How do I handle this insurance issue from my surgery?

December 28, 2016 9:52 AM

In August of 2015 I had brain surgery at the Cleveland Clinic to remove a tumor. It was benign. I've been back several times for radiation therapy and other follow-up appointments. Everything has been really, really great. I mean, as great as brain surgery can be, I guess. My right vocal cord is paralyzed as a result of cranial nerve trauma, but other than that, I am here, and I am happy. There is, however, the small issue of the bill.

I live in Michigan, and it took some research before I settled on the Cleveland Clinic... but, they rated really highly and they seemed a lot more interested in me than any of my local hospitals, so, hooray. Except, as I was laying at home recovering, I got a bill. Blue Cross Blue Shield paid for everything, save a rather disconcerting charge for intraoperative neurophysiological monitoring during the procedure. I'm not even sure what that is (although I've Googled it several times), but it sounds important. Blue Cross is adamant that they consider this experimental and they absolutely will not pay for it. Cleveland Clinic says someone has to pay them $8514. Yikes.

Thus begins a year and a half long saga where I try to get this sorted out, but a lot of this is really impenetrable to me. From my point of view, well, obviously, I don't want to pay this. I called BCBS in the months before the surgery and asked them if I would be covered for an out of state surgery. They said yes. Now they say I should have provided them with a list of procedure codes. Good to know I guess. The point is, no one ever said anything to me. I distinctly recall getting an automated calls from BCBS in the days before my procedure saying that they had received notice for pre-approval from Cleveland and I was good to go. Of course, no one has any record of this. It was a stressful time. Maybe I imagined it. But, look, no one ever told me, or asked me, or... anything. Why do we live in a world where my doctors in Cleveland want to make sure I get the best possible care and use some procedure for nerve monitoring (which sounds kind of important?) and then I'm left holding the bag afterward? Argggh. Doesn't someone have to tell me something?

Cleveland Clinic has... also not been overly helpful. I call them every couple of months. I've written them letters pleading with them to help. They reset the timer on it going to collections. They tell me they're looking into it and trying to get it sorted out so I don't have to pay. They tell me to call back later.

Yesterday I called and finally spoke to someone helpful. She put me on a three way call with BCBS (no one has done that previously) and tried to get everything sorted out. It became clear to me that no amount of "sorting it out" is going to make BCBS pay. They're not going to pay. The procedure is simply too new. They do not cover it and are not going to cover it. The person from Cleveland said she's going to send everything to the "Coding Department" to try to get it sorted out one final time, but I should prepare myself by A) writing an official letter to BCBS to ask them to pay, because if I write them a letter they have to open an official file and review it and B) she's going to send me a financial aid form from Cleveland and she wants me to fill it out with my financial information to see if I qualify for aid and she wants me to include a personal letter of physical and emotional hardship.

As you can probably tell, I don't know a lot about this stuff. I'm doing the best I can to sort it out. As I see it, I have the following options.

1. Do as suggested, wait for the outcome, and then pay what I have to pay because sometimes you have to pay for things, even when you really don't want to. My world would not end. I don't have that much money sitting around, but they have payment plans and I have a job and even though we're sending our kid to college and have a million other things going on so does everyone else and I'm not a special sob story. It would be a hardship, but I wouldn't, like, lose my home.

2. Contact a lawyer and review all this in the hopes that there is some kind of lawyer out there who specializes in health care and getting insurance and hospitals to work together so that I don't have to pay $8514. I'm not sure if this is reasonable or even a thing I could do. If it is, how would I even find an appropriate lawyer? Google searches lead me mostly to things that look like ambulance chaser mumbo jumbo.

Anyway, this has been hanging over my head for many, many, many months, and I guess it's time for it to finally not. Any advice on the appropriate path forward?

posted by anonymous to Law & Government (22 answers total)

You are probably going to be stuck with this bill. However, I would try to mediate the dispute with BCBS first with the Michigan Department of Insurance and Financial Services. They can't represent you, but "surprise medical billing" has become a big issue lately and sometimes the state's getting involved induces companies to at least soften their stance.
posted by praemunire at 10:26 AM on December 28, 2016 [7 favorites]

Do what the helpful Cleveland Clinic person told you to do. Maybe their financial aid will help! It's not up to you to determine if you're needy enough; just fill out the form and write a true and honest statement about how paying the bill would effect you and your family. They'll make the determination and then you can go from there, get that payment plan going if needed, and move on. But please don't give up on this lifeline to financial aid just yet.

I have a bill left over from surgery also hanging over my head right now, though it's not nearly as much money. The medical equipment company (it was some equipment for in-home rehab that I rented) was supposed to get pre-approval and claimed they did but now my insurance is refusing to pay. They asked for me to fill out a form giving them permission to appeal with my insurance company directly, which I was happy to do. The guy at the equipment company outright said to me "Don't worry, we bill the insurance companies enough to cover the patients whose insurance doesn't cover it. Your bill won't be nearly that much even if they reject the appeal."

The health insurance system in this country is royally messed up, and this is why: it expects people under medical duress to suss out billing codes of every procedure that may be performed and get pre-approval for every one of them, which is just insane. You do not deserve to carry this burden alone - think of any potential financial aid as recompense for this shitty, shitty system. Good luck.
posted by misskaz at 10:27 AM on December 28, 2016 [8 favorites]

Fill out the patient assistance form. They will most likely knock off a portion of the bill. Explain everything in the form, all the steps you have taken, the stress this has caused in your life etc. They lower bills for people all the time.

I'm sorry you are going through this. What really irks me is how is a patient supposed to get treatment codes before surgery. That is such Bull Shit from your carrier. I would put that in the letter as well and ask them how you could have done that.

Take care. Good luck. Glad you are feeling better.
posted by cairnoflore at 10:29 AM on December 28, 2016 [2 favorites]

First, verify that this testing was done. Talk to your surgeon. Get a copy of the operative note. Make sure that it specifies the testing on the results of the testing. I have seen many bills for procedures that we never done. It's a coding error;it's an assumption error; it's a mistake. Or it's something more nefarious, but I doubt that. If it's not in your chart with the results, Cleveland Clinic can't bill for it. Just an idea.
posted by SLC Mom at 10:33 AM on December 28, 2016 [17 favorites]

At this point, you could at least _talk_ to a lawyer or three. I believe you can get a no-cost interview which will let you know if they at least consider it possible that you have a case.

Also, I'd try to get all the information straight about what Cleveland Clinic told you about costs, your cost after insurance, etc. It may be that the miscommunication is somehow not your fault (although, you know, probably you signed something saying it wasn't their fault -- just look into that.)
posted by amtho at 10:36 AM on December 28, 2016 [1 favorite]

Also, in case you're worried about bothering people: the more fuss you cause, the more motivation there will be for insurers and large medical institutions to do anything at all about this huge problem. Lots of people probably roll over without a fuss, or just give up and let their credit ratings get destroyed -- people with fewer resources and less cognitive ability than you.

You're one of the few forces pushing back against this kind of thing.
posted by amtho at 11:06 AM on December 28, 2016 [1 favorite]

Definitely do as Cleveland Clinic recommended for now, to get that ball rolling. Along with your letter to BCBS, have your surgeon write a letter saying that the technique used is the standard of care in their practice, NOT experimental. It is pretty likely CC will knock down the bill significantly if you do as suggested. They bill an outrageous amount because they expect insurance to put up a fight and pay less than asked. They will probably allow you to pay a more reasonable amount out of pocket.

Instead of (or perhaps in addition to) a lawyer, try contacting a medical billing advocate. I haven't used one personally so can't speak to how helpful they are but you may be able to get a free consultation before paying to have one work your case.
posted by bobobox at 11:07 AM on December 28, 2016 [2 favorites]

You mention having a job. Is your health care through an employer?

If so, there will be someone at the employer whose job it is to negotiate the health plan every time it comes up for renewal. Try asking them to intervene on your behalf -- if you work at an employer of any size, the person will have a lot more familiarity with insurance jargon. Even more importantly, the health care insurance company will treat them much more seriously, because of the existing relationship, and because this person's opinion of them could make a difference come renewal time.

Last year, we got a surprise $30,000+ bill from our insurer because they felt Mr. Machine shouldn't have been admitted to the hospital after he showed up in the emergency room with chest pains that turned out to be a significant tumor between his heart and lungs. After trying to get it resolved myself, I went to the HR department at work, and they got some magic done. In the end, they essentially covered everything after our deductible.
posted by joyceanmachine at 11:13 AM on December 28, 2016 [4 favorites]

I couldn't find info for BCBS of Michigan, but I did come across this page for BCBS of Mississippi outlining their policy regarding intraoperative neurophysiologic monitoring. Chances are good that they are operating off the same principles, though of course it's best to confirm. The part of that page that jumps out to me is under the Policy section:

Intraoperative monitoring, which includes somatosensory-evoked potentials, motor-evoked potentials using transcranial electrical stimulation, brainstem auditory-evoked potentials, EMG of cranial nerves, EEG, and electrocorticography (ECoG), may be considered medically necessary during spinal, intracranial, or vascular procedures.

Intra-operative monitoring of visual-evoked potentials is considered investigational.

Due to the lack of FDA approval, intraoperative monitoring of motor-evoked potentials using transcranial magnetic stimulation is considered investigational.

Intraoperative EMG and nerve conduction velocity monitoring during surgery on the peripheral nerves is considered not medically necessary.

Intraoperative monitoring typically is done in the operating room (OR) by a technician, with a physician as a remote backup. In some ORs’ there is a central physician monitoring room, where a physician may simultaneously monitor several cases.

Intraoperative monitoring is considered reimbursable as a separate service only when a licensed physician, other than the operating surgeon, performs the monitoring while in attendance in the operating room throughout the procedure.

So it looks like if Cleveland Clinic can provide BCBS with documentation that the monitoring was done during an intracranial procedure by a licensed physician other than the operating surgeon who was in attendance throughout the procedure, you may have grounds for it being reimbursable as a separate service. If the physician was not physically in attendance and monitored from a remote location, they may just need to resubmit it under a different code reflecting that. (There's a list of codes on that page for reference.) This looks like a common problem with this procedure: see here and here for other folks having the same problem with denials of this procedure due to the specific CPT code they are using.

Find out exactly what CPT codes are being denied and work with the coding department to get it resubmitted under a code that aligns with their policy. Chances are a coding change will take care of it!
posted by platinum at 11:20 AM on December 28, 2016 [29 favorites]

Mostly, what everyone else said. You say you "don't know a lot" about navigating insurance and medical billing, but it sounds like you've done really well! I would regard the answer from BCBS as pretty much final - the insurance is not going to cover this.

However, about this bit:

...and she wants me to include a personal letter of physical and emotional hardship.

FYI, that is Cleveland Clinic opening the door to negotiate this bill down. Notice it doesn't even say financial hardship; they are open to being persuaded based on the personal impact on you of this surgery. If you want to reduce this bill, write the hell out of that letter and pack in all the detail you can.

Then, request a payment plan that you can realistically afford for the final amount they decide on, and actually follow through and pay it.
posted by Joey Buttafoucault at 11:28 AM on December 28, 2016 [6 favorites]

Also, if the coding changes don't resolve the problem, you should absolutely work with the Cleveland Clinic to negotiate the price down. All medical costs are negotiable!

Fairhealthconsumer.org has a calculator for estimating usual and customary (U&C) costs by code and region to help give you a target amount. I just did a quick search on CPT code 95940 (Continuous monitoring of nervous system during operation, each 15 minutes) and it came out to $172.85 per every 15 minutes. You'll need to find out how many units (15 minute increments) they are billing for, but that should help give you a starting point for your negotiations.
posted by platinum at 11:40 AM on December 28, 2016 [2 favorites]

I was going to strongly suggest starting the appeal process with BCBS, but the deadline is generally 180 days after you received your Explanation of Benefits showing the denial of coverage. Did you already go through the appeal process and were denied? Did no one at BCBS mention that you could appeal, but that there was a deadline?

If no one at BCBS informed you that you needed to formally appeal their decision within 180 days of denial, then I think that in addition to working with the Cleveland Clinic to get the bill reduced, you should talk to your state insurance regulator.
posted by muddgirl at 12:11 PM on December 28, 2016

Similar situation happened to a family member. They negotiated with the financial office and paid larger lump sums on their bill, and in turn, the facility knocked off significant percentage of the bill.
Talk to someone in the financial/billing office. (Get names and phone extensions and try to talk to the same person every time...) Disclaimer-this was not at CC.
posted by LaBellaStella at 1:00 PM on December 28, 2016 [1 favorite]

I had a similar charge show up from a surgery last year. Similar neuro-monitoring, similar amount.

However, what I had was *not* a direct bill to me, but rather a note from BCBS.

BCBS said they had rejected my appeal for them to pay ~$8k for neuromonitoring. I had not filed an appeal, apparently the neuromonitoring company had somehow appealed on my behalf (this seems shady, right?).

I had four players- the surgeon, the surgery center, the neuro contractor, and BCBS.

My surgeon told me that these guys do essentially calculated over billing, to make up for cases where they don't get payed what they want. They will ask for $8k, from insurance, and take it if they can get it. If they know an individual is paying, they will dial back to a much lower number.

Because my surgeon was the guy who hired the contractor, he was basically able to verbally admonish the contractor into dropping all charges. I even talked to the guy who billed my BCBS. He said that he never intended to bill me anything, but that he had to at least try to get money from insurance. That may have even been true.

So: you have a different suite of players, but maybe you can get your surgeon to lean on Cleveland Clinic billing dept.

If nothing else know this from my first-hand experience: at least some neuro-monitoring folks can and will accept $0 payment from the patient in some cases, despite thousands being billed to insurance.

Hope that helps, good luck!
posted by SaltySalticid at 1:02 PM on December 28, 2016 [9 favorites]

SaltySalticid has it: This is all a giant Ponzi scheme and the hospital doesn't actually expect to get its 8k from you. They've opened the door to negotiation with their financial aid paperwork. Get that ball rolling and don't agree on an amount higher than what you can reasonably afford.

Next, I'd be on the phone to a lawyer about surprise medical billing charges, plus the state's insurance commission. It's utter bullshit that we pay our premiums, do our due diligence to assure we are covered prior to procedures, and then get huge bills anyway. "You should have provided a list of procedure codes" is an UNREASONABLE demand on the patient. It's a shell game, full stop.

Can you tell I've had this happen before? I called BCBS, the hospital, and the surgeon's office and asked that, no matter what terminology anyone used or where the charges came from, how many dollars would we owe after my husband's spinal fusion surgery? The answer from all three was zero dollars, 100% coverage, no footnotes or fine print. So when we received a bill for 2k from the hospital that BCBS refused to pay, I told everyone to eat it, that we weren't paying any more than zero dollars. My father is a doctor (not a surgeon though) and claims this is standard procedure--that hospitals constantly send bills trying to get reimbursed for what they think insurance won't cover, and that most patients negotiate it down or don't pay.
posted by ImproviseOrDie at 1:17 PM on December 28, 2016 [8 favorites]

State insurance ombudsmen, for both your home state and treatment state, can be extremely helpful. (They will work for the state agency that regulates health insurance.) Their JOB is to intervene in situations where the billing is fucked up and nobody is being helpful and the consumer was told one thing before the procedure and one thing after. They can force insurers or health care providers to remedy their problems (not just for you but systemically) and complaints to the ombudsman can be considered in future certifications (if an insurer or hospital is routinely misbilling, the state can refuse to license them, or can fine them, or can require them to submit to monitoring). So they get better results because they know the system inside and out, and they have actual consequences to hand out if the parties don't cooperate with investigating the problem. There is no charge to you. It's usually even a 1-800 number.

It's not the be-all, end-all (that's probably a lawyer), but if you've exhausted your ability to work with the insurer and the Clinic, it's a good next step.
posted by Eyebrows McGee at 3:31 PM on December 28, 2016 [8 favorites]

Health care providers and insurers should work together to avoid this, but they don't, to everybody's pain. If you exhaust all options, push hard to have the charge substantially reduced; they should have known a lot more about the insurance than you did.
posted by theora55 at 3:36 PM on December 28, 2016

My right vocal cord is paralyzed as a result of cranial nerve trauma
Is this a result of the surgery? If so, maybe you should talk to a lawyer about that also...it doesn't even sound like the monitoring you're being billed for worked. There is no way I would pay a single cent of this charge. This is a scam. Call your state insurance regulator or at the very least ask your employer's HR department to have their insurance broker get involved. I work in HR and our broker is more than willing to help with exactly these types of problems.
posted by miaou at 4:35 PM on December 28, 2016

Platinum has it. Intraop monitoring is supposed to reduce the chances that working nerves become collateral damage during the surgery. I am surprised that BCBS would consider it investigational, but I'm not an insurance person. Do you know what exactly they were monitoring? The medical record would state whether it really was visual-evoked potentials (which would be a truly bizarre thing to monitor in a patient who is anesthesized and unable to stare at a blinking checkerboard!) Most likely this is a clerical coding error (e.g. someone typed 95153 instead of 95152, or G302.46 instead of G302.45, or something) and hopefully the billing&coding folks at CC will straighten it out.

If not, plead financial hardship. At my old hospital, there was some paperwork to fill out regarding how much you have in assets, and then you'd be put into a financial aid category, which ranged anywhere from 100% out of pocket to 100% charity care. I don't know specifics at Cleveland Clinic, but I would be very very surprised if they don't have a similar system.
posted by basalganglia at 4:46 PM on December 28, 2016 [1 favorite]

What SLC_Mom said - did they actually even perform this? I called my hospital once for a charge, covered by insurance, for a procedure that I was 100% confident they didn't actually do during my visit. Their response was "we charge for it whether we do it or not, since we don't get reimbursed by insurance enough for other services so we have to make it up somewhere."
posted by MonsieurBon at 9:51 AM on December 29, 2016

Take a multi pronged approach. Apply for financial hardship. Appeal with BCBS and ask them for all documentation on what they preapproved. Take that to Cleveland Clinic and ask them for their documentation on what was pre approved and all notes related to the surgery and all codes submitted to insurance. Pester them until they let you talk to a coder who will review your op note and the codes submitted and ask them why they were doing medically unnecessary procedures or if they can correct the coding to accurately reflect what was being done (CPT code) for what purpose (diagnosis code) and under what circumstances (op note). And I would be direct with Cleveland Clinic and explain to them that you are not going to pay a dime for this, but you will aid them in appealing to BCBS to pay their share if applicable.
posted by WeekendJen at 12:08 PM on December 29, 2016 [1 favorite]

Mod note: This is a followup from the asker.

Thank every last one of you for your suggestions. This thread was invaluable. I contacted my HR department through my employer and they were able to work directly with our BCBS account manager in a way that I never could by just calling the number on the back of my insurance card or writing a letter. I received notification this morning that they are covering the entire thing and that there is to be no "member liability" on my part. I can't tell you how happy I am. Thanks everybody!

posted by cortex (staff) at 7:45 AM on January 6, 2017 [4 favorites]