(or How to Financially Advocate for Yourself Without Going Totally Crazy)

FRUSTRATING! I am sure most of you have had difficulties dealing not only with your insurance company, but also your doctor’s office, the hospital and their doctors. I am going to try to help you out here with what I have learned and how I am dealing with all those different entities. I will try to keep it clear and easy. You may contact me for more detailed explanations and understanding for why I do what I do. [See comment section at the end of this blog]. There are many layers to this, and it looks like I will have to do it in a multi-part blog. This blog entry may or may not pertain to those of you on Medicare, but I would still check it out.

I have Blue Cross/Blue Shield administered by Anthem. It is my wife’s insurance, and I am the dependent. (Our insurance does not care too much; I am covered). Anthem does not care if I call in, but some companies do care if you are the primary or the dependent. My coverage will be different from yours unless you were a school office worker at Los Angeles Unified School District. Now that my wife is retired, it falls under the California Public Employees Retirement System (CALPERS).

Here are the most important items:

  1. Make sure you have the phone number to your insurance carrier for any and all questions. Know their hours of operation and where in the country they are located. Their time zone may be different than yours. This goes for any and all the companies you call.
  2. Keep all copies of your Explanation Of Benefits (EOB). Organize them by DATE OF SERVICE, not date of invoice!  If we have multiple service dates on the EOB, we make copies and organize only by one service date per sheet.
  3. Keep all of your medical provider (doctors, labs, tests, etc.) invoices.
  4. Match the provider’s invoice with the EOB.
  5. See if the provider’s invoice charges matches the EOB. Things to look for: was the provider in network or out of network? Why are they out of network? (More on that later).
  6. Try to make arrangements with that provider to pay any large amounts as monthly payments. Typically, there should be no interest on those monthly bills.
  7. Have a notepad to write down the notes on all of your phone calls. Get the name of the person you talked to, the time and date of the call, and the gist of the conversation.
As you go to the hospital for a procedure, there will be many different people involved: surgeon, anesthesiologist, nurses, and hospital administration staff. Here is an example of what happened to me: I was approved for a lymph node biopsy. Great. My surgeon called it in and got it approved. No problem, right? WRONG. The insurance company had not approved the anesthesiologist and wanted me to pay the costs for an out-of-network provider. This is much more costly to me, the patient. I had to appeal it.

The appeal was denied. I then started the next step—processing the appeal to the next higher authority: the state of California. When the insurance company found out that I was appealing it to the state of California, they called me and offered to settle for an in-network payment. My appeal was based on the fact that I have no control over the anesthesiologist. I had only met her the day of my biopsy. It is not my job to confirm the whole surgical team is approved and in-network. I only have control over the surgeon and the hospital. Anthem told me, “Yes,” it is my job to confirm that every member of the surgical team is approved through Anthem, although they still pay in-network benefits.

One of the main insurance issues that financially complicate things for the patient is that the doctors are usually not employees of the hospital. So for my lymph node biopsy, we received approximately eight bills: surgeon, anesthesiologist, hospital (two bills); surgical department, the general admin of the hospital, and the lab for the biopsy. Also, don’t forget all the pre-surgical tests like X-ray and labs (usually two or three of those).

Keeping you informed on financial solutions for your healthcare,

Eliot Finkelstein

Stay tuned for Eliot’s next installment of advice and self-advocacy. If you have any questions you would like to direct to Eliot, please use the comment section below.