Surprise medical bills are the result of being treated by someone outside your insurance company’s network of providers. So you want to avoid those out-of-network providers whenever you can.
Diane Carbo: Hi, this is Diane carbo with caregiver relief. Today we have Betsy Wurzel with us. That’s he is our dementia care specialists, caregiver coach podcast hosts. He also has started the Facebook page kick off Alzheimer’s ass.
Diane Carbo: Betsy also has her own podcast chatting with Betsy. Betsy, I’m so excited , we are talking about this. Actually, right before I got on the podcast with, got a call from a woman from New Jersey who is doing research because they want to know what they have to pay for and what they don’t have to pay for and what Medicare and insurance will cover for things. So today our topic is on how to avoid or stop surprise medical
Betsy Wurzel: bills. Hi, Diane. Thank you for having me on, excuse me. If I had the cloth, the air New Jersey here. Sick today, correct Ida. But thank you for, thank you. Surprise medical bill.
Betsy Wurzel: I have to tell you a personal story. I used to have my husband’s insurance, private insurance. My husband’s company said goodbye when he turned 65. So I had to go on the affordable healthcare act, which this is not affordable at all. And the benefits stink. So when I went for my stress test last year and opened up the bill, I had to grab my inhaler.
Betsy Wurzel: I couldn’t believe what a cost. Thank God. I’m fine. What I did do, and I can recommend this. If somebody told me about this, you can’t afford a hospital bill. There is charity. I qualify for it, but it was a high time of COVID and I said, I’m out of work. I can’t afford this. Can you reduce it down?
Betsy Wurzel: And they reduced it as I need it reduced down more. then they let it go. And it was well over $3,000, Diane. I was floored, but when we get our medical bills when you get it from your insurance, the insurance companies don’t plan on you signing with them or the doctor, but you have to make sure that your doctor.
Betsy Wurzel: Or the facility that you go to is in your plan. I can’t stress this enough. Doctors, hospitals, places they come and go in and out of plans, you could call your doctor. They could say, oh yeah, we take your insurance. And then you find out they’re like in my insurance company, there is a tier one and a tier two is you’d go to your one.
Betsy Wurzel: They, you just pay your copay for going to a doctor. As you were in tier two. Yes. Your doctor is in the plan, but guess what? They don’t pay for it until you reach your deductible. This is very important to find out before you go, because you will be shocked when you get your bill. ,
Diane Carbo: what are the issues that we have is we have too many different plans out there. , if you have a Medicare plan with a supplemental there’s different levels. Most of those are usually covered, but the government’s really pushing for us to do the Medicare advantage plans . Medicare advantage plans while they seem like they’re these wonderful plans, because they’ll bring you food and they’ll provide you with dental and I, and all of a sudden.
Diane Carbo: It’s in fact, they’re very limiting on what, when it comes to the medical care that you’re provided. You have to understand your plan when you purchase a Medicare plan, many people don’t want to pay for the supplemental. But it gives you so much more freedom and availability for things.
Diane Carbo: So you don’t have as many surprises, you still get them. But they’re very limited. I think that the Medicare advantage plans that people are seeing, you’re either an HMO, which isn’t health maintenance organization, or you’re a PPO, which is a participating provider organization. And while the PPO, you may have lots of opportunity.
Diane Carbo: What you said in the beginning of this call is what happens. Insurance companies don’t always continue to have a agreement with doctors or hospitals or even a specific practice or a specialist. So when you’re having a surgery, And you go to the hospital and you got to have the surgery and you say, oh, this is great participating provider for the surgery.
Diane Carbo: The hospital provides great, but you don’t know that the anesthesiologist isn’t covered under your plan or the lab that the hospital uses isn’t covered under your plan or even the pharmacy for the drugs isn’t covered under your plan. It’s very frustrating because number one, we’re aging.
Diane Carbo: We don’t have time for all this BS.
Diane Carbo: Our golden years should not be us in the hospital all the time in and out of doctor’s offices. And then dealing with the insurance companies and the providers. But it happens all the time.\ a surprise. Bill of anesthesia can be very expensive. Yes. Oh yes. So you have to be like a an Explorer, an investigator.
Diane Carbo: I detect. Actually, you have to be a detective. You have to do research before you have anything done, especially if you’re with managed care plan like a Medicare advantage, because they can be very limiting.
Diane Carbo: If you’re a person that travels you definitely are going to have out-of-pocket expenses. If you have an emergency if you’re on a cruise or something, or you’re out visiting your. Grandchildren and in another part of the country and you become ill or have an injury or an accident. You’ve got to understand your insurance and know what you’ve purchased.
Diane Carbo: Because I’ll tell you right now, it’s an all too common situation. There are ways you can combat the surprise medical bills, whether they come from an emergency situation or as a result of being Being referred to for a procedure or something , it’s better to prevent them in the first place, but if you can’t prevent them, you better be prepared to take battle with your insurance company.
Betsy Wurzel: Yes. It’s very important to know what your benefits are and it’s okay for you to call up your insurance company, question a bill. It’s okay to call up your provider, which I have done many times to their billing losses to coal up in question before you pay. And I am finding that they are very incompetent.
Betsy Wurzel: This year alone, I had a call up. They said that I owed my call pay and I said, no, I paid you my copay. I can’t even see the doctor until I do. They won’t even let you see the doctor. I had to pay it. I said, so what did you do with. Oh, I have to prove that I paid it. So I had to inconvenience myself, look for my check and send it over.
Betsy Wurzel: And I said, why don’t you find out who is incompetent? And that office goes, I got a big mass now, Diane,
Diane Carbo: you and I both in today’s with the present day medical delivery system, you have to have the strength and the energy to. I stand up for yourself or you need to hire an advocate to do that kind of work for you.
Diane Carbo: A perfect example is I know people will say, oh, they get on that on the internet. And they look at the direct online directory and they go, oh, everybody’s covered. The majority of time and shame on these insurance companies, but those directories are out of date and they’re not kept up to date. So the physician or the anesthesia group that you think you’re getting covered under your plan is basically not.
Diane Carbo: So I tell people if you’re going to have a procedure . Talk with the billing department of your surgeon and ask them who’s doing the anesthesia. And who’s doing any kind of consulting. If they’re going to have
Diane Carbo: consultants come in. If you have a procedure done, because you want to know if they’re in or out of the network, even though the radiology department, if they’re not within the hospital that you’re supposed to have an MRI or something done at an outside. Are they presently covered and you have to keep a notebook of who you’ve spoken to the date and time you spoken to that person and a brief documentation in your notebook of what they said,
Betsy Wurzel: because
Betsy Wurzel: yes, I even had my insurance company talk to the billing department. Three-way call a couple of times about a bill trying to get paid. I told me that I owe money and I don’t. So I get ready. We’re talking to. They already got the explanation of benefits and they still don’t get it. Oh, we didn’t get that.
Betsy Wurzel: Make copies. It’s just downright ridiculous. I had to share another story. I’m due for a colonoscopy. I’m all long overdue and endoscopy, but you know what? It’s a shame. I can’t afford preventive health because. With my insurance, they won’t pay for it. And dusk copy. I have to pay the, usual out of pocket and with a colonoscopy.
Betsy Wurzel: Now this is a good one. I’m used to my husband’s private insurance where they covered everything, but the colonoscopy. Yes. If it’s just the screening, yes. They will pay a hundred percent so that they take a biopsy. They can submit surgery and I get to pay 20% and my doctor’s office been a bully . They fell no, that’s not right.
Betsy Wurzel: And I said, no, I’m telling you it is right. I will get charged 20%. So even the doctor’s offices, they don’t even know sometimes of how crappy these insurances are. It’s ridiculous. You can’t even afford preventative care. Because of how the insurance is now. I highly recommend to people your senior centers.
Betsy Wurzel: Now the COVID, they might do it over the phone, but when my husband was going on Medicare prescription, I went to my senior center and they helped me because they’re not in it for a commission. They’re not a salesperson. Go to your senior center, you need help to navigate Medicare. Now with the supplement that Matt had, we got through our with his company.
Betsy Wurzel: So he got a little this time, his first year which is supplement was wonderful. Actually it paid for everything. I didn’t get any bills.
Diane Carbo: I paid for part G through Medicare, the supplement, and it does cost me but you know what? I can go anywhere in the country be seen. And I just have the initial $185, which will probably be
Betsy Wurzel: going up
Diane Carbo: The initial Medicare deductible that I start every year with. And that’s really important to that.
Diane Carbo: People understand that too, about the copays and deductibles when they kick in and what they don’t. I also want to make people aware that even though your hospital may be a part of your provider network with your insurance, if you go to the ER, The hospital may have an outside organization, which is usually occurs with the ER physicians and they may not be in your network.
Diane Carbo: So when you’re going to the hospital and you’re being seen in the emergency room it, you can actually have the radiologist and the ER, physicians in that hospital, maybe from a different practice that is not covered by your plan.
Betsy Wurzel: Yeah, that’s a good point. Alluded. Yes, that’s crazy. If you’re unconscious, you’re in an emergency, you don’t have a choice, you know where to go.
Betsy Wurzel: An ambulance takes you, God forbid you in a car accident and maybe you can fight that with your insurance. But it’s getting more difficult also. Diane, make sure people have to make sure they’re billing to the right person. They might get your name confused with someone. Else’s just the person who put in the wrong birthday.
Betsy Wurzel: That happened to me. That happened to Matt actually.
Diane Carbo: It w I was boring, Diane Smith. I was Diane Smith. You talk about my dad when my mom was sick with cancer. We got bills that were two, a Louis Smith. That was not my mom. So I understand that. Totally. And that was 50 years ago. Not like it is now.
Diane Carbo: It’s even worse now. Yes you, oh, you were talking about going by ambulance. That’s another thing, , you don’t even know the ambulance will the ambulance in your area take you to an in-network hospital?
Betsy Wurzel: That’s right.
Diane Carbo: That’s a whole nother ball game that you have to think about if there is an emergency and is the, an ambulance coming.
Diane Carbo: By your insurance, because it may not be, that’s another thing. So you really have to know your product that you’ve purchased. You need to be prepared for everything. If you’re going to buy a Medicare advantage program. find out what hospitals are involved with it. What providers within that hospital provide service and check out your local ambulance company.
Diane Carbo: Now there are ambulance companies around. You become a member to the ambulance company for so much money a year, and then, for private ambulance companies I don’t know how that is working in all parts of the country, but I know it does in, I know in Pennsylvania there were communities where you would purchase into the local.
Diane Carbo: The ambulance company. And then you were provided the coverage was taken care of your insurance coverage was taken care of. They accepted whatever payment they got. But that, again it’s taking the time to do the homework beforehand. It’s very hard when you’re not feeling well to do this.
Betsy Wurzel: Yes,
Diane Carbo: absolutely. One of the things that people also need to do is make sure that the billing codes and this is not our responsibility, but I’m telling you right now, the wrong billing code by your doctor’s office. Can do terrible damage. As far as surprises in medical bills. That’s right. So I think that it’s really important.
Diane Carbo: I would ask when you’re doing your research for your procedure, if you have an anticipated procedure coming up like a knee surgery or hip that you actually, or like you with your preventative care is ask them what billing codes that they’re going to be using and then call your insurance company to say, what kind of coverage do I have under this billing code?
Diane Carbo: And like you said, and I hear this all the time. That you can go in for a colonoscopy. There is not a doctor that does an endoscopy or colonoscopy that rarely does not take and do a biopsy. I They’re going down there for a reason. They’re looking for a reason. They’re looking for bacteria, they’re looking for things and or infection.
Diane Carbo: So of course, they’re going to take something so shame on these insurance companies, we’re playing this game. It makes me crazy, oh we can’t pay for that because it’s a different procedure. What no, I, it makes me crazy. So you should be able to understand that, that there is a medical code.
Diane Carbo: It’s a, it’s like a specific six digit code and it can determine the cost of a procedure. It can help you understand what may be fully covered or not covered. And what will consult in out of pocket charges for.
Betsy Wurzel: Yes, then I can testify that what you’re saying, Diane is a hundred percent true because I have encountered billing code problems that they don’t do the right billing code.
Betsy Wurzel: So that costs more money. And this is where you have two. Speak up because it can make a whole lot of difference. And it’s when you go for an MRI or a cat scan, make sure you’re going in network. Make sure you know what the cost. I know what my insurance, I have to pay upfront, whatever the cost is upfront, or they, you don’t get your tests done.
Betsy Wurzel: This. That’s insane.
Diane Carbo: It’s very frustrating and it’s hard because , it’s so convoluted and it shouldn’t be this convoluted. It shouldn’t be. You have to make sure that you have the conversation with your doctor to, to understand that. He needs to, or she needs to use N network labs for blood work, MRIs and other tests.
Diane Carbo: So you may have to call your insurance company and say, these are the tests I’m having. Where is the local in network lab or a radiology center that will be covered under my plan. again, don’t trust that what they have online is true, because it could be out of date.
Betsy Wurzel: Very true. And don’t trust the doctor’s office either. I can’t even say that enough and they say, oh yeah, we’re in network and you find out they’re not, or they’re at the lower rate. Like I have a tier two and some of these doctors. To be very careful about , seven or eight years ago, ducky.
Betsy Wurzel: And my husband’s name was Matthew Sloan. I got a bill, we got a bill for another Matthew Stone who I happened to know who he was. Cause we went to the same doctor.
Betsy Wurzel: No relation at all. And I got this huge bill for a rehab and I call it up and I said, you had the wrong Matthew. And they wanted me to write a note, proving it. And I said, no, you need a mistake. You fix it. I said, I’m a caregiver. At that time, I was working 40 hours a week and they had the nerve to say to me maybe your husband came here.
Betsy Wurzel: You didn’t know it. And that’s why I don’t think so because one of those Alzheimer’s, he doesn’t drive and I don’t think he would walk seven or eight miles to your facility. Exactly. Exactly. You know what I mean? I thought it was fraud and I called it Medicare and I called up the United health care, which is what my husband had at the time to tell him this was fraud.
Betsy Wurzel: I thought somebody was using this number and they had to pay it all back. I That was 10,000. If not more that they had to pay back. We can’t be afraid to question something. Don’t be afraid of a doctor’s office or building department. And as you’re not satisfied, ask to speak to their supervisor, say, I would like to speak to your supervisor.
Diane Carbo: Oh, you know me, , I always say, why go to the ass when you can go to the head? So I always go to the supervisor. It’s terrible to say, but I have. I’m also going to make a recommendation that you shop around for the best price on medical tests and procedures.
Diane Carbo: If you can do it beforehand, it’s great. If you know that the billing code procedure you can check your pricing, there’s a site called. I believe it’s called a healthcare costs.com or another one that I think is a healthcare blue book.com.
Diane Carbo: You can compare costs of your tests and of any treatment within your zip code. People automatically think that medical services are fairly uniformed, the cost and payment for them. And that’s not true at all. . An MRI, for example, can be as little as a couple hundred dollars to several thousand, like almost six to $8,000 in the same area.
Diane Carbo: Again, it depends on their insurance and all kinds of stuff.
Betsy Wurzel: Research. Yes, definitely. We have to be researchers and you’re right. The detectives. And I also want to comment, Diane, as far as medications. With your insurance or if you have Medicare prescription coverage of it’s covered by one of those Medicare ones, you have to find out before, do they pay for. The medications.
Betsy Wurzel: Now I know in my husband’s case , they gave us wrong information cause he took the generic as Exxon pods, give us something like that, the name of it. And did they tell me it would be covered and then it wasn’t and I had to appeal it twice to get it covered. So you have to really. I know, we always say this, Diane and I, you have to be an advocate.
Betsy Wurzel: That’s really what it comes down to. Folks have to be an advocate. You don’t have a choice unless you want me to pay. If you don’t want a question and you don’t care about paying, then don’t be an advocate. But if you don’t want to pay, you don’t, oh, they’ve made a mistake. Why should you pay it?
Betsy Wurzel: They’re going to be quick giving you your money back. Sure. One of your money quick.
Diane Carbo: Exactly. Exactly. And there are things that people can do. If you look at your billing, you think that you’re way off base. As far as the charges there is a procedure it’s called balance billing and many states offer protections against.
Diane Carbo: The practice., there has to be more transparency and you have the right to dispute a resolution, get a resolution. For the SOS. If you find the balance billed is like a surprise, like you said, 3000, $4,000 or whatever, even if it’s just a couple of hundred, I don’t care.
Diane Carbo: We’re on six incomes. The gravy train is not here to take care of us anymore. We’re not able to work and make money to make up for this loss. We live, social security to pay, check to social security paycheck,. So it’s important that you understand that you can negotiate with the hospital billing manager or the doctor or whoever to waive or to lower their fee.
Diane Carbo: And you can do it prior to a procedure. , because I’ve done that I did this I was in between jobs. In fact , I had taken time off to help care for my. And I took off a year to help him through his death and dying process. I was without insurance because I literally quit my job.
Diane Carbo: As so many caregivers do. This was many years ago and I developed a Morton’s neuroma while I I was off. So I had to have a tumor removed, a tiny tumor on my nerve, on my toe removed because I couldn’t walk without stabbing. Excruciating pain. , this was many years ago , I went to a podiatrist because I was going to the most cost-effective way I could find in office, in a podiatrist’s office. The anesthesiologist was going to be, there’s a gimme just light sedation and the, he, the anesthesiologist, it was, there was insulted.
Diane Carbo: In the beginning that I would even think to negotiate with him in regards to his rate and the doctor’s office as well. I had to go to their office managers and say, look, number one, I am negotiating because I know that I can, cause I did it for a living. That’s what I did for patients. I also knew that cash is king and I was paying cash right upfront for the care that I was being provided.
Diane Carbo: So they weren’t going to have to work sixty, ninety, a hundred twenty days out like companies like United health care, make them wait in order to pay, receive payments. So I used that as a bargaining tool. And I did get lowered rates, but that was like 20 years, 25 years ago. But they were insulted, but I’m like, get over it.
Diane Carbo: I’m sorry. I shouldn’t have to pay this rate. Not when I’m giving you cash the day of,
Diane Carbo: People have to just have the could spa
Betsy Wurzel: to. To negotiate. Yes. Definitely. Maybe, your doctor might write off a balance here in New Jersey. I highly doubt it, but they they might or for surgery, I know with this insurance, I have to pay 20%.
Betsy Wurzel: I keep my fingers crossed that nothing happens to me because I can’t afford to get to. Yeah it’s really close to healthcare and that’s a whole nother topic. Should not make somebody go bankrupt or homeless. And then it
Diane Carbo: happened. Think that free Medicare for all is going to solve that.
Diane Carbo: And I will tell you right now, it is not because , what’s happening in our situation right now in our country is Medicare is providing less and less for us and expecting us to pay for more private. Like you’re doing privately paid for care that we need or want or deserve, or have it in a timely fashion.
Diane Carbo: What we’re seeing in the other countries that have universal health care is the rich. Privately pay for care and they jump the queue and get the timely treatment and diagnosis and tests done. And everybody else , in the nationals system is, delayed and delayed because again, cash is king.
Diane Carbo: And if you can privately pay for something. And pay full price, which is what’s happening. They get seen first. In the other countries, those that purchase private health insurance outside of the national or universal health care. Also jump the queue. So you could be a person that needs treatment.
Diane Carbo: But if you’re with a national health system and you don’t have, or the free Medicare for all system, if you’re not able to pray privately or help your own private health insurance, then you also get delayed. , I will tell you right now, I seen this for the last 50 years in.
Diane Carbo: Healthcare Medicare is providing less and less coverage for us and Medicaid. If you’re on Medicaid, if you’re in a teaching hospital, you get the absolute utmost top of the line hospitals. That is provided available because they’re able to teach and they can have government write-offs and stuff.
Diane Carbo: But when you’re discharged and you need equipment or medications, or you need even to be placed somewhere, your options are so limited because nobody wants straight M a that’s what they call it straight in a and nobody wants straight, just plain Medicare without a supplement. So your options are limited, and that’s why
Diane Carbo: we’re seeing more and more doctors going to concierge services. , and in your area, Betsy, right now you’re even seeing nurse concierge services, nurses are providing services for private pay patients. Because insurance companies are not providing coverage for services.
Diane Carbo: And , the are unpaid family, caregivers are unprepared and uneducated in regards to the healthcare. Procedures that they’re expected to perform on their family members every day.
Betsy Wurzel: Yes. I’m sick of the concierge, my moms first doctor down now where she lives, what that route.
Betsy Wurzel: And she changed to someone else she had to pay. I think it was almost 2000 a year. And then I don’t know if visits were extra, but she said, no,
Diane Carbo: there’s so many visits a month
Betsy Wurzel: that you’re or a year
Diane Carbo: that you’re allowed to have with that. But that’s the wave of the future because. We’re going to have to pay more and more.
Diane Carbo: Privately for our things we’re already paying for our medications. Out-of-pocket more and more. We’re also paying for durable medical equipment is not available. Wheelchairs, walkers, that type of signs which was once covered by Medicare is now expected to be private pay. And people don’t understand that.
Diane Carbo: Or. Realize that they really don’t. They think that when they think Medicare is going to cover everything and it really doesn’t. So I’m really excited that we have this this conversation today because it’s going to be a situation that is going to creep up on people more and more.
Diane Carbo: You have to be able to know that you can fight to get coverage, or at least negotiate a lower rate. But don’t hesitate to do that.
Betsy Wurzel: Yes. Diane, I have to say this also in my area, more doctors are going into practice with a health care system. So you will be billed as if you’re going to a hospital.
Betsy Wurzel: So you will be paying. And this is going on here in New Jersey. I don’t know about anywhere else. The doctors asked me about.
Diane Carbo: It’s nationwide. And the reason why it’s happening is doctors can’t survive with Medicare reimbursement and maintain their practice and maintain the staff, needed to meet the government requirements of all the pre-authorizations and all this stuff knowing who’s in who’s out.
Diane Carbo: Who’s not. So it’s we’re moving more and more to where there’s going to be fewer. Physicians offering, services outside of a hospital system, it’s just going to be the way it is.
Betsy Wurzel: Private cases are, yeah, that’s very true. My endocrinologist, her son just finished his residency and I said are you going into private practice? He told me it is. Very difficult now to open up a private practice.
Betsy Wurzel: It’s like almost impossible. You have to go in with a group or in, with a hospital care system. No, no more doctors on the corner opening up their practice anymore. That’s just not going to happen.
Diane Carbo: The other thing is happening is because we have, the reimbursement rate has been so low for Medicare and Medicaid.
Diane Carbo: Teaching hospitals are closing all over the country so that we are going to see a shortage of doctors. We already have a shortage of specialists, dermatologists, and neurologists and neurosurgeons ., we’re seeing a shortage of those because there is no place for them to receive internships, residency, and fellowships for their for their specialty.
Diane Carbo: So we’re already seeing that. I’m in Myrtle beach. The healthcare system is not able to keep up with the growth here and people are having to go two and three hours to the bigger cities to receive the level of care that they need.
Diane Carbo: I can’t even imagine what the rural areas are doing. It’s gotta be hard for them. So telemedicine, I hope it’s here to stay.
Betsy Wurzel: Yeah, I hope cell unfortunate were in my area that I am by a large teaching hospital and other hospitals. And that’s a shortage with nurses because the average age of a nurse and doctors probably in their fifties or sixties and they’re aging out and they’re not putting up with this bull crap that oh, the government system . We’ve got the whole show that the healthcare, that’s broken.
Diane Carbo: We keep these longterm politicians in way too long and they have not done anything to improve, but only to bring harm to our citizens. But on that note, I think that I’m so glad we had this conversation today. I’m very blessed that it was very appropriate topic today.
Diane Carbo: Cause I did get a call about it in fact. So that’s why I say, just say thank you very much for your time till my caregivers out. Remember, you’re the most important part of the caregiving equation without you? It all falls apart. So please practice self care every day. Learn to be gentle with yourself because you’re worth it.
Diane Carbo: That’s the, until next time have a good day.
Betsy Wurzel: Bye bye. Bye.