On a Thursday in early November, 2011, I was diagnosed with inflammatory breast cancer. Because it is a fast, aggressive cancer, chemotherapy treatments were scheduled for Friday of the next week. On Tuesday (before chemotherapy began), our family attended a meeting with a social worker, oncology pharmacist, nurse navigator and an insurance specialist.
When the insurance specialist was introduced, we were told she was an “expert in insurance” and would be available to help us navigate through any insurance problems. as with everyone else in that meeting, her business card indicated she worked for the hospital and her official title was confirmed as “insurance specialist.” We asked miss Insurance Specialist if she would mind looking at our health insurance policy to see if she saw anything that could cause problems. miss Insurance Specialist indicated that she would be glad to. a week later she returned the policy and assured us that once we met the cap on our deductible and co-pay for the year, everything would be covered by insurance. that is how we also read the policy, so we were delighted to get confirmation from her.
I had made sure that all of the doctors and the hospital were approved in-network providers through our insurance. When I was on campus, I felt that I was in a medical all-inclusive resort. If the doctor said I needed it, insurance would cover the costs. Chemotherapy treatments were started immediately that week. the routine included an appointment with the oncologist, and then a walk across the hall to receive chemotherapy. At the time of treatment, no statements were ever offered for me to look at. as I would leave, I was told that insurance would be billed. the hospital bills insurance on a monthly basis, then insurance takes a few weeks to process the claim. I didn’t get the first insurance EOB (explanation of benefits) until I was two months into chemotherapy.
When the first EOB arrived, it was several pages of line items. Everything was described as “hospital services.” I was perplexed to see several $185 charges that the EOB stated were not covered benefits. All of those $185 charges were on chemotherapy days. I immediately called the insurance company to inquire why these charges were not covered.
Ins. Rep – “Oh, that’s a minute clinic fee and minute clinics are not part of your covered benefits.”Me – “What’s a minute clinic?”Ins. Rep – “That’s like when you go to a Walgreens and get a flu shot. That’s not a covered benefit.”Me – “the only clinic I’ve been to is the infusion clinic to get my chemotherapy. If chemotherapy is a covered benefit, surely the clinic fee for that is a covered benefit also. I don’t think the doctor would let me bring my chemotherapy home and administer it to myself.”Ins. Rep – “sometimes it’s the code the hospital uses that kicks this out. Call the hospital and see if they can resubmit the bill using a different code. If this is how they bill, then simply write a letter of appeal explaining this is how they code it. It should be covered then.”
I hung up, feeling confident these charges were nothing more than a clerical error by a claims processor not paying attention to what they were doing. My next call was to the hospital billing department. I repeated the conversation I had with the insurance company to the hospital’s representative. she listened and assured me that she would send it “upstairs” for review and maybe they could change the coding to make insurance happy. I assured her, if necessary, I would gladly write a letter of appeal.
At the next chemotherapy appointment, I made a point to find miss Insurance Specialist and ask her opinion of these charges. as I handed her the insurance EOBs we had this conversation:
Me – “the insurance says these are clinic fees and I’m responsible to pay them in addition to the deductible and co-pay. the only clinic I can think of is the infusion clinic. Do you have any idea why insurance would think this is my responsibility?”MIS (after a quick glance) – I don’t know. I read your policy. You don’t owe a penny more than the deductible and co-pay. I would keep track of everything I paid and when that maximum is reached, don’t pay anything else.
On a weekly basis, I would call the hospital billing department, talking to different people, asking them if they had figured out another code to bill my insurance company for these charges. I knew I had a small window to file an appeal and I didn’t want to miss it. After a month, I had a conversation with the hospital’s billing department representative where she stated:
“This is how we bill. I don’t know why your insurance company doesn’t want to pay this. It is a clinic fee and we are billing under the hospital name. they are standard fees. We bill under this coding all the time and every other insurance company pays with no problems. When you send the letter of appeal, send us a copy and we’ll put the contested amount back in the insurance bucket.”
I immediately mailed my letter of appeal – via registered mail, return receipt requested, just so the insurance company knew I meant business. I received a letter back stating it would take them 60 days to review the matter. during this entire time I continued to receive chemotherapy and book oncologist appointments, absolutely certain that insurance would see the error of their ways and rectify the situation. EOBs continued to come in showing those pesky $185 charges they said I was responsible for.
As chemotherapy ended, I was in a conversation with the hospital billing department trying to settle up what I knew I legitimately owed. their rep was badgering me to also pay those “clinic fees” that were under appeal. I explained that I had already made arrangements to wait on those until my insurance appeal came back. she wouldn’t budge on the issue, so I asked to speak to her supervisor. It was then that I received information no one else in the system had cared to share with me for five months.
Me - “I don’t understand why my insurance is not paying these fees. the policy states that clinic fees are covered. I just know in my heart that when the appeal comes back, they will find in my favor.”Supervisor - “Part of the problem may be in the method of how the hospital bills insurance. the clinic fee is the hospital’s fee for your visit to the doctor and it is a separate billing from the doctor’s fee. If you were going to a doctor across the street from us, you would not have this problem because they bill insurance with a single charge.”Me - “I’ve seen Dr. General Surgeon and Dr. Plastic Surgeon. they are both hospital doctors in the same building as my oncologist and you bill on their behalf, just like my oncologist. Why am I not billed clinic fees for them?” Supervisor - “You are right, they are all hospital doctors. However Dr. Plastic Surgeon has his own office in another part of town, so we can’t bill clinic fees for him. I’m not sure why there’s not a clinic fee charged for Dr. General Surgeon.”Me - “I love my oncologist, but for me to quit incurring these fees, are you saying I need to find another doctor across the street?”Supervisor - “Don’t worry. I think something can be done if the appeal doesn’t work out. You work with us, we’ll work with you.”
This was the first time anyone explained the multiple $185 fees I was incurring were hospital charges for seeing the doctor and had nothing to do with chemotherapy. I couldn’t wrap my brain around the idea that the hospital could charge a fee over and above the doctor’s charge. many years ago, my sister worked in the insurance industry. I shot her an email recapping the conversation. My sister has many talents, but one of the most extraordinary is her ability to research. she responded with a note saying “I think this is what you are being charged” and included links to two articles explaining facility fees. I don’t know how she did it, but she managed to make the connection that the term “clinic fees” equals “facility fees.”
After reading the articles, I looked at my insurance policy and there is clearly an exclusion for facility fees. to say I was angry is an understatement. I feel like the five year old who has been playing Monopoly with 12 year olds. Everyone knew the rules and I was asking questions, but no one wanted to share their knowledge. they even changed the language on me.
Two weeks after the hospital billing supervisor assured me their department would be happy to work with me, I received a call asking for payment of these fees – so much for “working with me.” Armed with new knowledge, I explained that THEIR employee – an INSURANCE SPECIALIST had assured me I didn’t owe these fees. the reply was that the hospital could not be held responsible for such statements. I was told that I received the services so I needed to pay the bill. It wasn’t my proudest moment, but I used the line “I need to call my attorney.” the rep ended the call telling me how many days I had until the matter went to collections.
I’m still waiting on the appeal from the insurance company; the sixty day period for review will expire in a few days. Based on my policy exclusion, I’m not holding out any hope that the insurance company will accept my appeal. I’ve changed oncologists. My new oncologist, who I also think is fabulous, said that their office has acquired several patients fleeing the facility fees.
I’ve reflected on the entire matter and tried to figure out how I could have prevented incurring fees I didn’t even know existed. I’d like to try to fight these fees but it’s difficult to figure out who is actually at fault. It ultimately would have been nice if the fees had been explained up front. the insurance specialist should have known how the hospital billed, caught the policy exclusion and put two and two together. I know I’m not the first to have these billing issues, so I feel someone in hospital billing could have set me straight during one of those phone calls. and I think the insurance company could have been more helpful with their explanation of non-payment.
Being older and wiser, I called a few days ago to inquire if the hospital charged facility fees for the radiation oncologist I was being referred to. It took three phone calls (at first I received two “I don’t knows”) to find out that, yes, facility fees would be charged. I told my new oncologist that I would stick my chest in a microwave and give myself radiation treatments before I incurred another facility fee – surely there is an instructional YouTube video for radiation do-it yourselfers.
I can only hope that my story saves you from incurring these charges. If it does, that will make me glad and make today a good day!
Note:Click >>> here<<< for my informative post on facility fees and how to avoid them. Click >>> here <<< for a Wall Street Journal article (found by my awesome sister)Click >>> here <<< for a Washington Post article (found by my awesome sister)If anyone has any ideas how they would fight this, or even if you think I owe these fees, I welcome your feedback. This is a public blog – if you think there is anyone that would benefit from this information, I encourage you to forward this to them. I sincerely believe knowledge is power. and finally, this is an unusually lengthy article. If you have stayed through to the end - thank you!