency surgery. And what was really cute about it is they didn't have CPT code up at the top. But the first line said, all right, OR services and hospital inpatient services like $365,000. Second line said pathology services and it had five digits. It didn't have CPT code next to it, but I know because of my work. Okay, this is CPT code for pathology services. Right.

$19.95. Wow. Wow. Third line. Insurance last adjustments, $270,000 something dollars. So it left like almost $90,000, which is a $1,000. third line, patient responsibility or patient balance almost $90,000. Jeez.

Yeah. Oh, this is really cute. So they can say, yeah, there's a CPT code in there for the pathology. Whenever you have a surgery and anything is removed from the human body, it needs to get sent to the pathologist to make sure there's nothing hiding in it, that kind of thing, like, you know, malignancy or something. Right. So they charged, whatever, 1995 for the pathology service.

Yeah, there's a CPT code for that. But the whole $365,000. all rolled into one. Wow. We'll come back to the show in just a second, but first. Okay, so you have this bill. Only one procedure has a CPT code, and it's for $19.95. And the rest of it is just, oh, here's $365,000 that you owe for some reason.

What do you do next in terms of actually battling it? So six months earlier I had the, I met Mia, right? So I've already started writing the book. And I said, you know what, this is going to go in the book. This is going to be good. So I call the insurance company just to make sure, just to see what they had to say, what they received, if they got a claim, a bill from the provider and what they were charged. It turns out, they said, yes, we got a bill for that date of service from that provider.

And I said, oh, great, you know, so how much did they charge you? Or what, what was the claim for that CPT code or whatever? I hadn't gotten asking them what, to the point of asking what the CPT codes they received on their claim. I just said, how much were you billed? was the company billed. It was something like almost 90,000, like basically the amount that they were billing me. So remember I said the total number was 365. Right.

And I was left with the balance of almost 90,000. It was like 89 something, something, something. The exact same number was what the insurance company told me they were billed. So they were trying to play both in towards the middle. They're like, well, if we don't get it from the patient, we're definitely going to get it from the insurance company. But maybe we can get more from the patient. This is the way they get down. This is their business model.

So the insurance company wasn't billed that 200 because it wasn't there a line item for like this is the. Yeah, the insurance. They weren't billed for that? So apparently they were billed. So this is the way the system works. You're billed for the services by broken down into CPT codes. The insurance company, I didn't look at the EOB. I didn't ask for the EOB for the CPT codes that the insurance company was billed and what they paid.

The hospital. sent me a total, you know, fake bill that said, okay, the adjustments is like the discount, the amount that the insurance company says that they're contracted to pay. That's what they said, okay, we'll pay that. That's what the insurance company in response to the CPT codes they got in their claim from the provider said, okay, this is the amount we'll pay. Right. So the point is, is that, yes, they know that they're going to get this amount, this $89,000, almost $90,000 from the insurance company.

But they obviously, it's their business model to try to get the same number from the, or trick, the patient of believing they owe that they owe that amount and not the insurance company. Wow. Wow. Crazy. So then what did you do when you reached out to the provider, to the hospital, what did you do? How did you know I call the provider? How did I call the? I had a suspicion.

I had a sneaking suspicion. Just wanted to see what they had to say for themselves, right? So, you know, I, again, you know, I play, I don't like to say dumb, but, you know, I definitely did not let them know that they were trying to put one over on the author of what your doctor wants you know to crush medical debt, right? So I just played like, just, you know, the average patients they're using to put this over on, right? So I called them up to see what they had to say for the book. And I said, yeah, you know, I got this bill, 90,000, you know, almost $89, $89,000, almost $90,000. And yeah, you know, I'm confused. What is this?

And so they're like, yeah, the gentleman who answered the phone said, yeah, yeah, yeah, that's a lot of money. You can't be expected to pay all of that. Can I transfer you to a team member who can help you make a payment plan? That's all they had to say. It's what happened next. So, oh, this is a great story. So about a year later, so I, I, I made a copy of it of the, of the bill, this fake bill and, you know, compile the story for the books.

The book's in printing and publication. But, but I mean, for that, because they're still billing you. They're thinking that you're going to pay. They're probably sending you notices. No. No. No. No.

I swear, Paula. Exactly. There's a story behind this. Okay. So they send me this bill. I laugh. And I don't throw it away. I need to keep this.

documentation, but I was like, this is going to go on the book. I make a copy, put the original away, and the book is in production. It's about a year later, my best friend and I are talking. She was asking about something with, there was a bill that she had gotten from when she had to have a procedure done, and we were talking about that, you know, kind of thing. And she said, you know, by the way, what happened with that bill that you got, that $90,000 bill that you got from the hospital from last year? She said, did you ever pay that? like, no, of course not. She says, you mean you really just totally ignored it? I said, yes. And she said, are you sure like you haven't gotten any like notices or anything like that? I said, no.

And she said, well, how do you know? Like, have you checked your credit report? Right. You got sent to collections. And I was like, who are you talking to? I just refinanced my mortgage last month. I have a 839 FICO score. Like, no. They know that it was a game. They know that I just didn't fall for it. I got one bill. That was the only bill I got.

They know that it's a game. This is their business model. Wow. Yeah. Wow. So I'm trying to figure out what the takeaway from that story is because, you know, it doesn't seem like the takeaway should be just ignore your bills. So that's a great point.

The takeaway that I like to say is you may not owe that medical bill, frankly. And that's why you have to know the three steps of the only right way to pay a bill, right? So we do the three steps. And the balanced bill, that's why I go into a little bit more into the book because there are some, like, I call them five general things and like mistakes that you'll fall for that without basic medical financial literacy that the system, I hate to sound conspiratorial, but the providers who are kind of a little unethical, they know. know it's, they know it's not illegal, but it is immoral and unethical. You know, and they know that many of us will fall for it because we don't have basic medical financial literacy in this country. So in your case, you receive this bill. It only had one very small CBT code on it, or a CB2 code for one very small fraction of the bill. And when you called the provider, you made the

decision not to ask for an itemized bill with CBT codes. And in addition to that, you also made the decision, therefore, not to move to the second step, which would be then researching those codes, finding a fair rate based on that research, and then calling back and saying, this is what I can pay. Those would be in the classic steps, those would be the steps that you follow before you then say, this is what I'm willing to pay. Let's get to a payment plan. In your case, though, you didn't do any of that. You just called them and they were like, yes, we, essentially they said, yes, we expect you to pay it. Yes. And you essentially said, no thanks and hung up. And then that was the end of the story. So, so. Okay. So, yeah, sounds like a big leap. The reason why I was able to say,

okay, thank you very much. You know, I don't need the payment plan discussion right now. Thank you very much. It's because I knew that it was one of the five big mistakes, or quote-unquote, 80 to 90 percent of the problems or mistakes that the providers expect patients to pay. Which mistake was it? It was number five. Which one is?

That is what I call double dealing. So there's number one mistake is being a non-negotiator, meaning not doing the three steps, which has you automatically negotiating. without having to know fancy words and be very aggressive. Number two is a care qualifier. That means if you received your care at a nonprofit hospital, that you are actually by law required to, they are required to give you a financial assistance application.

And even if you have like a huge income, sometimes your medical bill is such a huge amount in a comparison that sometimes is completely wiped off. Number three is that your credit crunch, meaning you put it on a medical credit card or some other credit card. Big, big mistake. Number four is you were dubiously denied,

which means that you have insurance, and the insurance says, oh, no, we're not paying for this. And you think it should have been covered. And so I talk about basically why you want to appeal things that you really think should have been covered. And number five is being double-dealed.

That is the category of balanced billing. Right. And so you recognized this to be a balance bill. Yes, exactly. I actually did ask them just to see what they would do, because I saw that this medical center, this is their business model. So I did call later and say, hey, you know, it was doing writing the book about this case, my case. I said, hey, you know what?

I didn't get a real bill for this particular date of service. And I'm like, oh, well, we don't have that here. And I said, well, yeah, you know, by HIPAA law, I am required to get a copy of a real bill. And they said, well, we can send you to medical records. Maybe they have what you want. I said, no, actually, the same information that you send to the insurance companies, that's what I need. I need a real bill. Now, you can actually, there's a term for it.

It's UB-0-4, UB-0-4 forms for people that don't have insurance or they have health shares where they get reimbursed. Right. So you can ask for UB-O-4 form dash-04 form. But because most of us don't know to ask for a specific UB-04 form, I pretended like, again, that I was the average consumer, the average patient. And I said, so I need something with CPT codes on it. And they said, okay, all right, they didn't end up transferring me to medical records the way she threatened. She was trying to get me off the phone, right, trying to say, no, we don't have it.

And I said, well, can I speak to someone who can help me? So she transferred me to her supervisor, whoever. I didn't ask to speak to the manager or the supervisor. I just said, can I speak with someone who can help me? So she didn't end up sending me to the medical records department. She sent me to a person, I guess, was a manager. And they said, okay, yeah, we'll send you a detailed bill. So, Paula, I get in the mail later, this big, thick thing that it did say detailed bill.

That means nothing. Itemized bill, detailed bill means nothing if there's no CPT codes. And Paula, there were no CPT codes on it. So what should I have done? What do I tell people do in this case? Because that's where you're going to get the most pushback when you ask for a real bill with C-P-T codes. They're not going to give it to you because they know that's where the money is eight to nine times out of 10. That's what we're dealing with.

So what would I do? I call back and I have done this. You know what? As per HIPAA federal law, I'm going to have to file a HIPAA complaint if you can't help me. What's your name again? You know, thank you so much for your help. You know, I call it a battle journal document, the date, time, who you spoke with, and say, well, you know what, I'm going to have to file a HIPAA law if you can't help me get a real bill with CPT codes as per HIPAA federal law. And you have filed HIPAA complaints in the last?

Oh, yeah. Oh, yeah. Is that relatively easy to do? Yes, it is. Somebody who's listening to this, can they go online? Yes. There's a federal office of civil rights. HIPA is a civil right law.

So that's the actual, it's very easy to do. follow the prompts. They use a lot of fancy language like government language, but it's easy to do once you hit the site address URL. Right. Going back to the five big mistakes, you recognize that your bill was mistake number five, which is the balance bill. And mistake number four is dubious denials, those denials in which you are in network, but they're still denying it for whatever reason. And one thing that that I learned, from reading your book is that if you are out of network, or if they claim that you're out of network, even though you are actually a network, if they deny you, you could end up paying more than your annual out-of-pocket maximum,

which is... Anytime they deny you, you're paying more than out-of-pocket maximum. If you have to pay for it, the providers coming after they say, hey, we're out of network. Oh, it sucks to be you, but you still owe that, you know, you should have figured this out before.

It's unfortunate. But unfortunately, there are a lot of providers that's their business model to say, well, we don't participate in any insurance. So all insurances were out of network with. So you're responsible for all of the bill that we decide to charge you. That's where the No Surprises Act came into play. That's why it was created to protect folks from doing all this research to find, for instance, a surgeon who accepts their insurance. but the surgeon's hospital where they do their operation does not.

Your x-ray does not. The pathologist who reads to make sure it's not cancerous doesn't accept they're out of network. And the anesthesiologist is out of network. So that's where the surprise billing act came in to say, hey, if you are in network with insurance, but the facility says, hey, we're out of network. We don't accept anything. You're going to have to pay for it all out of pocket, whatever we're. charge you, that's it. Sucks to be you, right, if you can't afford it. Instead of the patient being in

the middle and holding the bag and having to pay this, now per this as of January 2022, the provider has to, the out-of-network provider has to negotiate directly with the insurance company to get paid, and they have to accept whatever the end network reasonable rate is. Right. And that bill was passed in December of 2020 and then went into effect of January 2020. Exactly. Yes. You remember that. Yes, I do.

I do. Because that was a huge problem. Just like you outlined, you think that you're going to a provider who is a network. And then it turns out that there are all of these subcomponents of whatever you're getting that all have their own separate networks. Well, we are coming to the end of our time. Are there any final takeaways that you want to leave this community with? Yeah. You know, most Americans are just one accident or one serious illness away.

Even those of us with fabulous insurance away from a lifetime of debt or worse. And that's the bad news, Paula. The good news is it doesn't have to be that way. You know, we're on this mission to let folks know, hey, in this country, basic medical financial literacy is not hard. It's not complicated. Don't believe the hype. Don't feel that because you don't have formal education.

or don't understand all these fancy words, it's not necessary. If you can buy a car and if you can afford the repairs with a car, you know how to pay for repairs and keep it in your budget, you can actually save your financial life and your financial future. Wow. All right. Well, thank you so much for spending this time with us. Thank you so much for having me, Paul. You know, I love talking with you. It's been awesome.

Thank you. Thank you. What are three key takeaways that we got from this conversation? Well, each key takeaway is a step that we're going to walk through so that you can correctly understand and address your medical bills. Key takeaway number one, which is also step one, is that the big idea is to understand what it means to get a quote-unquote real bill so that you can analyze the details and look for information that will help you understand specifically what you are being charged

for because if you're not aware of the correct details, you won't know if you're being charged fairly. What you want to do is make sure that you apply three steps of the only right way to pay every medical bill to any and every medical bill that you get for any medical service. Unfortunately, if you have to end up taking ambulance services, physical therapy, whatever it is, any kind of medical services, dental care, you want to make sure that you apply the three steps. And that step one is that you want to get a real bill.

an itemized bill, you hear that all the time when folks are doing this work saying ask for an itemized bill. And this is the thing. Often they're very happy to give you an itemized bill, and that's still not a real bill. A real bill has CPT codes. CPT codes are to medical services, what products are, or I should say bar codes are to products in a store, in a retail store. So every medical service you can think of getting the United States, every test, every operation, every ER visit, every out-pays, every outpatient doctor visit, all has its own unique CPT code. And so when you get a bill, unfortunately, nine times out of ten,

you're not going to get a bill with CPT codes. It's not a real bill. If it doesn't have CPT codes or if it doesn't say CPT or sometimes it'll say CPT slash HixPCS, it's a subtype of CPD code. If it doesn't say that, it's not a real bill. So that is key takeaway slash step number one. Key takeaway number two, or step two, once you have a medical bill with CPT codes, do your research to understand what each of those codes mean so that you know what you're being charged for.

Step two, once you get the bill, this is where the money is literally, no pun intended, you're going to take each of those CPT codes and do an internet search. Google what is the description for each of those codes just to make sure. So like 99213, it represents a type of outpatient procedure or office visit, rather. You're going to put that in, you know, just Google CPT-9213 or CPT code 992-13. Just C-PT-9213 is fine. You're looking for descriptions of the services that you had. So just make sure it sounds roughly like you had to make sure there's no upcharging.

Right. You're not charged for like a humoral fracture intervention as opposed to like an arboral. arm sling. Finally, key takeaway number three, which is step three, is to know exactly what to say when you call your medical provider because it can be intimidating to ask for a significantly lower payment, and it can be difficult to figure out how to make the situation play out in your favor. She offers guidance to show you how to negotiate a lower payment that can be less financially

stressful. Step three, you're going to call back the provider because what happens is you're going to think, oh my gosh, I'll call back the provider and say, you guys really helped me with my emergency hernia surgery needed last month. The original bill was $10,000 I have here, but in my case, I am willing and able to pay $3,000 because your research with what Medicare pays for that hernia surgery is $3,000 as opposed to $10,000. Now, $3,000 is still a lot of money. So you're going to say, you know what, accidents and emergencies never happen at a great time, right? There's no way I can stretch my budget. I can't squeeze more than $50 extra out of my budget to pay

towards this. Who can I speak with who can help me make a payment plan? And that payment plan, $50 for $3,000. A lot of folks are thinking, oh, my gosh, they're not to accept that. It'll take forever literally years, like, yeah, five years to pay it off. And my response is, yeah, And yes. It doesn't matter how long it takes. You're asking for an interest-free payment plan directly with the provider because they know that you're coming to them. You're being proactive.

They don't have to chase you and maybe have to send it to collections and get only maybe at best pennies on the dollar. Those are three key takeaways slash three steps that we learned from this conversation with Dr. Virgie Bright Ellington. Thank you so much for tuning. in. My name is Paula Pant. This is the Afford-Anything podcast. If you enjoyed today's episode,

if you learned from it, if you have any reactions to anything that was said here, please share it with the community. If you are on Spotify, leave a comment. You can do so directly in the app. You can also reach out to me on Instagram at Paula P-A-U-L-A-P-A-N-T. And you can chat with other members of this community at afford-anything.com slash community. Thank you so much for being of this community. My name is Paula Pant. This is the Afford Anything podcast, and I will catch you in the next episode.