The business of healthcare

Another episode of the *Health Insurance Is Scary* saga.

This really is turning into a Scream franchise—me (Heather) writing about healthcare. Every time I think we’ve conquered an issue, there’s another scarier one lurking in the proverbial woods, waiting to inconvenience our lives.

At this point, I’m probably wrong to presume that we’re even dealing with people. There’s a greater chance that an AI tool or some sort of bot is denying our medical claims. What was already a horror show is now an even more complicated plot line. We need to defeat so many more goons just to make it to the End Boss, who is basically just the original representative you used to have direct access to from the start.

The technology making their lives easier makes our lives harder. That’s scary, but it’s also just…business.

For today, let’s put aside the morality of this conversation. Not because I am not infuriated by the lack of accessible, affordable healthcare to cover the basic needs of American families, but because we already know it sucks. The system is broken. I can go deep on this over a cocktail with any of you, but for now, yelling into the void doesn’t accomplish much. I keep writing about healthcare and health insurance (and other types of insurance) because apparently in 2024, people in the United States owed at least $220 billion in medical debt. Denied healthcare claims are an omnipresent threat to the average couple’s financial stability. I want to do my part to help change that.

The first time around, I offered readers a primer on selecting your health insurance plans. The second time, I dug into navigating the claims process. This will be a little different. What I want to offer you is some greater context for what’s happening to us.

I, like Elle Woods, have questions.

In a perfect world, the business of medicine and the practice of medicine would be separate and distinct affairs. However, our medical care is tethered to a network of organizations that want—err, need—to be profitable. It’s not just medicine. It’s basically any business or service provider. You could be a fantastic lawyer who writes killer legal briefs and fights tooth and nail for your clients, but if you can’t capture most of your billable time and expenses, or you can’t retain any staff, you’ll run into major issues with your business. Same goes for financial planners. You can be an amazing advisor but run an unduly complicated firm with too many personalities, too many products, too many distractions. In turn, your business suffers.

So what happens is, the business bleeds into the practice. Some of this will always happen, and it’s not always bad. I remember once after a catastrophic storm, an insurer I worked with agreed to automatically pay all policyholders’ claims up to a certain dollar amount. The business decision helped alleviate pressure on the insurer’s claims department, which was overwhelmed after the event. But the move also benefitted their policyholders, who got paid without delay.

Unfortunately, we don’t usually see such benevolent outcomes with health insurance claims. When the business of health insurance bleeds into the practice of medicine, real people lose. Patients’ care is denied, delayed, or financially devastating. Medical providers are then stuck dealing with the inherent conflict of providing much-needed care while balancing the pressure to capture the costs of giving that care from somewhere—from someone. That someone might be you.

Please know, the last thing I’d ever want this post to do is cause distrust in your doctors. I have the utmost faith in science and respect for the medical profession.

But I also want you to understand that the business is operating at all times. You deserve to ask questions like a customer, as well as a patient, whenever you see fit.

I haven’t shared the plot of my recent health insurance saga with you yet, so let’s get into it. Given my family history, I am predisposed to a higher risk of developing breast cancer. I’ve spent a decade under surveillance by wonderful breast specialists, whom I’ve always trusted with helping me make informed decisions about my care. But it hasn’t gone without hiccups. Just last fall, I told you about a coding issue that confused services from two separate billing years and took me months to resolve. Now, just when I thought I’d be in the clear, I find myself staring down another $300+ dollar bill for this year’s denied services.

As I would instruct anyone, my first step was to understand the claim denial by identifying the denial codes. There were two. The first I’ve become familiar with: “Your health benefit plan has an age restriction for this service and the member’s age is not within range.” Many health insurers won’t cover annual breast surveillance for individuals under 40 due to current medical guidelines. However, if you have family history or are designated as high-risk by your doctor, they can usually submit the claim under a different billing code, and it will get approved. I try to preempt this year after year—sometimes I am successful, sometimes I am not. This year, I am confident I’ll get it fixed, but to be honest, I turn 40 in a month (eek!), so it’ll be a moot point soon.

The second denial code was strange: “This member has exceeded the 1 visit limit for this service allowed per lifetime under the health benefit plan.” Uhhh, what? I figured out that the code was in reference to my breast ultrasound, which doctors recommend for women with dense breasts. I’ve been getting them for years on the same day as my mammograms.

The denial came as a surprise to me and my doctor, who I’ve now looped into this mystery. She couldn’t make sense of it but forwarded the claims denial back to the billing department. This is where things get weird.

When I posted about all this on Instagram, my DMs flooded with similar stories. Just this year, a handful of women I know had their breast ultrasounds flat-out denied for the first time. A friend told me that her health insurer advised that they’re no longer considering breast ultrasounds part of the “preventative care” covered under their policies. I didn’t bother to ask who her insurer was, because I know from professional experience that large insurers don’t make decisions in vacuums. They track each other’s moves. They follow industry trends. They make changes if not together than at least, with a full understanding of what everyone else is doing.

Which leads me back to the business: not just of health insurance, but of healthcare in general. If even a handful of my friends are facing new, novel denials of their breast ultrasounds, how many thousands of patients under the umbrella of my gigantic mid-Atlantic medical system also are facing denials of their breast ultrasounds? And why hasn’t that information trickled down to the most important employee, my amazing breast surgeon, who was just as surprised as I was? What would she do differently if she knew that most of her patients’ ultrasounds are going to be denied from here on out? Maybe it wouldn’t change her guidance for everyone, but it might for some.

At the risk of seeming like I have a tin foil hat on my head, I’m going to share my suspicions. I believe that the Higher Ups in Charge of billing at this medical conglomerate already know ultrasounds aren’t being covered. But they feel comfortable passing along a several-hundred-dollar charge to their patients, thinking it won’t bankrupt most of us. Those who need financial assistance can apply for it. The rest of us will be too confused or unmotivated to ask any more questions.

To be honest, if I wasn’t so disturbed by the chilling effect such business practices have on women being proactive with their medical care for a cancer that is so treatable when caught early, I probably would just pay the bill and move on. They are right—I am too busy to lose hours of my life to this issue. It’s a horribly dubious practice but an effective one to know that some customers won’t forge beyond the pain points you’ve set up for them to fail around. But I also know that if people like me, with the experience and insurance vernacular to move needles on big issues, turn a blind eye, what’s everyone else supposed to do?

One of my friend’s healthcare providers now advises patients before their screenings that ultrasounds are no longer covered under most policies. They’ve implemented a $100 up front charge so that their patients can pay and still receive the screening.

Before you get all up in arms about the indignity of it all, I’m asking you to consider that this is the second best outcome. The patient receives their screening; at a pre-negotiated rate (half of what I’m being left with); and no one in their billing department has to go through weeks of emails, calls, appeals, etc. It’s not perfect (ultrasounds should be covered as preventative care, dammit!). But we don’t live in a perfect world—far from it. Sometimes, we have to seek out our own solutions.

So, what will I do next?

I will appeal the age restriction on my mammogram. I will still fight the ultrasound with my health insurer, knowing they probably won’t budge. Simultaneously, I’ve sounded the alarm to my doctor that this appears to be an emerging trend with health insurers, and that her employer should address how they plan to prescribe and support their patients receiving the care they recommend at more affordable prices. I will then negotiate the bill directly with the medical provider, highlighting the fact that I know, that they know, I’m not the only one in this boat. Maybe I’ll be the reason patients get a flat rate next year. Maybe not, but at least I tried.

My point is, you are not limited to arguing with your health insurer when it comes to finding solutions for your medical costs. You need to keep your eye on the business practices of medical providers, too. You don’t need to be a skeptic to ask your doctor (and their office) simple questions, like:

• “In your opinion, is what you’re recommending medically necessary?”

• “What are some factors causing you to suggest we proceed this way?”

• “Can you please ensure you are coding this visit in a way that my insurer is most likely to accept it?”

• “If my insurer denies this service, I have concerns about my ability to afford it. Is there someone who can tell me how much this would cost out-of-pocket?”

• “Should I anticipate any additional costs outside of the main procedure (i.e., anesthesia, labs, facility fees, etc.)?”

• “Do you offer financial assistance or payment plans?”

• “Rather than continue fighting my insurer, I would like to negotiate this bill directly with your office. Who can help?”

Healthcare systems are larger than ever, and their business decisions can impact what happens in the room between you and your doctor. I don’t want this to be true. I can assure you, our doctors don’t want this to be true, either. But again, here we are. Let’s face this new reality by offering some solutions instead of waiting to be told what to do.

What do you think: are we screwed, or do we just need more ways to push back? Happy to continue the convo. Email us.

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I am shaken over the devastating floods and resultant loss of life in Texas. Anyone who knows me well knows that I am lifelong camper-turned-camp-mom who deeply understands that special places like Camp Mystic aren’t just about fun and adventure but about building character and instilling values that feed communities of people who hold those values close. Camp is a thread that tethers people together for life. But there is an inherent risk in sending your babies away, one that even in our darkest unreasonable mom thoughts, most of us could not fathom something like this happening. I write this from my daughter’s desk. She is away at camp for six more weeks.

In times like these, I don’t like suggesting just one organization to support. On Instagram, author Shannon Watts shared a diverse selection of larger and local organizations with boots on the ground. I donated to the Kerr County Flood Relief Fund and will be praying for the families of everyone impacted.

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TJA in the news

My quest to find Labubus for our daughters had me exploring the relationship between modern motherhood, privilege, and trend culture for SheKnows.

For CNBC, Doug weighed in on how buy now, pay later (BNPL) programs will begin reporting to credit agencies.

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