Afford Anything - How to Understand Your Medical Bill, with Marshall Allen

Episode Date: October 26, 2021

#345: Let’s talk about one of the biggest expenses you might ever encounter: health care costs. When you get a hospital bill, do you understand it? After all, it looks like it’s written in code (and sometimes it literally is). How do you know if the bill is accurate? Has everything been coded properly? Are you being charged for the services that you actually received? If you need to dispute an item, what’s the process? Pulitzer Prize finalist Marshall Allen joins us to shed light on the complex world of medical billing. He breaks down the “explanation of benefits,” describes a step-by-step process for obtaining your medical records, and explains an actionable plan for how to contest a bill. If you’ve ever felt overwhelmed by the complexity of your health care bills, you’ll learn a lot from this concise, informative episode. Enjoy! For more information, visit the show notes at https://affordanything.com/episode345 Learn more about your ad choices. Visit podcastchoices.com/adchoices

You can afford anything but not everything. Every choice that you make is a trade-off against something else, and that doesn't just apply to your money. That applies to any limited resource that you need to manage, like your time, your focus, your energy, your attention. Any scarce resource presents a set of decisions. And that set of decisions necessitates asking two questions. First, what matters most?

And second, how do you align your decisions? making around that which matters most. Discovering the answers to these two questions is a lifetime practice. And that's what this podcast is here to explore and facilitate. My name is Paula Pan. I am the host of the Afford Anything podcast. And today we're going to talk about one of the biggest bills that all of us over the span of our lifetimes face. Now we know the big three expenses, housing, transportation, and food. Those are for the average American, the three biggest lines. items in our budget. But there's a fourth, and it's medical bills, medical care. This is a complex and confusing world. The average, I don't know whether to use the word consumer or patient,

I'm going to oscillate between the two. The average, you and me, doesn't even know what word to use, doesn't even know how to begin to understand. The complex world of medical billing. And what that means is that oftentimes we don't know how to read billing codes. We don't know how to read an explanation of benefits. We don't know whether or not a bill that we've been sent is even accurate. Is it line itemized? Can we check for errors? Have we accidentally billed and build twice for the same procedure? In order to shed light on this confusing arena and to share practical, actionable, step-by-step tactics, the author Marshall Allen joins us today. He is a Pulitzer Prize finalist and the recipient of Harvard Kennedy School's Goldsmith Prize for investigative reporting.

He teaches investigative reporting at the Craig Newmark Graduate School of Journalism at the City University of New York. And as an investigative journalist, he has spent his career studying the health care system. Prior to becoming a journalist, he spent five years in full-time ministry. His newest book is called Never Pay the First Bill. Here he is, Marshall Allen. Hi, Marshall. Hi, Paula. How are you?

I'm doing great. Thank you. How are you doing today? I am fantastic. Marshall, you spent 15 years as an investigative journalist. In that time, you investigated the healthcare industry, and as part of that, you developed the knowledge to write a book about double-checking the accuracy of the medical bills that you receive and potentially saving thousands or tens of thousands of dollars by, virtue of catching errors or otherwise being more informed in knowing how to navigate the complexities of the medical system as consumers, as patients. Marshall, how much variation is there?

I don't think most people realize just how upside down the finances of the health care industry are and just how many financial pitfalls are in front of them every time they engage with the health care system. For example, different patients are required to pay vastly different amounts depending on the type of insurance coverage they have or depending on the place where they go get the care that they need. For example, you might need to get an MRI or a CT scan or something like that. If you go to a hospital imaging center, that could cost you thousands of dollars for that MRI, whereas if you go to an independent imaging center, it might cost you a few hundred dollars for that MRI.

It's the same MRI. It's the same quality. You're not getting anything better for your money, but you could spend exponentially more depending on where you go or depending on the type of health care coverage that you have. And so the healthcare system has all these secret hidden prices and all these secret hidden negotiated deals. So every time you engage with the health care system, maybe you need a new medication, maybe you need to get an imaging test like an MRI, maybe you need a procedure. The variation in what you pay could be huge. So if you just know that up front, you can avoid overpaying or

getting a massive bill. And then once you get the bills, people don't really realize just how sloppy this billing system is. And so whether it's because of mistakes or because of nefarious intent, never assume that a medical bill is accurate. They're processing millions of bills a day, millions of claims a day. And there are so many mistakes in this system and it is so sloppy that you have got to check the bills and make sure that they're accurate. So I just think this system doesn't work in a way that any other system works that we deal with, consumers. The prices aren't given to us up front. We just have to be informed. I would assume that different facilities have different levels of overhead, which would account

for some of the pricing variation. Is there any way that we, prior to going into an appointment or a procedure, can shop around? Or are there any generalized rules or generalized guidelines as far as the types of facilities that are typically cheaper? Well, so in terms of different levels, of overhead, definitely they're going to have different levels of overhead, but they don't give you the price up front either way. So it's not like you get a price up front and then know that in advance, and then you can actually shop it around. So that is why it's cheaper a lot of times at an independent imaging center because they don't have the same overhead. It's the same reason why an operation, let's say you need a hernia operation, doing that at an independent ambulatory surgical

center as opposed to a hospital is also going to be less expensive. Almost always anything you do outside the hospital, if you can do it outside the hospital, is going to save you a lot of money. You know, for example, one young woman I helped recently with her medical bills, she went to a hospital near her home and she got three stitches in her finger. And they did, you know, they code these emergency room visits by level one to five based on the complexity of the case. Now, in her case, they build it at level three. Well, now because of the federal government requiring hospitals to post their prices online, you can now look on a hospital website, and if they're following the federal rules, they're supposed to post their prices. So in her case, she could see that because

she had United Healthcare, she was being charged $5.5 for that level three emergency room visit. If she would have had Blue Cross, a Blue Cross patient would have paid about $700. If she had Medicare, she would have paid $230. And if she was cash pay, no insurance, she would have paid $256. So it's the same hospital, same doctors or nurses, same facility, same type of treatment. But if you have United Healthcare, your bill comes to $5. If you have Blue Cross, it's around 700. And again, if you have Medicare, it's much less.

and even a cash-paying patient would pay 22 times less than what she was being billed. So the variation isn't just between different facilities or different cases where there's different types of care. You can have the exact same facility with the exact same type of care, and the prices will be exponentially different depending on the type of coverage that you have. Let's look at drugs. So if you need a prescription medication, it's the same drug made by the same manufacturer, but if you go to one pharmacy, it might cost you $100.

If you go to another pharmacy, it might cost you $10. And you don't really realize that the pricing is that, there's that wide of variation in the pricing. Oftentimes, like I have a whole chapter in my book about how you can save money by paying cash and not running things through your insurance. So a lot of insurance plans have a $10 copay that's just the automatic amount that you pay for any prescription. but generic drugs often cost a lot less than $10 to fill the prescription.

It might cost $2. Well, they don't tell you that. They still take your $10. You mentioned earlier that when you receive a bill, you don't necessarily know even if the bill is accurate. There's also a likelihood that you may be able to negotiate that bill down to a lower price. Right. So let's talk about actionable steps.

What should a person do? upon receiving a medical bill? What's the first thing that a person should do? Well, the first thing you should do, again, I called the book, Never Pay the First Bill. Not because you should never pay the first bill. The principle is never pay the first bill until you have checked it to make sure that it's accurate and fairly priced. So the first step you want to take to do that is get an itemized bill. So especially if you go to a hospital, they'll often combine all the charges that were involved in your visit. into one lump sum payment. So it would be like going to the grocery store, throwing all the things in your card,

and they just tell you to pay one lump sum instead of giving you the individual charges for your milk and your meat and your cheese or whatever else you purchased. Obviously, we wouldn't stand for that at a grocery store because you need to get those individual charges so you can see how much each item cost and so you can make sure that those items

that you put in your grocery cart are actually things that you put in your grocery cart. there are a lot of times when hospitals will charge you for things that did not actually happen, whether it's a doctor visit or an examination or a medication. So there are some charges that are just flat out wrong because they didn't happen. And then in other cases, there are charges that are double charges. So they might bill you twice for the same thing. And then you also might have cases like I mentioned before where it's just overpriced,

where you can see that because of your insurance plan or whatever other reason, they billed you way more than a different patient would pay for the exact same thing. You want to make sure you have the billing codes. So I mentioned like with an emergency room visit, there's level one to five codes. It's usually a five-digit code for an outpatient procedure. These are called CPT codes. And they're actually really easy to look up online. You can just Google the five digits with the term.

billing code and it'll pull up a description of the code and so you can see a description of what that code represents so the codes are just a lexicon that's been developed to translate medical records into billing claims that they submit to insurance companies or that they turn into medical bills and then you can also go on now hospital websites so they're required like I said to post their prices online if you can't find it easily because sometimes they make it hard find, you can ask the hospital billing department to show you the prices. They should be able to direct you to them. And if your hospital's not complying, you can go to other hospitals in your community who are complying. Again, that's just to get that fair price comparison to see if what they're

charging you and what they're asking you to pay is comparable to what others are paying. And if it's not fair or if it's inaccurate, then the next step is that you want to contest the bill to the billing department. And so that process really just called a billing department and asked them to correct it. They may or may not be responsive to you. If they're not being responsive, depending on your budget, then you can fight it to whatever degree that you want to fight it. It's also important to make sure your insurance plan has properly processed the bill if you have insurance. Make sure that your insurance company has processed it correctly. A lot of times you'll get sent a bill and it hasn't even been sent to your insurance company yet.

And all you have to do is redirect it and say, actually, you guys need to submit that claim to my insurance company and then it gets taken care of that way. Let's talk a bit more about that because you talk about, in your book, you talk about how to understand your insurance company's explanation of benefits. And I think this is important because a lot of times we see that explanation of benefits and we have no idea what any of these columns actually mean. So I think it would be useful to go through all of that and really walk people through.

All right, what is the information that we're looking at here? None of us have ever been taught to read one. Yeah, it's funny. It is a really important thing to learn. A lot of these medical documents, you know, they seem like they're written in code because some of them literally are written in code. But I try and talk to people about this

as like health care financial literacy. you know, which is a little different. Maybe it's a subcategory just to financial literacy. It seems intimidating at first. And I try and ask people to think back to when they were maybe a teenager or a young adult and they got their first checking account. And they had to balance their checkbook or look at a bank statement and look at their deposits and their withdrawals and make sure everything lined up. You had to learn that skill too to protect the money in your bank account. And this is just in a similar way, it is learning. a new thing. It can be a challenge. And I say that because these explanation of benefits,

they have a lot of categories on them that can be confusing. But they have the same terminology that's required to be used by all insurance companies. So there is a uniformity to them. And if you can learn how to read them, they aren't quite as puzzling as they seem at first. But the first thing it'll have on it is the date. You want to check that, make sure that that's the accurate date and that you actually went for service on that date. They then have a category for what the medical provider build your health plan. And in health care, the build charges are a fictional made-up number, literally, that a hospital or a doctor will use as a starting point for negotiations with insurance plans. So those build charges are not something that a patient should

ever be paying. And an insured patient will then get a discount off of those build charges. And the discount, the billed charges, they might be, again, it's a fictional number. So they might, let's say the service should cost $100. They might say their billed charges are $1,000. So then they can say, we gave you a 90% discount. Again, it's a silly thing to say because they might as well say that it's $100,000. So they can say that you got a much, much bigger discount, you know. How much is billed is going to be that high fictional number?

Then the total cost or the allowed amount is how much your insurance plan says it will allow to be paid for that service. And so just to navigate where we are in the explanation of benefits. So what you've talked about so far is column one is the date. Column two is that bill to charge, the provider charge amount. And then column three is the allowed amount. That's right. That's that negotiated rate that your insurance plan has agreed to pay. And now they have to break down how they're going to pay it.

So they'll have a portion for the plan paid, how much the plan paid. Then they'll have a portion for co-insurance or copayment. Your co-payment is that amount that you have to pay when you first go to the doctor or when you show up at the emergency room, depending on your plan, it'll be a different amount. And your co-insurance is the portion that you share with the health plan to pay that bill. So let's say the total bill came to $1,000. You've already paid your copayment. you've already paid your deductible, which is another category, well, you might have an 80-20 plan

where you have a 20% co-insurance and the plan pays 80%. So if it's a $1,000 bill, the plan would pay $800 and you'd pay $200. Your deductible is the amount of money that you have to pay up front before your health plan pays anything. And so if you have a $1,000 bill but you have a $5,000 deductible, then your health plan isn't going to pay anything in that case. They're just going to have you pay your deductible, so you'll be on the hook for the whole thousand dollars. And over the years, as health care costs have risen, what's happened is that employers have been creating these higher and higher deductible health plans

where your premium, the monthly amount that you pay for your insurance will be lower, but your deductible will be so high that you're actually paying the first $3,000 or $5,000 or even $10,000. in that calendar year. So effectively, if your health care costs stay under 10,000 or under 5,000, you're paying the whole thing. It's really just that you have a catastrophic type of insurance plan for if you spend more than the amount of your deductible. And that's why these high deductible plans have created such problems for many consumers because the bills are so big. And then the plan doesn't pay anything until you've paid that deductible.

Then the last category on your explanation of benefits is your share. And that's really after the insurance company has processed the claim, they have taken the amount out for your deductible, for your co-insurance, for your copayment. And then they say, here's what your share is. So you want to make sure that they processed it properly. And then typically you're going to pay your bill based on the your share category, not based on just the first bill you get in the mail. Right.

So just to review, there's the date, there's the charged amount, there's the allowed amount, there's what the plan paid, there's the co-insurance, there's the deductible, and then there's your share. That's correct. And I encourage people, don't just look at what your health plan pays versus what you pay and say, oh, if my insurance paid it, I'm all good. Because the problem is, because we're shielded a lot of times from the out-of-pocket cost, especially people who have, you know, what you'd call like a rich health benefit plan.

Like, I pay no deductible. My insurance plan pays everything. Well, you're still paying a lot in premiums and your employer is still paying a lot for that health plan. And if you're overpaying or even your insurance plan is overpaying, then your employer has less money to devote to your compensation, your wages. And so one of the big reasons we've had wage stagnation across the United States over the last two decades is because high health care costs are consuming all of the money that our employers give to compensate us. So our compensation comes in the form of wages and health care benefits, maybe retirement benefits, paid time off. Well, that all comes from the same pool of money. It all comes from our compensation. So even if your insurance plan is paying

too much and it's not coming out of your pocket immediately, that's going to cause you to pay higher premiums down the road. And so that's why we've had this steady, steady march of health care costs going up year after year after year. It's because we haven't fully appreciated how even when our health plan covers something, if our health plan covers it at a price that's too high, it's eventually going to be coming out of our pocket in the long run. We'll return to the show in just a moment. Fifth Third Bank's commercial payments are fast and efficient, but they're not just fast and efficient. They're also powered by the latest in payments technology built to evolve with your business. Fifth Third Bank has the big bank muscle to handle payments for businesses of any size.

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Head to Wayfair.com now to shop Wayfair's Black Friday deals for up to 70% off. That's W-A-Y-F-A-I-R.com. Sale ends December 7th. Let's talk about the next actionable steps that a person should take. So one tactic that you mention is to obtain relevant medical records, if necessary. when would such a step be necessary and why? Well, let's go back to the case of the woman who had the level three emergency room visit and she had the $5,800 charge actually negotiated discounted allowable amount for her three stitches

in her finger. So she had cut her finger while cutting an avocado. She goes to the hospital because it's after hours. She can't go to a doctor's office or in urgent care. and they bill her for this level three emergency room visit. Well, she looked up the code online and she could see that in order for a hospital to bill something at a level three,

it actually has to be a moderately complex case. That's not a simple case. I mean, she had a simple case, just stitches in her finger. It should have been a level one emergency room visit, which would have cost a lot less money. But they do what's called upcoding. Upcoding is a common type of,

it's actually fraudulent to upcule. code things, but they use a higher priced code to, they exaggerate the level of care they provided so they can get paid more. And so in her case, they bill it for a level three. And in order to build something for a level three, you can look it up online and you can see what you have to do. You have to do an extended problem focused examination of the patient. She had no examination, because you just had a little slice on her finger. You have to do an extensive medical history of the patient? Well, she had no medical history taken because, again, she just had a little slice on her finger. And you need to have medical decision making of moderate complexity. In her case,

there was nothing complicated about the care that she received. It did not require complex medical decision making. Well, she was able to get her medical records. And this is getting to your question. Every patient has a legal right to their medical records. And it's a good idea to get your records anyway, just so you can see how they're documenting the care you receive. Sometimes there's some crazy stuff written in those medical records, or they might be incorrect and you might want to get them corrected, because that's a record of you and your medical history that's going to get passed around to other doctors and other people who treat you.

In her case, she could see that the medical records classified it. They actually used the word simple to describe the care that she received. That's really important because she was contesting this, this high medical bill. And so when she could show that her medical records documented it as a simple case, which should have been billed at a level one, that bolstered her argument when it came to getting the hospital to reduce her bill. So the medical records are the legal document that describes whatever care you received. And so there's a saying when it comes to medical records, if it's not documented, it didn't happen. And so they should not be billing you. And so they should not be billing

you for anything that does not show up in your medical records. And so that's a way to gather the evidence that you need to successfully contest an unfair or inaccurate or overpriced medical bill. Can you elaborate on the actual act of contesting it? So in a situation in which you've obtained the necessary medical records, and it appears as though you have been inaccurately billed, other than gathering the necessary documentation, as you've just described, what should a person do to actually contest the bill? What are the steps that they would take? What's the process? The starting place is always going to be the billing department for that hospital or that doctor or that dentist. Whoever does their billing, you want to call that person and make your case to them.

And I think it's always good, you know, consider this like a negotiation. everything is kind of negotiable in health care when it comes to prices. There are no set prices. They didn't give you a set price up front. And so you want to be friendly to that billing person. You don't want to start in a hostile way. You want to call the billing department and explain what you've identified in your record, ask questions about it, and ask them to correct it, especially if it's something that didn't happen.

That will hopefully be an easy correction. If it's overpriced, what they'll probably tell you is, well, that's our, contracted rate with your insurance plan, and so you just have to pay it. That's typically the response if it's just something where you're complaining about being charged way more than other patients would pay. You can also call your insurance plan, but I would not expect your insurance plan to take your side. Insurance companies typically treat the hospitals and the doctors like their customers more than they treat their own members. So don't be surprised if your insurance company kind of shrugs their shoulders, even if you've identified an obvious error or even blatant fraud,

insurance companies are pretty passive about protecting our money, unfortunately. So don't expect your insurance company to do too much, but you can try them. Another question you can ask if they're not correcting it is check and see if they have a financial assistance policy. Non-profit hospitals are required by the IRS to have financial assistance policies where they forgive bills up to a certain amount, depending on the income of the patient. And you would be surprised, actually, that even if you have a relatively high income, I've seen discounts that are quite substantial, even for people who make six figures, if that person who makes six figures also has, you know, other financial obligations.

Maybe they have other bills. And so ask them for their financial assistance policy. It's easy to apply. You can fill out the forms often just in a few minutes. you might be required to submit some pay stubs or maybe some tax forms to prove your income, to prove that it's below the threshold. But if you're making up to about 300% of the federal poverty level, those bills might even be completely forgiven, like wiped clean 100%.

So check those out. And if you're having trouble with the financial assistance policies, check out an organization. It's a nonprofit called Dollar 4. that's D-O-L-L-A-R-F-O-R, $1, $1, $1, what they do is help patients enforce financial assistance policies of hospitals all over the country. It's an amazing organization, and they're saving people a ton of money. So be sure you check the financial assistance policies.

And if they still won't, let's say you don't qualify for financial assistance, and they're refusing to correct an unfair bill or an inaccurate bill, and you want to keep fighting it, you can go public, you can tweet to them, call them out on social media, Facebook, or Instagram. That can be effective because marketing people are running those accounts and they might get involved in actually helping address your problem. You can also complain to regulators about something that's going on if you feel like it's blatantly wrong and possibly even fraudulent. Call the state attorney general's office, report fraud, call the state Department of health, which licenses health care facilities, and you can complain to them. You can also

enlist the help of a patient advocate. I especially recommend this if your case is a more complicated case, you know, like this young woman who had the three stitches in her finger, that's an easy one for her to fight on her own. But if you've had a lengthy hospital stay or you've been in the ICU or you have a really complicated type of chronic health care condition, enlisting a patient advocate might be a huge, huge help to you. And so go to the Advoconnect website, and that's just a listing for patient advocates all over the country. Find one in your community, and you will have to pay them a fee, but they might save you tons of money by helping you navigate the complexities of the health care system. You mentioned a patient advocate for people who are listening to this who have

never heard that phrase before, what is a patient advocate and what do they do? A patient advocate is a professional that is paid by patients to help them navigate the health care system and advocate on their behalf. And they can get as involved as you want them to get involved. I mean, I know patient advocates who are paid to sit by the patient's bedside while they're recovering from an operation to make sure that they don't suffer some type of a medication error to make sure that they get the care that they need. A lot of patient advocates will help people with their medical bills. So when they get, you know, hit with a bunch of bills after a lengthy hospital stay, the patient advocate has been doing this for years. They know exactly

how to look at these billing codes. They know exactly how to contest these charges. So they're invaluable. You will have to pay money for their services. But if you have a little bit of a budget, they can do all of these steps that I'm talking about with a lot of experience and a lot of skill navigating the system. And I think they are worth their weight in gold practically because they can be such a help to patients. You just have to be able to afford to hire them. If none of those steps work, what other final options would a person have? You can sue them in small claims court. And I've seen this be extremely successful. our small claims court system exists to protect individuals who are being taken advantage of by

powerful institutions or other powerful individuals. And so the limits are also quite high in some states. In Colorado, where I grew up, the limits are $7,500, which would cover a lot of episodic cases of care. In Texas, the limits are $20,000. In Tennessee, it's $25,000. Where I live in New Jersey now, you can sue for up to $1,000. to $15,000 without needing an attorney. So the limits are actually pretty big. And when you sue, it costs you almost nothing to sue. You don't need to have an attorney. It really costs about

$30 or $40 to file your case. If you've followed the other steps I lay out in my book, you've already gathered the evidence you need to make your case. You have the itemized medical bill. You have your medical records. You can show that you tried to get them to correct this. in fact, before you sue, you want to send them a warning letter. And I have one in my book that you can adapt to your own use. And the warning letter will say, hey, if you don't correct this within 30 days, I'm going to sue you in small claims court. And then once you sue them, usually these cases will be reconciled and settled before you go to court. They don't want to go to court. They have to hire an attorney for hundreds of dollars an hour to defend themselves against a case that might be worth no more

than a few hundred or a few thousand dollars. It's really not worth their while. And so filing that case gives them the incentive they need to come to the table and give you a fair deal or correct a mistake that they've made. We'll come back to this episode after this word from our sponsors. What should a person do if their insurance company denies their claim? Well, unfortunately, that is a common problem that patients have. And if you, if your insurance, company has denied you the care that you need or your child or other loved one, you're in a pretty desperate situation because they're saying that they won't pay for something that could possibly save your life. And so this is a case where it's complicated, but it's probably worth

your while to fight that because you might be put on the hook for huge medical bills or not be able to get the care that you actually need. So the first thing that you want to do is understand what type of health plan are you in. A lot of people don't realize it, but there are two very different types of health insurance plans that employed Americans are in. One is a fully insured plan. And that's what we think of as more traditional insurance. That means you and your employer pay a premium, a monthly payment to an insurance company. And in return, the insurance company takes that money and then pays out for your medication and the care that you need. And if your costs are more than the premium, then the insurance company actually pays whatever it's over that

amount or they have their own insurance policy to pay that. That's a fully insured plan. But actually, most of the 150 million Americans who are in employer-sponsored health plans, most of them are actually in what's called self-funded plans. That means that your employer is bearing the financial risk for your health insurance plan. And they've hired an insurance company to administer the plan. and pay the claims and establish the network of hospitals and other doctors that you need. If you're in a self-funded plan, which again, most working Americans are in a self-funded plan and your insurance plan is denying you care that you need, then your appeal needs to include your employer, not just the insurance company.

So again, if you're in a fully insured plan and they're denying you the care that you need, then your appeal and your battle is going to be with that insurance company. but if you're in a self-funded plan where your employer is funding the plan, then you want to involve your employer in any appeal that you make. It's really important to know that because usually your employer does not want to engage in this with you. And it's an extremely awkward position for an employee to be in where now they have to go to their own employer and advocate for themselves or for their child to get the care that they need and to have the health plan cover the care that they need. need. If you're in an employer-sponsored plan, they can adapt that plan however they want to accommodate their employees. And so do not let them say that they're not allowed to make changes on your behalf. They are. They just are not allowed to show preference to any individual employee

with the types of changes they make. So in other words, if they make a change for one person, they have to accommodate others by making a similar change for them. So they're going to be reticent to do it. And this is why you have to apply some pressure to get this done. And so they're going to tell you to go through their appeal route. Every insurance company has their own process where they say, fill out this form, we'll consider it, and then we'll either approve or will reject your appeal. What then would be the first steps that a person should do? If we break this down into a step by step process, what would be step one? Step one is for the the patient to know what type of health plan they're in. Are they in a fully insured plan or are they

in a self-funded plan? Step two when you're appealing an insurance company denial is do not make your appeal just based on emotion. It's really tempting when you've been denied the care that you need to explain how this is going to ruin your life, how it might actually cause you to die or be extremely sick or cause you to declare bankruptcy because it's so expensive. It's tempting to ring your hands when you make that appeal and plead with them and beg them. Just please, please, please, please. You don't understand how this is hurting me or my family. This is a contractual relationship that your insurance company or your health plan has with you. They have contractually agreed to take your money and in exchange provide you the care that you need. So you need to make your

argument with evidence by examining the relationship they have and by really picking apart the reason why their denial is nonsense and showing why the care that you need is legitimate and why it's not experimental or why it should be covered within the health plan. So try and avoid emotion as much as you can, even though I know it might be difficult, try and just make that appeal based on evidence and facts and arguing about the contractual. their contractual obligation to provide this care to you. So step two is the reasoned evidence-based appeal. Yes.

What is the third step after that? Let's say you make that reasoned appeal and it does not go the way that you wanted it to. What next? Well, the third step to making your appeal is to put this rational argument together in a memo that you don't just send through the route that they direct you to send it through. They're always going to send you to the insurance company and say, submit your appeal, we'll let you know what we say. Send it to your HR director. Send it to the CEO and the CFO of your company.

Bring in outsiders who also might have influence, like say some representative from the attorney general's office or a state senator, somebody with influence, not because they're actually going to read your memo and consider it, but because it will create the perception that they might read it, that they might be involved. Because the truth is, any types of care that a patient needs could be immediately approved by some powerful person within your health plan or with your employer. And so you want to make sure and make this a wide-ranging conversation with a lot of people of influence, including people even outside your organization, to create a sense of pressure that they need to approve this because it's the right thing to do.

If you do need to get your employer involved, you mentioned earlier that employers are often reticent to get involved and they may tell you that they can't make any changes. How can you convince your employer to be on your team? Well, first of all, you always have to realize you could lose your appeal. You know, there's no guarantee that you're going to win. So these are always fights that we have to take on with the hope that we will win. But again, I think it's important to be polite and be friendly and go to the top.

You know, don't be afraid if you've never had a conversation with your CEO or any of the executives in your organization, your life may depend on you getting this care. So now is the time to introduce yourself to them and urge them to please do the right thing by giving you the care that you need. You don't want to just stick with the HR office because HR often doesn't have a lot of power or a lot of influence. in the organization. You really do want to go to the executive level. So I recommend going to the people who have the power to make the decision to give you the care that you need or even a board member if you have a board for your organization. And so in that way, what you just said reflects the same advice that you gave about putting together that comprehensive memo that doesn't go through the traditional appeal channel but goes one step further when you're... That's correct. And even call.

them. You know, don't just send them an email and expect them to take a look at it. Call them and get them on the phone. And if they tell you to call back, call back another time. But make sure that they know the situation, make sure that they're aware of the desperation of the situation, and urge them to do the right thing according to the contractual relationship they have with you by approving the care that you need. What should a person do if they follow all of these steps and yet they don't win, the outcome does not come out in their favor? I mean, you know, it's hard to answer that question because everybody's in such a different circumstance. So it's kind of an impossible question to answer that in a really, really clear

way. I think one of the hard things about this process is that you don't know the outcome until you engage in the conversation. And so you're in a vulnerable position already. even if you've been overbilled or if your insurance company has denied you care that you need, you're in an extremely vulnerable situation. And so you have to have the courage and the vulnerability, frankly, to engage in these conversations and to challenge the status quo. They're going to try and route you down a path that typically has things work out in their favor and not yours.

And we need to have the, conviction and it doesn't mean that we're going to win every time. And if we lose these battles, people might be stuck in debt. They might not get the care they need. They could end up being sicker or possibly even dying, you know, if they're not able to get the care that they need. But it's all the more reason why we need to stand up for ourselves and fight whenever we can because often you can come out on top. And often they will make the decision that's in your favor. they will reduce your bill or they will approve the care that you need. And so we can often win.

It doesn't mean we're always going to win. But if we don't stand up for ourselves to begin with, then we're going to lose every time. Great. Well, thank you so much for spending this time with us. Where can people find you if they would like to know more about you and your work? It's my pleasure to talk to you. People can follow me by going to my website, Marshall Allen.com. And I recommend people subscribe to my newsletter. If you subscribe to the newsletter, you get a free copy of the introduction of my book.

And also, you can stay tuned with other work I'm doing. I'm developing a health literacy video curriculum that's based on the book and explains the principles in the book so that people can easily digest that information in a quick way instead of needing to read the entire book. So I thank you very much for this time and wish the best to your audience. Thank you, Marshall. Now, typically at the end of any interview, we do. key takeaways. As I was thinking through what key takeaways I wanted to discuss for today's

episode, it occurred to me that what's different about today's episode is that most shows that we do, most interviews that we do, are conceptual in nature. So for example, recently we interviewed Ryan Holiday about the concepts of courage, bravery, valor, and how these concepts, particularly when it comes to moral courage, how these concepts apply in our daily lives, in our work, in our families, in our friendships, in the choices that we make around our finances and our careers and the use of our time. And so for an episode like that, each key takeaway is a broad philosophical concept to nibble on, to look at through the multiple lenses of a prism and to see how it may refract into your own life. The conversation that we just had with

Marshall, however, was less conceptual and more procedural. And so rather than standard key takeaways, I thought it might be best to invite you to share your stories and or your fears, your concerns, your questions, your worries about this very topic, about how to fully understand and then proactively handle medical bills that either you are receiving or that you may receive at some point in the future. Often when we think about retirement or just when we think about the future in general, healthcare costs are a big question mark. And part of what makes the topic so hard to predict

is that not only do we not know what our own health challenges will be, 10, 20, 30, 40 years into the future, but we also don't know what the prices associated with those types of health challenges are. And so there's a double unknown. So I'd like you to share your stories, share your thoughts, If you go to afford anything.com slash community, that's where we have a vibrant community

that can discuss all of these topics and offer great peer-to-peer advice. So afford-anything.com slash community is a place to go to continue the discussion that we started here today. You can also share your feedback with me on Instagram. I'm there at Paula P-A-U-L-A, P-A-N-T. That's a wrap for today's episode. on our next episode, Joe Saul-Sehigh, former financial planner, and I, answer questions from two different callers who both want to reach financial independence by age 35, but they both have very different life situations. We tackle each of their questions, plus we talk to a caller who has questions about his pension, a caller who wants to buy a house in cash and doesn't want his name on public record, and a caller who is facing a certain cap that limits how much.

she can sell her home for. We tackle these five questions in our next episode, so make sure that you hit the follow button in whatever app you're using to listen to this podcast, whether it's Apple Podcasts or Spotify or Pandora, hit the follow button so that you don't miss our next episode or any of our awesome upcoming episodes. You can subscribe to the show notes for free at afford anything.com slash show notes, and if you enjoy today's episode, the most important thing you can do, share it with a friend, a family member, a colleague, share it with anyone who you think would benefit from listening to what we have to share in this podcast. You can share it either by forwarding the show notes or by sending a link to the episode at afford anything.com slash episode three, four, five. That's afford anything.com

slash episode three, four, five. Thanks so much for being part of this community. My name is Paula Pant. This is the Afford Anything podcast, and I will catch you in the next episode. episode.