The Health Insurance Industry
On a recent episode of our Lawgitimate Podcast, we talked about the fun world of healthcare, health insurance, and everything related to that industry. Our featured guest was Kristine Kassel, owner of Benefits by Design, a health insurance and employee benefits agency located in Tempe, Arizona.
Benefits by Design
Kristine is a native in Tempe and yes, our offices are just down the street from each other. She loves Tempe, and always tries to be involved. We found each other through the Tempe Chamber, which she has been very involved with. It has been very successful for Kristine’s business.
Benefits by Design helps employers find the perfect medical, dental, vision, life, disability, and other types of benefit plans to keep their employees happy. She also helps provide competitive prices and benefits that everybody desires within the firm for all of the employees. And they don’t only just stop there with finding that plan, Benefits by Design helps service it. They work with small businesses and are like an extension of the HR department, which with those of us that have small businesses, we don’t typically have an HR person until maybe we get about 30 employees.
So Kristine and her team tend to be that until you grow and you get an HR person. They can help out your employees with anything from claims, benefits, questions on doctors, billing issues, and ongoing things throughout the year. Benefits by Design has been in business 22 years and a very active part of the community.
Especially now, in the world, the healthcare industry is such a hot topic. A lot of people are really concerned about what healthcare is going to look like in the future, what all the changes are going to be if there are going to be any, and healthcare, in general, the number one concern is usually cost.
For most people, if they’re self-employed, one of the biggest hurdles they see is unaffordable healthcare coverage. And that’s what leads to employers offering group coverage and group benefit packages because it’s substantially cheaper. And here in Arizona, we typically don’t have that great of an individual market if you are employed, or just working for a company that doesn’t offer insurance. All the plans that are out there are HMO type plans. You’re very restricted to the doctors that you go to and hospitals, or else you can get some of these MedShare plans which might not have as much thorough coverage as you would want. They are also more expensive, which you find odd, but there are a few people that can get a subsidy on those plans if their income is of a lower level. But outside of that, your average worker would not be eligible for those subsidies. That is where the group plans definitely can be better and you’ll have more selection of PPO plans, HSAs, lower deductibles.
I remember when I was first starting our law firm, we did not have enough people involved to get a group plan, and this was when ACA was fairly new. And I went out looking for a plan that I could buy as private insurance to meet my needs. I was a mostly healthy young person, but I had recently been dealing with a pretty serious kidney stone issue. So I thought there was a good chance I might have some real health care expenses coming up and I wanted the best insurance I could get. Completely disappointing selection of plans. There was hardly anything I could buy that would actually cover my needs and really provide top quality affordable care. It just wasn’t available.
Today we do have some more choices. Price is still a problem and smaller businesses are ones that are hit harder. When you have a couple of employees, you’re just based on the age of those employees. They don’t rate on health anymore, which is good. But really your rates can be substantial until you get a lot of employees that balances out with young people, older people then the rates tend to get a little bit better. But you have more selection now than you did when it first came out.
Health Insurance Terminology
So let’s go back to vocabulary. You hear PPO, HSA, and all of the fun terminology. Let’s just run through that real quick. What is an HMO policy?
HMO stands for Health Maintenance Organization. Between me and you, basically the difference between an HMO and a PPO is you typically have to get referrals, and you have to stay in-network with your plan, you cannot go to an outside provider. Let’s say you wanted to go to Mayo Clinic for something serious that wasn’t on the plan. You just can’t go. You’ll have to pay 100% of it if you did go, unless it’s an emergency. If it’s an emergency, you can go out of network.
A PPO plan allows you to go in and out-of-network. You typically pay more if you go out of network and you don’t have to have a referral. Which is nice, you’re saving the time going to one doctor appointment directly to the specialist instead of going to your general practice doctor and get referred to a specialist. It stands for a Preferred Provider Organization. Most of us like the PPOs. HMOs were a big deal back in the day. You had like zero copays, $10 copays, which isn’t around anymore. And so people think they typically like the HMOs, and then I think people got spoiled wanting their own doctors. Now, HMOs aren’t even really an option or that much of a savings.
That’s what you’re seeing on the individual side. If you are a sole provider, that’s all you can have in the marketplace, is an HMO plan. POS is another one, which is Point of Service, it really is like a PPO. So don’t even worry about that one. HSA, Health Savings Account, that’s a really awesome one if you know how to use it. It doesn’t work for everybody. But as an employer, it’s something that you can contribute money to a savings plan for your employees pretax, and your employee could also contribute money pretax. And if you ever leave that firm, if you are an employee, that money that you’re putting into the savings account is yours to keep. But nowadays the premiums are so expensive. People definitely don’t have a lot of money to put away into an extra savings account to plan for that. So it really works when the employer possibly gives to the savings account. Because not alone, you have the savings account, but you also have the part that you have to pay for the premium just like you would if it was a PPO or an HMO.
So Many Options
There are so many different healthcare options. I think one of the biggest problems that we see is dealing with health insurance and people not really understanding how to navigate that when they’ve got their card. You call, you make a doctor’s appointment and they ask, “What kind of insurance do you have?” “I don’t know, United, Blue Cross.” “Okay, cool. We accept that.” And you get there and it’s like, “Oh, just kidding. No, you’re out of network.”
We all have, right? I’ve probably just seen it maybe a couple of hundred times in the last year or so. Dealing with health insurance from a consumer perspective, people want us to get involved in the health insurance disputes and claims, and unfortunately, there’s no real arena for attorneys in health insurance disputes. It tends to just be all based on the consumer. So from someone who is trying to navigate the medical insurance side as a person, what do you think their best course of action could be? Do they call their agents? Do they call their broker?
Who do they call?
That is probably the most complicated thing about our system, is how to actually use it correctly. So most agents what they should do, and if they’re not, you definitely need to find another agent. But if you have a claim and you have something that you don’t think is paid properly, then that agent should work with you directly with the insurance company. Because you can always call, let’s just pick on United Healthcare, if you have a benefit summary, you don’t understand the explanation of benefits on how a claim was paid. And if they say, “Oh well, it’s just not covered.” And then they stop at that. And you’re always talking to someone different, and by the way, you’ve had to wait on hold like an hour.
We have our clients send their explanation of benefits or their bills directly to us, and we try to work with it and get as much information as we can, and then we share that back to the individual that’s having the issue. But the first thing that I think people should do which is so hard is if you are having a planned surgery or anything, I know typically your doctors will be the ones saying, “Let’s pick your anesthesiologists. Here’s the hospital.” They make all the arrangements for you. Try as a consumer to get involved with that because if you can make sure that the facility is in-network, that doctor’s in-network of course. Unfortunately with the anesthesiologist, we do find a lot of them are out of network. So that is not even something that you can really try to help out with.
The emergency room doctor could be out of network, which you’ll find in a lot of these hospitals. They contract out with the emergency room doctors. So what an agent can do, and you can do as an individual, you can write an appeals letter and you’re right. Is this something you as an attorney wants to get involved with? Unless they try everything and everything, and they have a real lot of bills stacked up it would be worth your involvement.
But I want to say sometimes we write two or three appeal letters and sometimes he’s out of network doctors. There’s nothing we can do. Last year, the State of Arizona, the Department of Insurance got involved and they do have an area like if you’ve already gone through the appeals, you’re not having luck, they can try to work with if it’s out of network doctor claims. So that’s the Arizona Department of Insurance, they can also get involved. But between me and you, I’m not seeing it. There’s much more change or difference that happens there. And then sometimes the insurance companies have a difficult claim situation. Like they have an area where they can work on that claim as well. But sometimes what people will do is they’ll really just try to work directly with the doctor after they’ve tried a couple of things and get that cost reduced just being like, “Hey, if I pay you… I can pay this much today. I don’t have $4,000, I have 2000.” But if you do wind up having a claim and as long as you’re paying monthly and it can be as low as $10 a month to the provider, they’ll take your money and they will not send you to collections as long as the payment is being made.
From the Legal Side
That used to be the case, but then all of a sudden these accounts started popping up on credit reports like crazy. Like, “Oh, I thought it wouldn’t go to collections if I just paid $50 a month to the hospital or to the medical provider.” And that was true, but now there’s just no incentive for them to not report it because it gets sent to a third-party collection agency so early on. So usually if the account is still with the service provider and you make payment arrangements with them, usually they won’t send you to collections. But there are some that just do it routinely, and it’s really unfortunate. People always want to know like, “How can I prevent this from being on my credit?” And it’s like, “Pay it.”
That’s really your only option. And sometimes it’s important to note that the medical provider doesn’t necessarily know you received a bill. So in a lot of times when people have insurance, they have their own billing department. They’ve got their billers, their medical billers, their own support staff, and they just assume that these bills are being paid. And so when it gets sent to a third party for collections, or you’re getting 30 or 40 medical bills and say, This isn’t a bill. This is a bill. Pay this amount. Don’t pay that amount, pay this amount instead.” Usually, the person that gave you the treatment has no idea that that’s happening, especially if you had a poor outcome or subsequent followup.
So just keep that in mind when you’re talking to your doctor or nurse or medical assistant, that they probably have no idea what you’re talking about when it comes to the medical bill. So be nice to them and try to just remember that because usually if you can get a human on the phone and explain your financial situation early on, they’ll work with you. But don’t assume that they know that this is happening and that you’re getting all these bills or even that they know what the amount is. Most of the time when they bill to insurance, they just assume it’s been paid. So they don’t know you got a bill for $27,000. It’s usually a sticker shock for them as well. So most of the time they will work with you if they’re private companies and sometimes they don’t.
The Health Insurance Broker says
Some people just get frustrated when they see a bill that says 27,000 and they won’t do anything with it. And they think it’s going to go away and it doesn’t, and I’m sure that’s what you all deal with in your careers, fighting those. But as much as you can get involved, the second that you get a bill, if you don’t think it’s right and you have somewhere to send it, either HR department or an agent that your company is working with, try to match that up with your explanation of benefits which is from the insurance company, just to say, “Hey, did they even get it? Did they even process it?”
A lot of times you’ll get a bill and you’re right, and I’m going to pick on some lab companies. Like lab Corp, for example. The second you go, you’ve got a bill from Lab Corp, and then the insurance company has a bill. And there was many years ago, they were almost receiving some possible double payments because you just pay it and you’re like, “Oh, it’s $50. Not a big deal. I’ll just pay it.” But your insurance company never received it. So you obviously didn’t get that money sent back if the insurance company paid it too. So it really is important to compare it to the explanation of benefits. And a lot of people don’t even know how to… All that stuff gets overwhelming. I’m like get a file, put all your bills in there relating to surgery, and put the explanation of benefits in there, and just try to put it on an Excel spreadsheet and try to see what’s paid and what’s not.
Make it easier for yourself because it does get very overwhelming, especially if it’s a major health issue and you’re dealing with either someone who’s deceased, maybe you’re not capable to even handle this and another family member’s handling it. The biggest problem can be when people get that bill, they just assume insurance is going to pay it. And sometimes the insurance company just didn’t get it. A lot of small offices these days, especially if they only have one or two locations do not submit insurance claims on your behalf, they expect the consumer to do that.
Read The Fine Print
There’s a timely filing fee. If your insurance company doesn’t get it like within a year, they’re not going to pay it ever. So it’s really important that before you start in a new facility that you’re reading those financial agreements. Because if it says that they’re not going to bill to your insurance company, go somewhere else. Don’t deal with the headache, because sometimes they cut checks to you, and I’ve seen that in the past especially with behavioral health. They’ll cut checks directly to the patient, and then the patient’s supposed to endorse it over to the facility that they went to. I have no idea why they do that. They’re just setting people up for failure, because it looks like it’s reimbursement for medical costs when it’s actually payment of medical costs.
I do see that a lot with… and sometimes a lot of the providers and I’ll just take a chiropractic office. Sometimes they don’t want to deal with insurance companies and they say, “Hey, instead of the copay of $75 you’d normally pay me, why don’t you pay me $50 cash, then I’ll have to file it.” And so then it’s not filed and hopefully taken care of. But what happens in that case that might not be the best choice for you to do because as an individual, every copay that you’re paying now, whether it’s for prescriptions or a copay for an office visit, it all accumulates out of pocket maximum. And if you’re paying this person cash, that’s not going to that maximum. So you’re not getting any a record of that adding to your full… Especially if you’re needing surgery or something, you could have met that maximum sooner. So there are advantages and disadvantages of that. I’m not sure that’s the best way, but if it’s enough savings then it might be worth doing.
All the Options
There’s a lot of those concierge-type doctors now, which I know you guys have heard of where hey, I’ll pay $3000 a year and they’re kind of on call. You get the first appointments, and that’s totally separate from your insurance. But I find a lot of people like doing that because they feel secure, but then I’m like, “Wow, but you’re paying for health insurance too.”
It just depends too on scheduling and what you can afford. It’s so funny in this world of health insurance, there are all these little niches out there. There are companies that do the concierge now, everyone seems to have their own health plan. Even if you go to urgent care, there’s a monthly subscription so you get a reduction on certain procedures that you do in office. But you’re still paying health insurance and they still bill to your insurance, and it’s all kind of a mess right now. So for those of you who are wondering what your options are for healthcare and health insurance and is it really that bad? Yes, it’s really that bad. It’s kind of a mess and there aren’t any really good options other than making sure you keep copies of everything, making sure you start that Excel spreadsheet, having a tracking system, especially for those of you who are receiving any kind of state benefit.
If you’re on AHCCCS or ALTCS or any government type of benefit, you really want to make sure that you’re not getting triple billed because that happens every now and again. It gets pretty complicated pretty quickly. So if you’re ever confused, there’s tons and tons and tons of online resources for people trying to figure out their medical bills. And then of course you should always contact your insurance agent and see if they can provide you with any guidance.
The one thing, those of you that have coverage, there’s a lot of things on your plan that you might not know would be covered. Like you might not know that Hey, Telehealth is free. Like I can do a FaceTime with my doctor and I don’t have to take my child if they’ve got pink eye. A lot of these things are free. There’s a lot of wellness benefits. Maybe you can earn HSA dollars or you can get some deductible credit for… Really also when you do those annual meetings and someone like myself comes in, I know everybody falls asleep or have something better to do than listen about health insurance. But try to understand your benefits, so you’re making sure you’re getting the most for what you’re paying for.
You’re leaving money on the table if you’re forgetting to file those claims. It’s like with any supplemental insurance, a lot of people will pay for Aflac or any of those other companies, but then forget to file those claims. So they’ve been paying on them for years and years and years. It’s just automatically deducted from their paycheck every month, every paycheck. And it’s like, “When was the last time you filed a claim?”
Yeah, and a lot of those Aflac policies have wellness things. So if you have a cancer policy or any of the policies, if you’re going to get your physical, which is free now on your health plans, Aflac will pay you like $50. So you make money by going to get a physical on some of those coverages. So don’t leave money on the table. Know your benefits. Most employers are happy to either have them and if you’re not using them, but you’re wondering what your options are, Talk to them about it. Talk to your HR departments. Most of the time, just dealing with medical bills, I think can just be really, really overwhelming. So transitioning into that, the medical bill side, what your options are for actually paying them.
These days, the trend that I’ve seen since about 2018 was most companies want 80% of the medical bill in a lump sum. So back when I started dealing with this in 2012, I would see maybe an ambulance visit being or an ambulance trip costing around 300 to 500 bucks. They would settle with you for about 30, 40%. They would do payments, no big deal. Well now your ambulance costs about 1500 bucks and they don’t settle.
They want it in full, in a lump sum right now, and forever in the future. And last year was the first year I started to see lawsuits over medical collections. So accounts that had gone to third party medical collections, they started to sue, and in other states, it’s become a much issue because we already have a lot of default judgments in Arizona based on credit card debt. But we’re going to see a lot more based on medical debt in the next couple of years. So if you have a lot of medical bills and you’re wondering what your options are, and you’re thinking about pennies on the dollar, that is not a thing. That’s gone. You don’t have a choice. These companies are just not willing to settle at all because they think everyone’s made money right now. So if you’ve got health insurance, it probably costs about 10% of your income. And then you have your $6,000 deductible, and then all of the stuff that you pay for that doesn’t count towards your deductible.
Then of course, if you have something serious medically happen you were already broke by the time you finished paying for the insurance for the year. So we’re probably going to see a lot more medical bankruptcies. That’s really the future of how all of this is going to culminate because people just don’t have the funds. So if you’re feeling the pinch and wondering what your options are, talk to an attorney, see what kind of longterm planning you can do to sort of offset that liability. But realistically you probably are looking at a medical bankruptcy if you’ve got more than $20,000 in medical collections, especially if they’re going to sue you. So just keep that on the horizon. I know it’s not the best news, but that’s the state of affairs.
Better to Be Protected
I do have some clients that occasionally will ask and I’ll say, “I don’t want to pay for health insurance. It doesn’t cover anything anyway.” They get frustrated, but I’m like it’s way better to be covered. Let something major happens, it could be like… I mean you know you can’t get in and out of the emergency room for less than 5,000 for a bee sting, anything. But let’s say a major accident happens. You’re looking at probably $500,000 to a million dollars.
So truly, even though you have a high deductible, those typically cap off if you have a health insurance policy, high deductible high out of pocket max. Potentially if it’s in-network, the most you could pay would be at the highest level like $8,150 for the entire year. That would be much better to be having to pay claims on than $500,000.
If the question is, should I get health insurance since healthcare is already expensive? Yes. Get health insurance. Of course, you should get health insurance. It’s way cheaper than paying for any of this stuff out of pocket. Going to the emergency room for someone who’s not insured is not unusual to see a $9,000 bill come across my desk. When I see little kids’ medical bills, it gets outrageous. Five, six grand for Phoenix, Children’s Hospital, a couple thousand for an ambulance, and then you’ve got all the pediatric care, which is super-specialized. And you’re dealing with people who don’t know, you’re getting all these bills. When it comes down to it, the provider just doesn’t know, and if they did, they would work with you.
What about Medical Malpractice?
That’s a very separate issue from health insurance and billing. We get a lot of calls from people who have concerns about the way they were billed for their medical care or some aspect of the business process. And that is not a malpractice issue, that is not something that a malpractice attorney will deal with. And as Rochelle mentioned earlier, there isn’t really a clear role for attorneys in that process right now. And the reason for that tends to be that there just isn’t enough at stake in most of these billing disputes for it to justify getting an attorney involved. And perhaps even more importantly, usually the insurance companies are correct. Whatever the situation is that involves a patient getting a huge and objectively unreasonable bill at the end of their treatment, usually that is in compliance with the terms of that policy.
Usually, it’s because your insurance isn’t very good. Maybe it’s the best you can get, but the bottom line is there is no good way right now to absolutely ensure that you’re not going to end up with a gigantic medical bill. Even if you have what qualifies these days as good insurance coverage, you can still end up owing a huge amount of money out of a medical situation. And there’s nothing anybody can do about that because those are simply the terms of the policy, and the deal you made with the insurance company is that you owe a whole bunch of money for your medical care because the insurance isn’t great. So under those circumstances, that’s not a legal issue that either my firm or any other firm can really deal with, if the billing was done correctly. Now malpractice instead comes out of bad outcomes that are the result of a doctor’s mistake.
If someone has a medical issue and does not get successfully treated for it, perhaps it’s not diagnosed properly, perhaps the surgery that’s done to correct an issue turns out to have been completely off base was misdiagnosed before surgery and did the wrong procedure. Perhaps test results are misinterpreted. All kinds of things happen. Wrong medications given for a condition. The breadth of malpractice that can occur is very wide, but typically unless it results in a serious injury or a death, it’s not something that you would be able to pursue. And the reason for that is that it’s very complicated and expensive to sue doctors in hospitals. And the reason that it’s complicated and expensive is that they are specially protected by law specifically to make it difficult to sue them for their mistakes.
Whereas you can go out and sue anybody else, those of us here in the studio, the owners of this building, anybody, you can sue for a broad variety of negligent acts. If you say that they hurt you because they did something that was careless, stupid, poorly advised, whatever it may be, you can sue that person for negligence. And if you prove your case to a jury, you can collect money from them for the injuries that they caused to you. Not really with doctors in hospitals. Doctors in hospitals get special protection so that in order to sue them, you’ll have to get other doctors who are exactly the same kind of doctor with exactly the same qualifications to say that they made one very specific mistake that only a doctor can make, and that because of that mistake you were specifically severely injured as a result.
Because of all the special evidence you’ve got to bring in the special procedures you have to use for these cases, if you don’t have more than about half a million dollars in clearly provable damages, and that is a serious permanent life-altering injury, it’s probably not going to be cost effective to sue your doctor or hospital. So those are the kinds of cases we end up looking for. And what we find is that on the whole, most people who have been injured by bad healthcare cannot sue over it. Most people who get bad care, who were hurt by a doctor, who get bad outcomes that were preventable, there’s usually something wrong with that case that makes it so that we can’t actually pursue it more often than not. And that’s very unfortunate, but that’s the system we’ve got. So as a malpractice attorney, I end up sifting through huge numbers of potential cases from people who got bad outcomes and are upset with their healthcare, and many of those people were legitimately hurt by real mistakes. But either they weren’t heard enough or the evidence isn’t clear enough to prove it, or because of the way the medical specialties are all divided up, we don’t think we can get an expert who’s going to be willing to stand up in court and stick up for our client. And as a result, we end up taking roughly 5% of the cases that we consult on. So that’s the situation. It’s very difficult to hold healthcare accountable these days.
Positive and Negative
But, there are always good things that you can say, certainly there are good doctors out there. Medical technology is better than it has ever been before. There are all kinds of new and emerging treatments. We can treat more diseases now than we ever could in the past. Those are good things. Unfortunately, hate to be a downer, those have their own downsides. Costs are going up partly just because we have more advanced care now. Back in the ’80s, ’90s, and even early 2000s, there were plenty of complicated medical situations that we simply could not treat then, that we can treat now.
Where you’ve got some shot at getting some kind of benefit today that you never could have before. The problem is, that new drug costs $400,000, or that new surgery is going to cost you 1.2 million. And it’s experimental so your insurance refuses to cover it. I don’t know, we get these benefits from progressing technology, but we’ve made our healthcare so complicated at this point scientifically and industrially, that it’s simply not affordable to do the newest and best thing for every patient. And that’s where we end up with some of these arguments about how we can move to a nationalized healthcare system and how we can improve the effectiveness of our industry and insurance when the costs are just fundamentally so high for some of these treatments.
Kristine has been in this industry for 30 years and it has definitely changed a lot. The advancements, the ability to cure to get people out of the hospital faster, or the drugs that are available are awesome. But we are all paying for that. So in everything they want to say, “Hey, this should be covered. This should be free.” Everybody has to pay for that even though we might not need that particular benefit. That’s definitely the way it is, and the nice thing that… I know one of the things that you didn’t mention, but the fact that preexisting conditions are covered is awesome. Because when I started my business, I can honestly say I used to talk to people on the phone. They’re like, “I’m currently pregnant.”
Simple things that we all could potentially deal with, I couldn’t find a plan. We now have options for everybody, and that has also increased the cost, which is hard… And I don’t think that’s anything they’re going to take away because of course we hear the news and that is awesome because that is an important quality to have. So if someone is uninsured, everything that was wrong with them before would be covered. But just all these things increase our cost and nothing is free. And technology is a great thing, also a little scary. Technology, isn’t always working to its advantage, but we’re getting more and more on that with the growth of that as well. So that’s another thing that insurance companies have had to add cost towards, is improving all these technologies and everything.
And not to come to the defense of insurance companies too much here, but it is true, decisions have to be made about the cost-effectiveness of care under some circumstances. A lot of the new drugs and treatments that are coming out are often being called biologics drugs that end typically with MAB or another one of those abbreviations that indicate that it’s an immune system modulating drug or a drug that interacts with your antibodies. And those tend to be extraordinarily expensive to produce. There just is not a real good way to make those on a commercial scale. Plus the development costs, since these are all new drugs, have to be recovered at some point. And the problem we see is, many of those are great treatments for a huge variety of things. They’re being used for cancer treatment for autoimmune disorders, for all kinds of different diseases across a broad spectrum of problems, but they’re outrageously expensive and sometimes not all that effective for those conditions.
So people are running into these situations with their insurance companies, where their doctor says, “Well, we could try this drug. It may work for you. It provides a benefit for a significant percentage of people with this kind of a condition.” And the insurance company says, “We’re not going to pay that. It’s going to cost you $300,000 and there’s a 50-50 shot it’s going to do anything. So we’re not going to pay that.” And it ends up on the news. They end up in court. But the bottom line is we can’t shell out that kind of money for every single person who has a problem we might be able to fix. The money has to come from somewhere, and the work of the healthcare system has to be done by someone. The challenge we all have to figure out as a country, I think, is what kind of a system we’re going to use to sort that out and pay for it ultimately.
I think overall, just looking at the healthcare system we have, it’s overly complicated. There are a lot of moving parts and pieces, there’s a lot of inefficiency and a lot of bureaucracy. So what we had before wasn’t particularly great, and there’s been a lot of improvements with covering preexisting conditions and general health overall is good.
But what can be improved upon?
That’s the question we should all be asking. Like switching out and replacing a new system, an old system, or a new system with a new system, it’s probably not the right solution. There’s too many moving parts and pieces, and we need to start with like how about a universal medical billing system? Every single insurance company has a different medical billing protocol. They all have different billing insurance codes. So it’s kind of insane when you work in billing, when you go from one company to another, you’ll find that, “Oh, it’s a totally different system.”
You interact with Medicare completely different than you did at this other health insurance company. So there’s just a lot of logistics going on on the insurance side. And then of course for doctors who just want to provide care, they don’t know about medical billing. It’s not their job. They didn’t go to school for it. It’s practically its own language. So if you’re thinking like, “This should just be an easy fix.” Well, it’s a very complicated problem, so there are going to be a lot of complicated solutions. So hang in there, we’re in the midst of it, it’ll get better, but with anything, new system, it takes time to work out the kinks. So keep talking about it.
You just need to take ownership and be informed. Again, know what you have, and then don’t be afraid to reach out for questions. Again, if we were a resource, I don’t charge you every time you call to ask questions, try to use the resources you have. We’re trying to make this easier for people because it is a bit overwhelming. But the more that you can take ownership of it, and there’s a potential you can try to… If MRI, maybe you can look online and compare costs, things like that. Healthcare is the only thing that we, we go in a doctor’s office, we have no idea what that bill is going to be when we walk out. So do the best you can, but yeah, the more questions you can ask is always helpful.
People are really starting to talk about the rise of the financial transparency and medical billing, like being able to be set a price quote. And it’s kind of funny because for lawyers, we typically deal with billable hours all the time anyway, because you never know what the problem is going to look like when you really get into it. And it’s the same in healthcare, if you want to have a surgery, why can’t they just flat rate price and tell you up front? Well, they don’t know what’s going to go wrong. You’re a body, you’re a person. There’s a lot of stuff in there. It’s squishy and gross, that’s how I think about it. I don’t know what medical professionals think, but I know it’s complicated. And I don’t know if I would feel comfortable as a medical professional if you just think about it, being able to say with certainty, “Oh, this is all this is going to cost.” What if you’re in there for 20 hours. You never really know what you’re going to get into, so that’s why they really don’t flat rate that kind of thing.
Price Shop and Second Opinions
But you can price shop. If you’re an individual and you’re looking at doing a surgery, you’re not really obligated to stay at the facility that you’re planning on doing your surgery, you can shop around. You can find other physicians that are in-network. You can get second opinions. Yes. You’re going to pay more money for it, but in the long run, you’re going to save money because you’re being a really, really great consumer. Education is key. Educate yourself, find out what your options are, and don’t just go with what your doctor says. Trust them, but get a second opinion.
Big fan of second opinions over here, especially for anything complicated. If you’ve got some kind of a mysterious health issue that you haven’t really been able to figure out, and especially if your doctors haven’t really been able to figure it out, go run that by somebody else. Just because your family doctor thinks they figured it out, and you’ve started some kind of a treatment or scheduled some kind of a procedure does not mean they got it right. Lot of this stuff is more wishy washy than you would think it is. A lot of it is a whole lot less determinant than the healthcare system leads you to believe. It’s an interesting statistic that I think it’s around 9% of the population, if I’m recalling this correctly, about 9% of the population has some type of a disease or condition that’s classified as a rare disease or condition.
In other words, something that is uncommon enough, that there isn’t a lot of research on it and it’s not common knowledge within the healthcare profession, and perhaps there is not a clear route to diagnosis or treatment of that condition. Well, why does 9% of the population have a rare disease? How can that many people have them? Because there are so many rare diseases to choose from. The chances of having any given one might be one in a million. But if there are a million different diseases to choose from, then chances are, you’ve got one of those, right? So if you’ve got mysterious unexplained symptoms, you may need to doctor shop some before you get that figured out. And the reason that I’m bringing this up is many of the people who contact us regarding a potential malpractice claim are upset with a doctor for not diagnosing their uncommon condition despite repeated visits over many years and a whole bunch of tests.
And they say, “Look, my family doctor really screwed this up. I’ve been suffering with this disease for 10 years. I’ve been going to them and complaining and complaining, and he’s tried all these tests and put me on these vitamins and gave me these shots and none of it worked. And now I moved and my new doctor says, it’s this weird disease that I had never heard of and he put me on this one pill and I’m fine now. So why did I have to suffer with this for a decade?” The answer to that question is you had to suffer with it for a decade because you didn’t doctor shop in the first place. If you’d been going around town, getting a few other opinions on this, perhaps it would have been resolved sooner.
But that’s not malpractice. You can’t expect every doctor to identify every odd condition. It takes a team to identify some of this stuff, and it would help an awful lot more people if rather than just taking one professional’s opinion for it and sticking with them, they would go out there and get a variety of opinions. See what the whole town has to say about your weird problems. Get a few opinions. You don’t have to believe everything a doctor would say and just assume they are right.
You don’t have to necessarily take that prescription. You do definitely need to maybe research, see a naturopathic doctor or some other experts that maybe there’s ways to do things without having to take a prescription. So really it is up to you. I wouldn’t always assume everything and get that second opinion. I totally agree with that.
Also Google your health issues and learn about them. You do know how to use the internet, so use it. Learn about your medical conditions. Doctors would far prefer to deal with informed patients who know which signs and symptoms are relevant, what conditions are likely. Especially if you’ve got something kind of weird and the doctors are having a hard time, help them out. Do your own research, keep journals, learn about the medications you’re taking. Learn about your disease processes. Informed patients do better in the long run and communicate more effectively with their healthcare team. Let me clarify. Do not self-diagnose. Taking a few stabs at it and coming up with some possibilities can be helpful. Just don’t go overboard with it. Don’t assign yourself all of the weird diseases in the universe, just because you’ve got a few of the symptoms. You got to be rational about it.
But if you’re going to the doctor for some kind of a problem, you should probably have a general idea of what the most likely issues are going in there. We have the technology now to make that pretty easy. Make sure you respect what the doctor’s saying though. You’re not a doctor. Unless you are a doctor Googling your own stuff, good for you. But if you’re not a doctor, do not mistake web MD for a medical degree. But it is helpful. It’s full of useful information.
Kristine Kassel, with Benefits by Design offers direct appointments on her website benefitsbydesignaz.com. Or you can reach her at email@example.com. But definitely give us a call at (480) 831-7700 also if you don’t want to go online. But happy to help, and again, just consultative. There’s no fee for a call and we answer all kinds of questions. So don’t be afraid to call, just love to help you out and get through this lovely healthcare system successfully.
So if you’re a small business owner and you are looking at what your options are for health care, this is who you call.