The Administrative Burden of Getting Healthcare

by Honolulu Mother

In this Vox article, Sarah Kliff describes the process of coordinating her health care for a minor medical issue as “a part-time job where the pay is lousy, the hours inconvenient, and the stakes incredibly high.” She writes that

But American medicine demands another scarce resource from patients, and that is their time. The time it takes to check in on the status of a prescription, to wait for a doctor, to take time away from work to sit on hold and hope that, at some point, someone will pick up the phone.

I found dealing with the copious administrivia stemming from my daughter’s broken limb last year to be frustratingly time-consuming, and I wasn’t even dealing with the lion’s share of it. The billing disconnects between providers and insurer, the denial based on my husband’s name having been accidentally entered in the patient slot for one provider, the confusion as to whether some new piece of mail was an issue to be attended to or just another routine notification; it seemed that once we left the safe and familiar harbor of routine annual appointments we were at sea without a compass.

How have your experiences as a patient or patient’s family member been? Do you think the burden of administrative health care management falls on patients because practitioners aren’t aware the burden is there, or do you think it’s a more deliberate outsourcing as suggested by the following quote?

“Patients can often become the health care system’s free labor,” Mayo’s Montori says. “The health care system knows that patients are motivated, that they want to get better. So it gains efficiencies by transferring the work.”

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101 thoughts on “The Administrative Burden of Getting Healthcare

  1. I don’t know that it’s intentional outsourcing, more that these various components of the health care system have just no incentive to make things easier for the patient.

    This is my favorite thing about Kaiser — as long as you’re in-system, it is completely seamless. Then again, if I had something really life-threatening, I also wouldn’t want to be restricted to Kaiser. It’s all tradeoffs.

  2. I have what we fondly used to call our million dollar baby because of the bills he generated before coming home from the hospital. I am organized, detail-oriented and had a lot of available time to deal with the providers and insurance company. It was a huge nightmare and took years to straighten out. At certain points, I just kind of gave up and paid amounts that I knew were incorrect. We also had a representative from the ins company assigned to us because it was such a mess. She was helpful but couldn’t mess sense of a lot of it.

    I can’t imagine trying to deal with this kind of stuff while being the patient. I came away with very little confidence in the health system.

    Also, the number of mistakes that were made/almost made was frightening.

  3. “Basically I call the pharmacy, and tell them I’m out of medication,” he says. “And sometimes they’ll call my doctor for a prescription, and sometimes they won’t. So I call the doctor’s office to say, ‘Hey, I’m out of meds, either the pharmacy will call you or you need to call them.'”

    He should be able to request a refill online or his pharmacy should push an refill request to his doctor electronically. If his doctor isn’t using e-prescribing then he needs to find a new doctor.

  4. Having just spent 4 phone calls and one hour trying to get a referral, I agree!

    Also, this problem doesn’t speak to the availability of health care. The simple act of getting health insurance is an issue with our family.

  5. The healthcare system is a nightmare to navigate. Do you only have one insurance company or a primary and secondary coverage? Are the providers in or out of your network? Are certain providers allowed to bill you the balance and does all of that apply to your out of pocket annual maximum? Then, as HM said, is this a bill, a notification, a form that requires your signature to bill the insurance?

    It takes a lot of patience, documentation, and time to get it all worked out. I will say that with my mom’s care this past year, most of it went fairly seamlessly. The big issues were EMS, who can’t bill insurance or medicare without your permission, even though they collected that information up front. Between medicare and her Part B coverage, very little wasn’t covered.

    My biggest gripe is that your insurance company constantly says, you should be informed and manage costs, but when you ask them for information on what your percentage will be on a specific procedure….you even have the code…the don’t even want to give you a range. So, how in the heck can you manage a cost they won’t tell you? So, you just jump off blind. I deal with that much better when it is something urgent, its the optional stuff shoves me over the edge.

    My personal story is my DD#1 has a mole on her hand. It isn’t growing or changing, but pediatrician thought it should be removed and sent us to a general surgeon. Well, no, you need a pediatric plastic surgeon and this is elective surgery. So, all office visits are at the “surgery center” – minimum of 3 visits – initial consult, day of procedure, and follow up. Each are billed separately with a $100 copay, because the facility is the same as visiting the hospital. Plus, the 20% of the costs and getting balance billed by the anesthesia team as they aren’t under contract and are considered out of network. So, about $600-$1000 for a mole removal that is optional. Back to pediatrician for WHY she thinks it should be removed. Answer – (1) cosmetic and (2) it is on her hand so if it does grow it could be a bigger deal to remove. We asked for referal to dermatologist, who said – if it doesn’t bother her just watch it. So, we see him every two years or if she things its changed or bothers her….so far its every 2 years.

  6. Oh…and when I was pregnant, the hospital was billing for something and the insurance was denying it. The problem was neither of them could tell me what is was for because…get this…of HIPPA. They could give me codes to ask my doctor about, which I did and his office could not find that code anywhere. They called the insurance and the hospital who refused to explain the code….again…because of HIPPA. I told them I didn’t have any record of service on that day and if no one could tell me what is was for, I wasn’t going to pay. Ultimately, it went to collections. At that point, they offered me an amount that was 1% of the original bill and under $20. I paid as it was less hassle than to keep fighting.

  7. My DH had an ACL surgery a couple of years ago, and I handled the claims/billing. To say that it sucked was being generous. Everyone tries to bill you based on what the insurer says is left in your deductible at the time they verify insurance. Due to the timing of billings, that means you end up overpaying, and as the claims roll in from every individual provider who so much as glanced at him, the deductible is met and you are then in your own to seek repayment from those providers who were overpaid.

    I learned that a few providers do not voluntarily refund your overpayment, even though they can see you have a large credit balance. You have to request it, after sitting on interminable hold with multiple departments. It made me really miss having an HMO where you just pay one fee. One provider charged over the agreed upon rate and wanted us to pay what insurance disallowed, and DH was charged for therapy equipment he never received.

    I worked from home then, so could at least waste the time on those calls from the privacy of home. I can’t even imagine dealing with such time-consuming personal stuff here in Cubeland.

  8. I consider myself to be above average intelligence and I think medical invoices are so confusing. We are often billed incorrectly (overcharged)

    my husband handles all of this, he used to work for an insurance company

    sometimes there are so many issues, it is almost a full time job

  9. There was a recent article by a physician about how difficult and expensive it can be to navigate even if you’re a doctor. I think it was in NYT, but I can’t look for the link right now.

    I recently had to pay extra for some additional follow up test for something on a breast ultrasound. I was fine, but I had to pay out of pocket because it was done at six months instead of waiting for an annual mammo and sonogram. There is very little that I like about Gov Cuomo laws in NY, but he recently signed a law that will require insurers to pay when additional mammograms or ultrasounds or needed within one year due to suspicious findings.

    I’m sure the reason is because he is now very familiar with how the system works due to Sandra Lee’s treatment of breast cancer.

  10. @Rhett, electronic prescriptions aren’t always an answer.

    My DD is on specialty meds and they are highly regulated. I have to phone in a refill each month, and the earliest date I can call to place a refill is a regulated. Her doctor has to file an appeal to get the meds released to her, and the insurance company will only approve it at 6 month intervals. So every six months I have to call the doctor and have her refile, which then takes the insurance company a week to review and approve, and then I can reorder the next 30 day supply. I’m currently down to the last week of medication and I’m waiting for the insurance company to approve the latest round. I’ve been on the phone and on hold for much of Thursday, Friday, and this morning with multiple medical offices and the insurance company to make sure that all necessary documentation has been sent and received.

    I would love something as simple as auto refill or online refill, but unfortunately it isn’t an option for this type of medicine.

  11. I have reached the point where I just don’t pay any bill I haven’t received three times, after learning that that is how long it takes for our insurer and the provider to figure out what we really owe.

    Even then, I think we are frequently overcharged.

    It would be nice if the standard EOB had a line for “amount of deductible spent” for the individual and the family, and the “percentage of procedure covered by deductible”, because then I would trust their math more.

  12. We had many insurance issues during my illness, including a denial of a portion of my surgery three days beforehand. My DH dealt with it because I was in no shape to do so. We have a friend facing a terminal cancer diagnosis, whose spouse is a physician, and it took 24 phone calls to get the insurer to approve a chemo regime that it had previously approved without issue. If Totebaggers have this much trouble, then the janitors and fast food workers are simply out of luck. It is a travesty and very difficult to help others because insurers and physicians won’t talk to neighbors or friends.

  13. Don’t even get me started on this. At one time, we had boxes of bills and EOBs. I don’t think there was ever a single EOB received that didn’t have a mistake in it. And when you are spending lots of time inpatient, with a desperately ill, puking all night toddler, you don’t have time to spend on hold for hours with an insurance company rep.
    We finally had to hire a case manager who specialized in this stuff. We couldn’t keep up and the bills were piling up. At one point, we owed almost 100K, or so we thought until the case manager sorted through all the mistakes.

  14. When I worked in health IT, I had several colleagues who had worked on the payer side. They told me that these companies intentionally lost claims or slowed them down. They realized that most people wouldn’t challenge mistakes. Doing things slowly and incorrectly is a money maker for the payers.

  15. Oh insurance… the blessing and curse of the first world…

    For years I had dual insurance – my grad school’s catastrophic plan I could not opt out of (I tried yearly) and DH’s. Usually it was never a problem – I handed over the grad school card and then DH’s. I made sure to tell them the grad school was primary, DH secondary. For normal things, this was fine. Most of the time the catastrophic plan covered something routine.

    Then we went to fertility treatments. The clinic kept losing my grad school insurance. I gave them my extra card so they ALWAYS had the information in my file. The billing department kept kicking it out of the system. So, DH’s insurance would be billed as primary. They would reject and I’d get a nasty letter from the clinic claiming I lied to them. So I’d be back on the phone saying “no, DH’s is secondary. They will only pay after my primary rejects the claim. Try again.” It got to the point I was doing their job for them.

    After I got pregnant, I was no longer covered by the grad school. I gleefully filled out the paperwork with DH’s insurance to turn them to primary. When I got put into high risk, the billing got crazy. I think I spent ~2-3 days a month dealing with it. I was advised to wait everything out at least 30 days, and to call in every bill to make sure we were charged properly. So I did. Spending those 2-3 days a month verifying bills saved us >$50,000 in out of pocket expenses. I must have had a wonderful sticky note on my file at the insurance company. And, of course, those days were work days, so I was always on hold while working in the background.

    Like Kate, I had a million dollar baby. All told, we paid next to nothing for him. But I always wonder if I wasn’t so organized and high on the executive function spectrum what would have happened.

  16. We had a little taste of this last summer again, just for nostalgia’s sake. My kid gets longterm followup at MSKCC. Last summer, they asked if he would participate in a clinical trial in which he had to go over to Cornell-Weill and have some tests run. Since it is a clinical trial, our insurance was not supposed to be charged, but they warned me, Cornell often did it anyway. And sure enough, they did. The insurance company denied and we got a bill for a couple thousand dollars. I called Cornell and explained and they said they would fix it. Well, they didn’t. We kept getting bills, and then we started getting threatening phone calls. I kept calling them, and they would say they didn’t know anything about a clinical trial. I called the doctors office at MSKCC, and they said that Cornell had been properly notified. Finallly, I called the doctor herself, and said we would not be participating in this year’s data collection for the trial if she didn’t get the problem fixed. It has been 4 months since the last bill so I think we are OK now

  17. My recent issues have been with the cost of meds which have skyrocketed. I now shop around at different pharmacies before I fill a prescription, and I regularly refuse prescriptions if I think they’re priced too high. I’m finding more and more that the pharmacies and docs will work with me to find a program that offers the same drug at a discount or the doc will find a lower priced alternative. Fortunately, none of these meds are for life threatening conditions.

  18. I’m still waiting for one of those bills to crop up again and cause mass panic. We kept a file of every EOB, bill, etc we received. When we paid a bill, we copied the check before we sent it and attached the copy to the bill. Every time we spoke with someone I took detailed notes. I’m patiently waiting for the day I can burn that file box to the ground.

  19. And, yes, those with less time available and/or executive function are likely worse off.

  20. Since it is a clinical trial, our insurance was not supposed to be charged, but they warned me, Cornell often did it anyway.

    Most likely someone entered your insurance as the payor not Study_AXY. From a computer science perspective how to you ensure that doesn’t happen? From here in the trenches, part of the issue is that work flows are being developed in isolation without a thought to the overall workload of the user performing the action.

  21. I know we are mainly discussing the horrors of dealing with insurance companies, but there is another kind of unpaid labor in all of this – caregiver labor. When DS2 was inpatient (and he was inpatient for over 100 days), it was expected that a parent would be inpatient too, sleeping on a little couchette jammed in the corner of the (shared) room. Of course, we appreciated that – who wants to be separated from their toddler in the hospital? But it also meant that the inpatient parent took over a lot of the caregiving from the nurses and other staff. For example, as I mentioned, DS was puking a lot, often 2 or 3 times a night. When this happened, I was the one who dealt with it. The nurses had shown me where all the sheets were kept in the hallway, so I would get up, clean everything, and change the sheets. And of course I was going to to do that – no mom would wait for a nurse while their kid was covered in vomit if she could do the job faster herself. I was also the one who sat up all night holding a blow by tube over my kids nose. And I didn’t mind, but I couldn’t help but think of how much labor was being savd by the hospital by using the parents to do the low level nursing jobs. Years later, when my father was in the hospital, his wife stayed with him and did much the same. When it is a loved one, you want to do the caregiving – but that means the hospitals don’t need as much staff.

  22. Rhett, you are completely right. The problem is that once something is incorrectly entered, there is no workflow for fixing it. And when the issue spans two hospitals, as this one did, it becomes really difficult.

  23. Add to mistakes the fact that EOBs are so opaque. If a claim is denied, they’re supposed to tell you why. When my insurer denies a claim, the only reason they give is “This amount is not payable under the plan.” Well, no s***–if it were payable, you would have paid it.
    What especially annoys me is when they deny part of a claim. I just got a bill where they paid $200 of the bill but denied $383 as not covered under the plan and therefore my responsibility. So which $383 did you deny and why?

  24. As stated above, I’m pretty sure they are deliberately inefficient to save money. I’ve heard anecdotally that a lot of things are denied the first time simply because so few people will appeal that it automatically cuts the costs of certain procedures. When I had serious medical issues, my DH had to take care of me and then deal with all of the bills and double check them. Plus work full time– he was exhausted.

    It’s also true that so much of the time or money-saving tips are only useful for things you are managing chronically. When I’ve had prescriptions, they’ve been because I was really sick and not thinking very clearly, or some emergency had happened. In those instances we have just gone to fill the prescriptions, noticed how horrible the costs are, and muttered and dealt with it. (I don’t take a family member with me to the doctor for a kidney infection, etc.) All our family members are not experts at paperwork, experts at insurance rules, experts at prescription medication, etc. Anything truly urgent seems to take all the tips and throw them out the window.

  25. The problem is that once something is incorrectly entered, there is no workflow for fixing it.

    Sure there is. The problem is getting your issue routed to the person who can take action on it. That said, their system might also be set up such that the presence of a billing related ticket doesn’t stop the billing/collections process. So, Debbie might have a “change the payor and resubmit” in her queue but the billing system doesn’t know about it so they keep calling and sending you letters.

  26. Ginger and anyone else – I have found that if I google the medicine name and coupon, many of the manufacturers have discount programs where you can get the medicine at a steep discount. For our family, I can think of 2 expensive prescriptions we are getting for $0 copay, and 2 that we pay $25 for that without the discount program were $75-$100 per month. These programs will not let you enroll if you’re on Medicare.

  27. You can also check goodrx.com to compare prices locally. S&M put me onto that one.

  28. When it is a loved one, you want to do the caregiving – but that means the hospitals don’t need as much staff.

    If families weren’t doing it, the hospitals wouldn’t hire more nursing staff. They current nurses and CNAs would just be doing more work and it would take longer for the patients to receive the care. Hospitals view nursing and CNAs as an expense, which is why they are chronically understaffed.

  29. I have sat in the room of a large, national insurance company where decisions on coverage were being made. “Let’s just deny it, the more appeals we have the more job security we have” is a direct quote from one of those meetings. It’s deliberate, and it’s appalling. And it should be criminal.

  30. Denver Dad (and Ada, if you’re around): why is there so much contempt for dermatologists? When my mom had a weird rash on her leg, I did what I always do — I asked nurses who was the best local derm. The three I asked warned me that almost all derms are bad. They agreed on the one best one (it’s Migs Muldrow, in case you are interested, DD) and she was indeed good.

  31. MM,

    Finallly, I called the doctor herself, and said we would not be participating in this year’s data collection for the trial if she didn’t get the problem fixed.

    By the doctor herself do you mean the Principal Investigator? At a place like Cornell the PI should have been assigned a Clinical Research Coordinator who is responsible for billing issues. However, I bet there system is based on the payor being entered correctly and if it’s not and all you have is the ordering provider, there is no way to easily look up who Dr. Smith’s CRC is. So, even if the billing person knew to e-mail Dr. Smith he/she would need to either take action on it or forward it to their CRC. But, providers prioritize clinical actions and decisions above billing related issues so it’s not a sure bet that he/she acted on the e-mail.

    And, at every step of the process someone who is missinformed can route the issue to the wrong person. The CRC may think that admissions needs to the change the payor but it’s actually billing. Or, admissions thinks that changing the payor causes billing to resubmit the charges but it actually doesn’t so they e-mail the CRC that it’s all set when it really isn’t. And, all along, it may be that the CRC was supposed to be trained to resolve the issue but they never were.

    And, it can get even more complicated. You could have someone who was hurt at work, hurt in a car accident, in a reserach study and they have an issue billed via their regular insurance. And, they have reoccurring appointments. So, at ever step of the way each person who places or releases an order or books an appointment has to be sure to chose the correct payor or the charges are going to bomb out.

  32. Rhett, yes she is the PI. And the reason is that I needed someone to actually get the process going. My problem was that Cornell is a “foreign” hospital – my kid wasn’t being treated there, I didn’t know anyone there, and had no idea how to find the right person. The people in Cornell’s billing office were definitely not the right people. They had no idea how to handle an order that had come from a clinical trial at a different hospital. I didn’t have the name of anyone at Cornell to give them. So I needed someone at MSKCC to handle the issue. One thing I have learned is that it is really hard to accrue kids onto these clinical trials, especially late effects trials. A PI can get stalled for years waiting for the numbers to accrue. So threatening to leave the study was the best way to get action taken. And it seems to have worked.

  33. When we have this discussion on here, we often wonder sadly about how anyone with lower “executive function” and less time handles these. I figure they probably don’t bother. Totebaggers love HSAs and FSAs and high deductibles, but working/middle-class people, I think, prefer $10 co-pays in exchange for much-higher monthly premiums. After reading this, you can’t hardly blame them. And further down the ladder, the providers can just bill Medicaid, so there’s even less of an incentive for the patients to correct the record.

    Maybe that’s the problem. All the overbilling and obfuscation generally works out well because very few people have any reason to fight it.

  34. MM,

    Then operationally, when you agreed to the study they should have given you the CRC’s (or the PI if there was no CRC) contact information and instructed you that they are the single point of contact for any issues related to study.

  35. “Maybe that’s the problem. All the overbilling and obfuscation generally works out well because very few people have any reason to fight it.

    That is totally the reason why the system is like it is. The insurance companies make more money if they make the system so complex that most people give up.

  36. Yes, I had the PI contact info, and that is who I contacted. I contacted her first, but not much happened. It wasn’t until I put more teeth into it that I got action.

  37. MM,

    Then I guess they way they usually try and deal with those problems is to use clinical research coordinators to handle some of the study administrivia.

  38. Milo – you at exactly right. In Virginia, there is institutional Medicaid for any neonate who has a hospital stay in excess of 30 days from dob. Without regard to income. Guess how many people really care about trying to straighten out the insurance mess when Medicaid will just pick up the balance? It drove me nuts.

  39. Guess how many people really care about trying to straighten out the insurance mess when Medicaid will just pick up the balance?

    What makes you think they “just pick up the balance?”

  40. Because that is how it happened to the people I knew. And when the financial aid office met with us, that is what they told us. And every time I would have to work with them about messed up things, they basically told me to STFU and not worry about it. I wouldn’t be paying anyway.

  41. Denver Dad (and Ada, if you’re around): why is there so much contempt for dermatologists? When my mom had a weird rash on her leg, I did what I always do — I asked nurses who was the best local derm. The three I asked warned me that almost all derms are bad. They agreed on the one best one (it’s Migs Muldrow, in case you are interested, DD) and she was indeed good.

    This is the first I’ve heard of contempt for dermatologists. I will keep Dr. Muldrow in mind.

  42. The other thing that is frustrating is that even in this high tech world, systems that should talk to each other dont. Example, my mom was feeling badly. I took her to her primary care, who referred us for some tests at a related facility down the road, but said if she is worse, go to the ER. During the visit, was wasn’t feeling as bad and thought maybe it had passed. She started feeling worse again at the end of the last test – an xray. By the time we were leaving the building, she could barely walk. So, off to the ER. EVERY SINGLE test we had just done was redone on this woman. They were related facilities, but couldn’t talk to each other!

    This is partly why we would always go to the same hospital. At least they had the records from the prior visit. This often helped as my mom aged to see what things “looked” like a year, 6 months or whatever ago.

  43. Mooshi – I have never really thought about the free inpatient caregiver before. I’ve heard that patients with frequent visitors typically have better outcomes, but naively thought that was because of emotional health (mind over matter) and having an advocate to make decisions (not physically helping in their care). Having that visitor as a caregiver means that the patient isn’t laying in their own vomit or waste for long, decreasing infection risks and what not.

    I continue to be amazed at all that you have had to do for your child. Thanks for sharing tidbits of your journey.

  44. “That is totally the reason why the system is like it is”

    “you at exactly right”

    And I wouldn’t have said anything, except just last night at an Independence Day get-together, I was talking to a Kindergarten teacher who works at a non-Totebaggy school, although not even one that is particularly disadvantaged.

    She told me how, with many of the kids, she can’t get the parents to do much of anything. On here, we bitch about the amount of time required to assist with projects; these parents don’t even open the folder of the work sent home. The papers just pile up week after week, and come right back to school with the child.

    So there’s just no way that these same people are putting on their green visors and comparing the EOB statements with the provider invoices. They don’t spend one second on it.

  45. Kate,

    Where do you get that Medicaid pays every claim that is submitted? Off the top of my head provider A orders a $6000 genetic test on Monday and provider B needs the same test on Tuesday so he orders it again. The bill hits your insurance and the second charge rejects because genetic test X can only be ordered once a year. It then hits MEDICAID and is rejected as well. It then hits a rejection batch and someone looks at it and says – “Oh yeh, we can’t do that.” And it gets written off. A report gets generated and if the numbers get high enough someone sends a sternly worded e-mail to the providers that they better be more careful about their orders or their ability to order is going to be locked down.

  46. “So, off to the ER. EVERY SINGLE test we had just done was redone on this woman. “

    I’ve had similar experiences. And AFAIK, radiation exposure for one patient is not tracked by any medical entity, so that concerns me.

    Does anyone happen to know the main objectives of the recently enacted mandate to place all medical requirements in electronic form? I’ve noticed some of our doctors are using significant resources of time and money to input some of this stuff, and from their comments the input menus don’t allow for putting in exactly correct information.

    My main challenge recently has been to manage medical history information for myself and family members. What tests, results, procedures, prescriptions, diagnoses, etc? It would be nice to have all of this information in one spot somewhere so that one provider does not run the same test that another provider just ran. I know that’s a pipe dream. I’ve tried to become more organized about maintaining all these records myself.

    “I have reached the point where I just don’t pay any bill I haven’t received three times”

    I’ve been doing something similar for years. I also round up my payments to the nearest dollar, and from one lab I regularly receive checks back for a few cents. Other businesses typically credit me against the next bill.

  47. Thanks MBT. I did use a manufacturer’s coupon for the last two meds. In one case, price I was quoted was $975 for a 30 day supply. When I balked, the pharmacy tech produced a coupon and the price I paid was reduced to $50. Another med was $450, and my doc gave me a coupon that got me a slightly smaller amount for free.

  48. COC – regarding the electronic medical records. At one of my daughter’s specialist the doctor has to inform me at each visit that the diagnosis/comment section (I’m not sure what it is really called) is not applicable, but because her medical condition is not an option for her to select, and she can’t leave it blank, she has to put something in. This something generates a summary page of what the diagnosis means and other babble that I have never read because it isn’t what my daughter has. It is such nonsense.

  49. I agree that that there are significant risks with the government and other powerful entities having easy access to all our medical records.

  50. EMR (electronic medical records) mainly track billing and prescriptions to detect over prescribing of generally opiods. They are not really designed (in general) for doctor’s notes. This becomes a nightmare if you try to file a complaint with a regulatory agency and they are trying to determine if the medical professional met the standard of care. Sometimes doing X would be considered a violation, but if the doctor notes why she/he did that based on what symptoms or test results they saw, then she/he would be in the clear. If this portion is not improved, it could be either harder to discipline a poor provider or for a good provider to prove his/her behavior was appropriate.

  51. but because her medical condition is not an option for her to select, and she can’t leave it blank, she has to put something in.

    Did she report the issue? My guess would be that it happens relatively infrequently such that she never gets annoyed enough to call the help desk and report it. But, it’s hard to fix something if no one ever tells you it’s broken.

    I get calls fairly often about something being broken and I’ll ask, “When did it stop working?” “Oh, it’s never worked, we just finally got annoyed enough to call it in.”

  52. Rhett – I got to know lots of families in the NICU. We were squished in there like sardines with not a lot to do except stare at our babies in isolettes and talk. No one had to pay anything. It was kind of a joke that you didn’t want the kid who was discharged on day 29. You would stick it out a little longer.

    When my son was born, they pre-certed him for 60 days. His stay was longer but the hospital forgot to get more days approved. So the insurance denied those days. We went round and round about it because they wanted to submit it to Medicaid and I didn’t want them to sinCE they effed up and I knew the private ins would pay.

    Not every state has this (I believe most do not). But Va has a very comprehensive program that essentially assures NICU families that they won’t have much in the way of medical costs. Which is great. Except there should be some income caps and they need to figure out how to incentivize everyone to care. I am pedantic, so I cared, but I think I was pretty unusual.

  53. I agree that that there are significant risks with the government and other powerful entities having easy access to all our medical records.

    Which has to be weighed against the cost and risks involved with all the information being in discrete silos.

  54. Kate,

    I assume the hospital has a policy of “throwing it against the wall to see what sticks” so they just submit everything and work the rejections. It’s possible that you’re right, I’ve never worked in Virginia. But, I expect MEDICAID would have denied the claim as well.

  55. I am sure the hospitals do. They want paid by whatever entity will pay. I think their first preference is private payors since the reimbursement is higher, but Medicaid acts as a backstop and creates some weird incentives with people who otherwise probably would work harder to fix the issues. I kind of used the insurance stuff as a diversion so I wouldn’t lose it over my really sick kid, but that is my personality. Other people just kind of held up their hands and let it go.

    Regardless, the system is kind of terrible and is super inefficient.

  56. I just went through immigration hell on the East coast. I’ve never been through customs at a NYC airport without a staff member screaming (at an agent, at a passenger, or at each other – as happened today). Welcome to America.

    On dermatologists, I think that private, aesthetic practices are so lucrative and derms are already so few. I don’t hear a lot about terrible derms, just that they all have the month waits.

  57. Kate, NY has a similar program, though the conditions are tighter (40 continuous days inpatient and must be discharged on life assisting equipment that would normally required skilled nursing), and my DS eventually ended up on it. Medicaid was never billed a penny even though they became the secondary. What it meant, though, was that MSKCC had to bill at Medicaid rates, even when they submitted claims to our primary insurance. Medicaid rates are typically the same or less than in network rates. Before my DS went into the program, we were out of network, and had to pay the balance between what our insurance deemed “usual and customary” and what MSKCC was charging. After, MSKCC charged Medicaid rates which was always less. No more balance billing.

    Rhett is correct in that if your primary insurance rejects a claim, the secondary (Medicaid in this scenario) must reject as well.

  58. My main challenge recently has been to manage medical history information for myself and family members. What tests, results, procedures, prescriptions, diagnoses, etc? It would be nice to have all of this information in one spot somewhere so that one provider does not run the same test that another provider just ran. I know that’s a pipe dream.

    Not really. Join an HMO that uses Epic (perhaps they all do?)

  59. Rhett said “I assume the hospital has a policy of “throwing it against the wall to see what sticks” so they just submit everything and work the rejections.”

    This is actually illegal if done by computer (can’t write a software system that submits electronic claims to every and all payer in the hopes someone pays), at least here in NY. But the hospitals obviously have great incentive to do this. You can submit claims if there is a plausible reason to think the patient might be covered. One of my big contributions to the world of health IT was a software system that used some AI methods (rule base reasoning) to figure out likely payers for patients listed as uninsured (self pay). It worked. It actually made a noticeable dent in the number of self pays at a large hospital that had a huge percentage of uninsured patients.

  60. About 10 years ago, there was a big push to try to develop personal medical record systems. The idea was that patients could keep their own records. The software would be able to snarf in data from the provider EMS systems. Microsoft and Google both invested a lot of money in the idea. But it went nowhere. The problem was interoperability – the big provider EMS systems (Epic, Centricity, Allscripts, etc) can’t even talk to each other, let alone to some personal system developed by a company that knows little about healthcare

  61. Is anyone aware of data on how much medical care provided to ACA bronze plan owners is not paid for and goes to collections? The expected family contribution under ACA plans seems unreasonably high for “affordable” care. My experiences with nonroutine medical care are consistent with what others describe. One of the reasons my FIL survived so long was his skill in reading radiology scans and assessing provider competence.

  62. We used to be part of a regional HMO that we were very happy with, both because of good service and virtually no paperwork – just $10 – $20 copays. We switched to a PPO plan when our kids went to college out of state and would otherwise have to pay $2000 – $4000/year each for the college’s insurance plan (because the schools were out of our regional HMO area.)

    The paperwork is unbelievable tedious, and we have very few issues medically. I remember when we first made the switch, I Googled to see if there were any software programs out there that were designed to help people manage this stuff – sort of like a Quicken for health insurance – but didn’t see anything useful. Has anything been invented recently? Seems like developing a tracking method for medical bills would a good business opportunity for someone. This would be particularly helpful for us now as we’ve moved on to managing our parents’ bills as well.

  63. It is all so terribly infuriating. They could do a better job making the EOBs understandable, they could do a better job making the bills understandable but they don’t. The fact that people have to manage this on top of serious illnesses is astounding. I also have issue with the difficulty getting appropriate pain meds for people with cancer and chronic illnesses. If I had my druthers we would do away with the HIPPA – everybody has something going on. Getting rid of HIPPA would make things a lot easier on all sides.

  64. On the topic of unpaid caregivers in hospitals- when Riobaby was born, I discovered there is a trendy new hospital initiative called “baby friendly.” It’s supposed to be about promoting breastfeeding and bonding, but I suspect it’s really about cutting costs.

    Basically, they have closed the healthy newborn nurseries so the baby stays with the mom in her room the whole time. Which is great in theory for bonding, but exhausting for new parents since you do all the baby care while you’re recovering, and if the baby won’t sleep, tough luck. I had a c section and then a baby who screamed the moment put down in the bassinet, and would only sleep on one of us. Plus there were breastfeeding troubles early on so I had to pump every 3 hours at least around the clock, on top of nursing, because they consider formula to be the worst thing ever and wouldn’t give me any to supplement (artificial nipples are banned). I think I averaged less than 2 hours of sleep per day (non-consecutive) over my entire 4 day hospital stay. I was absolutely delirious from sleep deprivation and seriously afraid I’d drop my baby. And that was with my husband staying with me the whole time to help. I’m just waiting to read about a lawsuit where a baby is injured or worse from this.

  65. Rio, I had that situation with all mine. I agree, they really should let the new mothers get a little sleep right after giving birth!

  66. @Rio – my first kid went to the nursery and I felt rested in the hospital. I had enough sleep deprivation to deal with when I returned home, so the rest was vital. My second kid roomed with me in the hospital, it was exhausting. The hospitals say that it promotes bonding but I would have been more alert and cheerful and apt to bond if I had enough sleep.

  67. Rio – it was like that for ours, although the naval hospital had a little more of a nursery than the private where my other two were born. Although #3 was in the NICU for observation the first night, having been born around 11 pm? I think? Who the heck knows any more. Anyway, I stayed there dutifully and watched for about an hour, but having been up almost all night the previous night, I just left and went to sleep around 1 am.

    Supposedly the nurses came in a few times and tried to wake DW and me, but were unable. And neither of us is usually a heavy sleeper. We were both out until about 8 am. I have no idea what they did for feeding.

    I hate absolutely everything about childbirth.

    Rhode – I’m reading The Living Great Lakes and enjoying it immensely.

  68. Here’s a follow up to my “what to do with the young teenagers during the summer” question. The camp thing we found didn’t work out so they are staying home for the summer. They did a week volunteering at vacation bible school, I took a few days off, and we took a trip to NJ for almost a week, so they haven’t hit the long stretches of being home alone yet. They were telling us what they did today (a lot of bike rides – they just got new bikes, DD actually emptied all the garbage cans and cleaned her room) and DD said “being home all day is boring.”

  69. Ah yes, “rooming in.” It really would not have been so bad if not for the constant interruptions for vitals etc. that would wake all three of us up as soon as we had fallen asleep. I was more delirious by the end of the 3 day hospital stay than at any point after, even with my husband handling putting Baby June back down every time she was woken up. Rio, I can’t believe they didn’t let you supplement! The hospital where I delivered was militantly pro-breastfeeding in what seems to be the standard way at this point, but we did a little supplementing in the first days at their suggestion.

    I have at least two friends who were having third and fourth babies and refused to room in so that they could get rest before returning home to multiple kids. Apparently it worked, at least at the hospitals where they delivered, even though it’s not presented as even being an option.

  70. @Milo. That was me with The Living Great Lakes. I’m glad you are enjoying it! I really need to get back to Lake Superior!

    I have been very lucky in that our family has never had more than routine doctor visits. (e.g., strep throat, minor infections). We switched to PPO recently because our Doctor/hospital dropped out of our HMO. What a pain in the butt the PPO system is in comparison?!!

    I do like that we’ve been seeing he same network of doctors for over 10 years though. The electronic records seem pretty seamless to me. I recently had a minor infection. Saw three docs over a week in two different offices, and they all pulled up my test results/notes from
    previous visits easily. I could also pull them up at home on my own. And I communicated with my PCP over secure messaging in the app which was great. Quick answers to questions & she sent notes to a doc in another office that I needed to see for a quick follow up when the first medication wasn’t working.

  71. I declined rooming in with all of my kids. It’s unfortunate that cost concerns and militant bonding advocates are depriving current new moms of the option to recover before going home.

  72. I declined moving in, but I had to be a true NYer at this NYC hospital to make it clear that I wanted to sleep in my one night in the hospital.

    Rio, sorry you had to go through that because my roommate was so sick from her delivery and surgery that she could have not cared for her own baby.

    My neighbor is delivering her third baby next week nearby because she said she can’t deal with the stress of the NYC hospitals.

  73. I went into labor with DD late at night, and delivered the next morning, so I had no sleep at all that night. After the full day at the hospital the day she was born, I was beyond exhausted come early evening. But DD was not an infant who slept easily. When one of the nurses came in at about 8:00 p.m. to check my vitals, I broke down in tears and told her that I desperately, desperately needed some sleep. The party line at the hospital was to advocate rooming in and exclusive breast-feeding, but the nurse told me in a low, conspiratorial voice that she could actually take the baby to the nursery for the night, and feed her from a bottle when needed. I’m not sure I’ve ever been so happy in my life. I slept like the dead that night, DD was no worse for the wear, and we both went home the next day without incident. I am still grateful to that wonderful nurse!

  74. June I agree with the interruptions for vitals. Everyone that came in during the middle of the night was chipper and chatty and turned on lights. I had a c-section, so my husband had to do all the picking up and putting down. By the end of the 2nd day I cried when the dr came to check on me and begged her to let me go home so I could sleep without people constantly waking me up.

    But – I was on an HMO when I had that one. It cost me $5 for my first appointment, and I didn’t pay anything else through my final discharge from the hospital. That seems a little crazy in hindsight.

  75. I have had routine annoyances with medical billing or prescription refills, but really nothing like any of your horror stories. (My child’s terminal illness was in the 1970s, so the experience is remote, forgotten and out of date). DH has a great medicare advantage plan, (Tufts Medicare Preferred), with care provided by the oldest MA HMO (Harvard Vanguard), and all of his bills are straightforward. His week long hospitalization last year ended up costing us about 1400. All his cardiac rehab was covered in full. He gets checks back when they collect copays that they shouldn’t. His biggest recurring expense is dental care – he exhausts his coverage and deductibles every year. I am looking forward to joining the same Medicare advantage plan in a couple of months, but I will still get my care through my current primary physician and specialists and an HMO style “care circle.” Premiums will go down from 500 a month to 270 a month this year and 180 next year.

    I vastly preferred being left alone with the latest baby – as long as someone else was taking care of the other kids. I did have the last one in the hospital, and I paid extra for a private room and stayed an extra day – but he was with me most of the time. Childbirth and nursing for me were not difficult medical events – obviously so since I chose to give birth 5 times in 8 years.

  76. I have been very lucky in that our family has never had more than routine doctor visits. (e.g., strep throat, minor infections). We switched to PPO recently because our Doctor/hospital dropped out of our HMO. What a pain in the butt the PPO system is in comparison?!!

    And I think the HMO system sucks and am so happy we have a PPO. We’ve made heavy use of specialists over the years and I would hate to be locked in to the providers in an HMO. Our PPO has a very wide network and I love having the flexibility to change doctors when needed. The first pediatric neuro place we took DD ended up being a nightmare. I hate to think how she would be doing if we weren’t able to switch to a different one.

    And I like being able to see specialists without having to go through the referral process. In my last experience with an HMO, the PCP couldn’t give a referral until they saw you for the specific issue. So when something would come up that I knew I needed to see a specialist for, I still had to waste everyone’s time and see my PCP first.

    Apparently we’ve been really lucky with billing. We had one major issue several years ago that took two months to resolved, but that’s been it. And we hit our out of pocket max every year, so it’s not like we don’t have a lot of bills coming through.

  77. June I agree with the interruptions for vitals.

    For all the talk of evidence-based practice, this is another example where the actual practice ignores the evidence. Hospitals still insist on checking vitals every 4 hours yet studies show there is no improvement in outcomes over checking vitals every 8 hours.

  78. I just got a refund check in the mail for overpayment of $1600 for a minor surgery I had in 2013. To be honest, we don’t check our EOBs carefully, or keep track of deductibles. Most of our care is preventative or non-negotiable (yearly specialist follow up), so there is no shopping around.

    We had one big, significant illness a few years ago and had enrolled in the local HMO the week before. I was tired of trying to juggle our high-deductible HSA plan, even though DHs employer was funding the HSA. It took more than 6 months before we saw a bill for the hospitalization, and it was surprisingly undetailed. There were less than 10 line items that added up to $400,000. Insurance wrote down $150k, paid 250k, and we were left with $400. The whole situation was ludicrous, and we were fortunate to come through financially unscathed. Also impressive was the HMO response when the specialists recommended an off-label us of a medication, not covered under our plan. The course was going to cost around 75k for 5 doses (if I remember). We contacted our HMO pediatrician who handled all the paperwork of getting it approved within a few business days.

    Not all HMOs are magical, but all of them do a better job of coordinating care and controlling costs than other systems of care.

  79. Hospitals still insist on checking vitals every 4 hours yet studies show there is no improvement in outcomes over checking vitals every 8 hours.

    I’ve never seen evidence that this is true in a post-partum patient, where change in blood pressure, temperature and heart rate may be early indicators of signficant post-partum complications. The frequent vital sign checks are annoying, but I think rationale.

    However, I am completely on board with the idea that “rooming in” is terrible and motivated by cost savings. I just laughed and laughed when I saw a patient information sheet for care post-vasectomy. Pretty much, bedrest is required. However, have a vaginal birth or a c-section, and you should be getting out of bed every two hours and changing diapers, walking a fussy baby, etc. It is so unkind to expect so much of mothers in the first 24-48 hours post birth.

  80. “That was me with The Living Great Lakes.”

    Ahh yes, sorry.

    It’s a tall order for an author to make geological history appealing and interesting to me, but he does it well, and the frequent segues to the accounts of his voyage help move it along.

  81. In the home country the tradition is for a woman to go to her parent’s house for the birth of her first child. All of my cousins did this and for three months they had not only their mom and dad but aunts, uncles and siblings to lend a hand with the new baby. Their husbands would visit in the evenings.
    Never a question of not having time to take care of yourself. It is a big adjustment to go back to your own house after three months and all that help.

  82. Ada – There is no way I would ever fly into New York from overseas. I purposely choose my itineraries so that I make first US landfall in Boston by routing through London, or on the West Coast or in a pinch Toronto (US immigration is handled there).

  83. “Hospitals still insist on checking vitals every 4 hours yet studies show there is no improvement in outcomes over checking vitals every 8 hours.”

    Jah. My favorite was after DD was born, and I needed several transfusions and ended up with 4 days in the hospital to recover my strength. What did I need? Sleep and rest. Which they interrupted around the clock, to check vitals — the best part was that they couldn’t even coordinate the two groups who were supposed to run the tests, so I was more often woken up every 2-3 hrs. ARGH. (Although it pains me to admit that Ada is probably right: given my bleed the first night, it was probably a good idea to check me frequently for a day or two after).

    But at least both hospitals where I had my kids offered the nursery at night. I also lucked into the older, experienced nurse who offered the “bonding” of rooming in but then whispered in my ear that I might really like to get some rest, and I’d get plenty of time to bond with DD during the day.

  84. I went to an older community hospital for my first child. The staff, care and rest I had was awesome. There are ads on the local radio promoting the maternity wing of the local hospital. A man’s very soothing voice promises the best care for mother and baby and says they encourage bonding. I wanted to yell at them for running an untrue ad.

  85. I feel fortunate not to have the terrible stories some of you do. Lemon’s regular fight for meds is ridiculous.

    My strategy these days involves hanging onto all medical bills for a few months. Inevitably, the amount I owe changes as the months go by. I pay right before I hit the 90-day mark and usually find it’s a far smaller amount than if I had paid the first invoice.

  86. Off Topic – I’ve been reading through the Looper’s blog that Milo posted last week. I really enjoyed their Great Lakes portion, as I’m familiar with most of their stops. They aren’t quite totebaggy, because they have a pet snake on board, but some of their comments are over the top.

    On Topic – With my first Lemonbud I used the hospital nursery for just a few hours. When the second Lemonbud came along, and my DH was at home at night, I proudly took advantage of the nursery, and came home well rested. Looking back at both deliveries, during that first week, I think I initially bonded better with #2 because I was so well rested. I was fortunate that the hospital I delivered at didn’t force rooming-in, and didn’t give me problems when I asked for formula.

  87. Lemon – I forgot about the pet snake.

    I’m always incredulous at how boring their schedule is, and that’s coming from me, which really says something. Their typical evening is “we were still full from a big lunch, so we just had a little salad, and were in bed before 9 pm.”

    Either that, or they’re having tons of sex.

  88. Well, they do seem to have a lot of cocktail hours with other Loopers. At just about every marina they mention stocking up on booze.

    And it is true that up at Mackinac (the blog spells it wrong) the sun doesn’t set until 10:30. I miss the days when we use to pay twilight rates for golf and easily get in a full 18 holes.

  89. Rhett – http://www.integritycruise.com/

    “Well, they do seem to have a lot of cocktail hours with other Loopers. At just about every marina they mention stocking up on booze.”

    That could be it. Two drinks, and I’m ready to go to sleep. I think that would be one of the really fun parts about the trip, because everyone’s motivated to socialize and hang out since they’re removed from their usual demands of home and families and jobs.

  90. Milo – Do you recommend any Looper blogs that had children along? I’d be interested in reading about the same route from a different perspective.

  91. Thanks. I vaguely remember this. I’ll take another look. I have no desire to be a Looper (I don’t being on boats), but it is an interesting trip that I never knew existed before.

  92. we took advantage of the nursery both nights at the hospital where DS was born. they did bring him in every 3-4 hrs in the night for feedings and they woke me to check vitals

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