“Why would they decline my wife’s ED visit?” Brian asked, still perplexed. “That doesn’t make any sense.”
“As I said, Peerless is particularly creative,” Roger said. “But my guess in this particular instance is that the rationale is pretty straightforward. Even some of the big insurers like Anthem and United are getting involved. Here’s the deal. There is a lot of talk of the cost of healthcare needing to be curtailed, and that insurance companies have an obligation to put on the brakes or at least appear to be doing so. One area that stands out is the ‘emergency’ overuse situation. Running emergency departments, particularly Trauma 1 centers like ours, is very, very expensive, and far too many people are abusing them for non-emergency ambulatory care rather than for true emergencies, like heart attacks, strokes, massive trauma and bleeding, and the like. Many insurance carriers feel that they have to put a stop to such abuse by denying claims, especially during normal business hours when patients can see their general practitioners or visit small, independent urgent-care centers.”
“You mean that Peerless is saying my wife, who had suffered a grand mal seizure, shouldn’t have come to the MMH Inwood ED?”
“That’s exactly what I believe they are saying by denying the claim,” Roger affirmed.
“Well, that’s preposterous,” Brian sputtered. “A grand mal seizure is surely a medical emergency.”
Roger shrugged his narrow shoulders and spread his hands, palms up. “I’m afraid that is going to be between you and your insurance carrier. Meanwhile, there is this sizable bill that needs to be addressed. That is why we need to set up some sort of payment plan going forward, especially now that your wife is an inpatient and using significant resources like an intensive care bed.”
Brian’s thoughts were churning a mile a minute in every conceivable direction. How could this be happening to him? Was his wife’s care now in the balance because of their irresponsible insurance carrier? The whole situation was ridiculous, and mind-boggling.
“Well, what has Peerless said about my wife’s hospitalization?” Brian managed to ask while trying to rein in his thoughts.
“They have said nothing because they have yet to be billed for that,” Roger said. “Here’s what I propose. If you were to, say, pay five thousand a month, we would be willing to accept that without adding interest. We realize that this is an imposition to anyone’s budget.”
“Imposition?” Brian exclaimed. “You don’t understand. I don’t have that kind of money, and certainly not under these circumstances.”
“Well, you tell me what kind of time frame you have in mind,” Roger offered, tenting his fingers, elbows on his desk.
“Well, first, let’s talk about this bill,” Brian snapped. “Twenty-seven-something thousand dollars! How in heaven’s name did the bill come to that? I could buy a new car for that kind of money.”
“That’s easy,” Roger said. “It’s par for the course and certainly not out of line. As I mentioned, Emergency Department care is very expensive. Your wife had multiple radiographic studies, a spinal tap, various consults, expensive pharmacological agents, many sophisticated laboratory tests, and her care tied up a number of highly paid nurses and doctors. She also had a seizure while being attended, which had to be treated. It adds up quickly.”
“I want to see a copy of the bill,” Brian demanded.
“You can request a copy from the billing department. That’s certainly your right.”
“I want to see a copy right here and now,” Brian said. “It’s all computerized, so it can be printed out in minutes.”
“The way it will immediately print out won’t be understandable to you.”
“I don’t care,” Brian countered. “I want to see it.”
“Suit yourself,” Roger said. He picked up the phone and made a quick call. It was obvious that he was now finding the meeting almost as vexing as Brian.
While Roger was on the phone, Brian tried to calm himself. He realized he needed to talk directly to Peerless. It was absurd to think that a health insurance company wouldn’t cover an obviously necessary ED visit even if some other people abused the situation. It had to be some kind of misunderstanding. Maybe they didn’t know there had been several seizures involved, as well as a serious diagnosis thereafter.
“Okay,” Roger told him, hanging up the phone. “I’ll have a copy of the bill in short order.”
“Can the ED bill be added on to the bill that will be generated by my wife’s admission?”
“No, it can’t,” Roger said. “The ED bill must be taken care of separately. Can you give me an idea of what kind of time frame you would be able to propose?”
“I’m even behind on my mortgage,” Brian blurted. “With the pandemic tying the economy in knots, how the hell do you think I can come up with twenty-seven thousand dollars within any conceivable time frame without being a goddamn fortune-teller?”
“Please, calm down,” Roger snapped. “Let’s try to have a civil conversation.”
“You’re right,” Brian said. He had to get himself under control. “You’ll have to excuse me. I’m just blown over by this whole situation. I never thought about any of this. I’ve always had good health insurance. I guess I’ve just taken it for granted. What I need to do is talk directly with Peerless and get them to step up to the plate and take care of this.”
“That is a good plan, but you have to do it right away,” Roger insisted. “You can’t put this off. Talk to your carrier and then get right back to me. As I’m sure you understand, MMH has its own financial responsibilities it has to meet on a daily basis.”
After a knock on Roger’s door, a secretary came in with a small stack of papers and handed them over to him before retreating. Roger briefly glanced at them and then handed them over to Brian. “Good luck,” he said as he did so.
Brian took the papers and glanced through them. It was immediately clear that Roger had been correct. The bill was entirely unintelligible, with every page mostly composed of long lists of alphanumeric entries followed by dollar amounts. Disgusted, Brian tossed the stack onto the desk. “It’s not in English. It’s all in goddamn code!”
“I warned you that it would be incomprehensible.”
“Why is it in code? Why isn’t each procedure or product just listed with a price? This format doesn’t make any sense.”
“Prices are proprietary information,” Roger explained. “We have to keep that information confidential for our negotiations with insurance companies.”
“I don’t follow,” Brian said. “Isn’t there one specific price for every product and procedure?”
Roger scoffed at Brian’s naivete. “There are different prices for different insurance companies. It’s all a matter of bargaining. Surely you must know this.”
“That’s crazy,” Brian said. “I’ve never heard of such a thing. Do I get a chance to bargain?”
Roger genuinely laughed, although he was obviously losing patience. “No, you don’t get a chance to bargain. As an individual, you have to pay full freight.”
“Why is that? Why do I have to pay more than health insurance companies for the same service?”
“This is how American hospital-based medicine works,” Roger snapped. “I don’t have time to explain it to you, nor is it my job. It’s complicated. But, look, I can have a slightly more comprehensible bill drawn up, which I can email to you if you give me your email address.”