If you’ve ever read a book “Little Dorrit” by Charles Dickens or watched excellent mini-series by the same name, you may remember the Circumlocution office.
It’s a fictional/dysfunctional establishment known for its incompetence, an example of how not to do things. Their goal is to never give a straight answer. As Wictionary puts it, Circumlocution office is any organization that wastes time on bureaucracy to the detriment of its actual business.
Dealing with our insurance company and to a certain extent with the billing departments of various clinics, I couldn’t help but think that the whole health insurance system setup in the United States is the definition of Circumlocution office.
No, I’m not here to tell you that other systems are the way to go. I grew up in the Soviet Union, enough said. All I know is the mess I had to untangle over the last six months is not for the faint of heart, and I get why people simply give up after a certain point.
But let me back up and start at the beginning. Last fall we had a number of financial setbacks, but the biggest one of all was my son breaking his arm. Our insurance policy has a $5k individual deductible, a big chunk of change. And of course, the little rascal was healthy up to that point, so we were on the hook for the whole thing. After several trips to the urgent care, the hospital and multiple X-Rays, it was determined that he would need a surgery.
Of course, after the doctor’s billing rep looked into our insurance, they could see most of the deductible. So could the surgical center. However, many of the claims were pending, so I knew the deductible would be met by the time they did the surgery.
I tried to reason with both places, to no avail. In the end, I had to prepay $1,600 to the surgical center and $1,800 to the surgeon, with the promise from both that I would get a refund as soon as our insurance covered the bills. Well…
The good news is, the surgical center filed the paperwork the next day after the surgery (middle of November) and indeed, I got my refund a month later. Naturally, I had to call and request it. For whatever reason, the surgeon’s office dragged their feet and filed the claim at the end of 2023. And that’s where the trouble began. You see, my husband’s insurance switched carriers for 2024 and he forgot to tell me.
Although even if he did, I’m not sure I would do anything differently. After all, our old policy was valid until the end of the year. What could go wrong? On top of everything, my kids had their expensive yearly physicals at the end of December. Those were supposed to be covered 100%.
My husband and I had physicals as well, and then I went to a specialist since we met the family deductible by that point. We didn’t go crazy with various expensive procedures, but certainly tried to make lemonade from lemons thrown our way in 2023.
Threatening calls begin
Sometime in January of 2024 I got a call from our pediatrician’s office. The lady on the other end said my kids’ claims were denied and that we were responsible for $1,500. What?! I told her they were/are insured and the claims should have been covered 100%. She was skeptical and asked me to come in. I brought both insurance cards and she said they would file the claims again. Surely, there must have been a mistake.
Just a few days later I got phone calls from other providers telling me the exact same story. Hmm… I got a bad feeling and called the number on my new insurance card. Turns out, all of our claims filed in December of 2023 had to go through third-party that would facilitate the payments, not the old insurance company. I was given instructions on what to do, and passed them along to the medical providers looking to get paid.
Few weeks later I got a phone call from the pediatrician’s office telling me the claims were denied again, and that they are running out of patience. These folks were clearly the most cash-strapped out of all of my collectors. Nevermind the fact that my kids went to this clinic for 16 years and enriched them greatly up until this point. I never owed them a dime before. But OK. I told them I wanted to get it resolved as much as they did and was given another month.
I called the third-party again and asked for clear instructions on how the claims should be filed. This time I was given a totally different information. Out of curiosity, I hung up and called again. It was a different set of instructions altogether. By that point I’ve escalated and asked to speak to the manager. No dice, but they said they would assign someone to my case. Finally we would take care of this mess. Or so I thought.
Over the next several months, I would call the providers (who were super irritated by this point) to ask about any progress. Over and over again I was told that the rep called them, they filed the claims according to her instructions and that they were denied a few weeks later.
I would call the rep and she would say that she is working on it, and it’s the providers who are not following her directions. When I asked what the instructions are exactly, she would tell me it’s too complicated to explain. Terrific. But she promised me to call the providers and put a temporary hold on my bills. Again. And she did, but that was just kicking the can down the road.
After this rigamarole went on for another few months, I’ve had enough. The final straw was when the surgeon’s office said they were tired of filing this same claim over and over again only to get rejected. And remember, they are the ones who collected $1,800 from me. I escalated to my husband’s HR manager and things finally started moving in the right direction.
Even then I had to follow up with the same rep because they lost some of the claims, but then magically found them when I escalated. Just yesterday I saw that the last pending claim was finally paid. At last, I’m done with this nonsense. Oh, and I got my refund of $1,800.
Things I’ve learned from this experience
1) Take a deep breath because it will probably be a bumpy ride
Any time you are dealing with plethora of medical claims, you have to pay attention. For example, the ER doctor’s bill was never filed to my insurance. I just got a statement in the mail, wanting me to pay $1,300. After examining it, I didn’t see any information about my insurance, so called the company. They said they never got it, which is a lie. But the point is, you have to examine everything and look at the fine print. Don’t assume that other people will do their job correctly.
2) Do whatever you can to avoid making pre-payments to medical providers if you are sure you won’t owe them anything in the end
This one is easier said than done, and I wasn’t prepared to play chicken with my son’s surgery. But I’ve heard from friends who played hardball, and their surgeries went as planned anyway. YMMV
3) Apply for financial assistance
When I got the bill from ER, there was information on it on ways I could reduce it. I didn’t have much hope, since we are solid middle-class. However, turns out, we would have to make over $120k per year not to qualify.
I did include information on our US savings bonds (around $15k), but that didn’t preclude us from getting help. In the end, I got $2k knocked off the bill. A pretty good return on several hours of my time. I should mention that I tried to send our application electronically, but somehow they never got it. I sent it via registered mail and received a letter telling us we were approved.
You won’t get financial assistance for scheduled procedures, and the hospital would have to be non-profit. But my point is, you should always apply for discount. What do you have to lose?
4) Document everything
My big mistake was not insisting on doing all communication with the third-party rep via email. That way I could ask her to outline to me exactly how these claims are supposed to be filed. Afterwards I could show it to medical providers to make sure we are all getting the same information.
As it was, the providers blamed the office that the insurance company outsourced to, and the latter blamed the providers. Since I wasn’t there for their interactions, I couldn’t be sure who exactly was at fault. My money is on the insurance company.
I’m not into conspiracy theories, but it doesn’t take a genius to see who benefits from this whole scheme falling apart. I can just picture people throwing their hands up in the air and agreeing to making small payments to providers just to be done with it. Not me. No, sir.
Which brings me to my last point.
5) Involve HR if you have health insurance through your job ( or get a lawyer)
This is probably the most important tip of all, and many people are not aware of it. I actually had to ask for HR help in the past, and it’s something I prefer to save for extreme circumstances. Well, this was it. I really wanted to untangle this web myself, but at certain point had to admit defeat. Plus, several providers were about to turn my son’s bills to collection agency. If that happened, it would ruin my credit score. How would I get approved for new credit cards?! That’s my bread and butter.
It goes without saying that I would NOT pay all these bills on principle. Of course, I would also have to say goodbye to my $1,800.
If you are insured through a marketplace and if the sum owed is relatively large, it’s time to lawyer up.
Author: Leana
Leana is the founder of Miles For Family. She enjoys beach vacations and visiting her family in Europe. Originally from Belarus, Leana resides in central Florida with her husband and two children.
@projectx It was indeed a mess. It was essentially my part-time job for 6 months. I wish I was kidding! And in the end I still had to go through HR.
What a mess. Health insurance companies should be classified as a criminal enterprise.
@Russ Oh, that doesn’t surprise me! It’s interesting how the mistake is always in their favor.
I absolutely detest the health insurance setup in this country. I know there is no perfect system, but there has to be a better way.
Health insurance is a racket. My wife and I are on Medicare and lately some providers are sending bills directly to us and not submitting them to Medicare. They hope we think that Medicare has processed these claims and this is what we owe, so we pay their full bill and they do not have to take a reduced payment from Medicare. I call and ask if Medicare has received the claim, their response–we didn’t know you were on Medicare! We’ve been dealing with this hospital for over 25 years. Healthcare needs to be non-profit, pay the doctors, not the administrators and systems.