Insurer Paid to have MRI Taken but Not for a Doctor to Read It.


(Interview 10/2011, oil on linen, 40 ins. x 30 ins.)



Update 2021

I didn't know what a surprise balance bill was when I wrote this portrait story. Holly never used the term in our 2011 interview about her 2001 experience with her very big and unexpected medical bills. She had health insurance. She did not know what hit her when unpaid medical claims fell to her to pay. By 2021, twenty years later, most of us -- the INSURED population -- fear unexpected medical bills if we get sick.


"The stroke was easy. That was nothing. Health insurance and billing were tough. It's an industry with no controls. Where is the responsibility for the product?"

This portrait story is about so much more than surprise balance billing and an insured person's unpaid medical claims.


The theme running through this story and most of the Healthcare in the US portrait series is how getting healthcare in the US often causes chronic stress, anxiety from accruing credit card debt to pay medical bills, fear of the mundane like going to the mailbox. What if I get another unpaid medical bill? Quiet desperation infiltrates every part of life.


A surprise balance bill is when people get medical care outside of their health plan's provider network and don't know it. An out-of-network provider is any hospital, doctor or any other healthcare provider who has not signed a contract agreeing to the insurers' negotiated prices.


Insurers pay the out-of-network providers according to a person's out-of network plan coverage. Out-of-network coverage can be very skimpy or none at all. The patient is left paying the balance of the the out-of-network provider's bill. Out-of-network surprise bills can run into the thousands. Patients are blindsided. Why am I getting these bills when I have

insurance?


After a year of intense wrangling with billing departments, $8,000 of uncovered medical claims, hours on the phone, credit card debt, Holly said she "dropped out." "I just wanted peace -- relief from the financial nightmare."

~


My adult son had a short hospital stay. I was on the phone with his wife when a doctor came in to see my son. I told my daughter-in-law over the phone. "Ask your doctor if she is in your insurance network?" The doctor had no idea and the question seemed preposterous to her as I knew it would. How could a random doctor know the ins and outs of every patient's insurance policy? I wanted to make a point.


Why is the patient responsible for knowing if a doctor-on-duty, who drops in to check up on a patient, is in a policy's network? Not the doctor. Not the hospital. But the patient?


Since this interview, Congress passed and President Trump signed into law the Consolidated Appropriations Act, 2021. This massive piece of legislation addresses a multitude of concerns like COVID relief, climate change and more. The law also bans surprise balance billing as of January 1, 2022. Out-of-network providers must give patients 72 hours notice and an estimate of their charges before they can expect the patient to pay what the insurer does not. (The protection does not extend to the cost of ground ambulances.)


Holly had many surprise balance billing persecutions after she had a stroke in 2001. The insurance company would pay to have the MRI taken but not to have it read. I now have language for what she was telling me. Sounds like the hospital performing the MRI was in her policy's network, but the radiologist who read the MRI that day was not. In 2001 Holly then became responsible for unpaid out-of-network charges from a radiologist she never met sitting an a room somewhere -where? -reading her scan.


At one point Holly hyperventilated on the phone with a customer service representative.

~


The undiagnosed stroke happened on January 29, 2001. Holly's face went numb. "I'm 27," she said to herself. "A stroke can't be happening to me." Four days later on February 2 the symptoms returned, and Holly finally went to the hospital.


In those four days from undiagnosed stroke to the emergency room, Holly went from being an uninsured person to qualifying for employer-sponsored health insurance through her job. Her employer's mandatory six month waiting period for health benefits had just ended on January 30.


On February 1, Holly had health insurance. On February 2 Holly entered a hospital's emergency department as an insured patient being treated for a second stroke, the first one, undiagnosed.


If Holly had known the seriousness of her symptoms on January 31 and sought treatment, she would have been uninsured and saddled with enormous medical debt.


When we're uninsured we talk ourselves out of an incident's gravity because we're afraid of what getting care might cost us. I did it many times when I had private insurance. I saved old medicine for possible future use. I used ten-year-old steroid eye drops without medical supervision.


Being uninsured plays tricks on one's mind. We talk ourselves out of seeking medical care because of the money. Did Holly talk herself out of seeking care after noticing the symptoms from the first stroke?


Holly was insured when she sought treatment for a stroke. Still, her medical claims nearly broke her. Unpaid claims almost went to collections until she broke and handed over her credit card. She was paying 19% interest on medical debt.

"I was ill but most of my energy was spent on the medical bills and trying to stay afloat. I became afraid of the mail. I'd recognize the look of the 'Explanation of Benefits' envelope and wonder who I was going to have to fight."

~

In 2001 Holly now had a major preexisting condition parked in her medical records at a time when one's medical past could be held against a person. If Holly ever left her employer-sponsored health coverage and wanted to get a single policy for herself, insurers could dig into her medical records, asses her risk worthiness -- would she have medical claims? -- and charge her more or decide not to sell her a policy at all.


In 2001 none of President Obama's 2010 signature healthcare legislation existed to protect Holly.


For one, the Affordable Care Act (ACA or Obamacare) banned health coverage waiting periods of more than ninety days. Holly would not be waiting 6 months to be eligible for health benefits.


Second, that preexisting condition in Holly's medical records would not have mattered starting on January 1, 2014. The ACA ended the practice of digging through medical records to find a health reason to justify charging individuals more, or not sell them health insurance at all.


Third, Holly could have bought an insurance policy on the Affordable Care Act's online exchanges and possibly qualified for a subsidy to help her pay the premium during the period her employer was not providing health benefits.


My mouth is dropping all over again as I update this story. If one portrait story epitomizes how for-profit insurers can wreak terror and havoc in a person's life, it's this one.


2012 Bearing witness in Washington DC
So many bills. I asked the billing department why something wasn't covered. They didn't know. Maybe blood was taken in the hospital but sent to a lab out-of-network. I'd get a bill for $500 which was 75% of my paycheck.

"The stroke was easy. That was nothing. Health insurance and billing were tough. It's an industry with no controls. Where is the responsibility for the product?"


Artist's Note (from 2011)

At the start of the interview, Holly showed me a stack of files about 5 inches thick. These files contained correspondence with her insurance company about her coverage for her stroke. The ordeal inspired Holly Gonyea Dolan to travel across her home state, Pennsylvania, to interview folks and explain the Affordable Care Act by using the circumstances of their lives. The results of her one-year journey can be found on her blog, Health on the Horizon.


Holly's said. "I was plagued by uncertainty and fear of screwing up by going to an appointment that wouldn't be covered by insurance. What if I didn't jump through the hoops right? I have insurance but no faith the appointment would be covered. I feel like the insurance companies try to confuse you. In our system you have to be your own advocate And most people are not told how to do that. I carried my medical records to all my appointments to educate the doctors. Electronic medical records would prevent costly mistakes. Even if I was told something was going to be covered, I had no faith that it would be. The system is broken."

 

A study. Oil on canvas, 24 ins. x 20 ins.

(from a 2011 interview)

Adjunct Sociology Professor, Writer, Health Advocate, 38, Insured. Previously, a High School Health Teacher, 27, Insured (during time of health crisis)


On the morning of January 29, 2001, Holly heard her own voice slur as she was saying goodbye to the dog and leaving for work. She kept repeating her words to listen to her own babble.


Her face went numb. "I'm 27," she said to herself. "A stroke can't be happening to me."


The symptoms went away. She drove to work. A co-worker suggested she might have Bell's palsy.


On February 2, four days later, while Holly was teaching her class, the symptoms reappeared. This time she went to an emergency room. She got a CAT scan and was admitted to the hospital at 11:30 at night.


If Holly had gone to the emergency room when she first experienced symptoms on January 29, she would have been uninsured. Her 6 month waiting period to be eligible for health insurance coverage at her teaching job did not start until February 1.


Holly went to the hospital on February 2, one day after becoming eligible for insurance.


The office assistant at the school where Holly taught was anxious. "The woman was sweating it out counting the months until I was eligible for health insurance. Had I gone to the hospital when I first had symptoms, I would have been uninsured. I qualified for insurance by ONE DAY! "


Holly spent a week at the local hospital where they confirmed she had had a stroke. The hospital did extensive blood work, a spinal tap and checked for multiple sclerosis and lupus. A month later Holly's neurologist sent her to a teaching hospital in a neighboring state. She consulted two hematologists. Holly was diagnosed with a clotting disorder.


Holly had just started teaching. She had to take more sick time than allowed. Her unapproved sick time was deducted from her wages making her take-home pay almost nothing. At the time, Holly's husband was a full-time graduate student. He was not earning wages. The family had little income.


Holly's co-workers offered to donate their sick days but the employer would not allow it. Instead, the coworkers covered for her when she needed time off to go to the doctor.


The doctors at the teaching hospital where Holly's neurologist sent her were out-of-network, as Holly would later discover. Many of their charges were not covered by her insurance. But the hospital itself was in-network meaning the insurance company would pay for the bloodwork done at the teaching hospital.


Holly said the insurer would "pay for the MRI to be taken but they would not pay to have it read." Holly first realized that a big chunk of her medical care was not covered when the "bills started rolling in."


At 27 years old Holly found herself spending much more energy dealing with her medical bills than on figuring out her medical condition."I was naive. I didn't know the game, the tricks.


"So many bills. I asked the billing department why something wasn't covered. They didn't know. Maybe blood was taken in the hospital but sent to a lab out-of-network. I'd get a bill for $500 which was 75% of my paycheck.


"I was lying in the MRI machine thinking, 'How much is this going to cost and am I covered? How much more fighting am I going to have to do over this bill?'


"I was ill but most of my energy was spent on the medical bills and trying to stay afloat. I became afraid of the mail. I'd recognize the look of the 'Explanation of Benefits' envelope and wonder who I was going to have to fight."


Collection agencies started hounding Holly - first, second and third notices. Panicked, she gave them a credit card number. " I am a very responsible money manager. We never had credit card debt. I became very desperate."


"Now I was paying 19% interest on hospital and doctor bills. I should have had a payment plan. But I got scared because of the collection agencies....expensive mistake. Then I learned the game. I turned into a crazy person on the phone with customer service."


At one point Holly hyperventilated on the phone with a customer service representative. But eventually, she learned the billing departments' language. She would make sure that her procedures were coded properly to get the most payment from the insurance companies.


"The stroke was easy. That was nothing. Health insurance and billing were tough. It's an industry with no controls. Where is the responsibility for the product?"


After a year of intense wrangling with billing departments, $8,000 of uncovered medical claims, hours on the phone, credit card debt, Holly said she "dropped out." "I just wanted peace -- relief from the financial nightmare."


Finally Holly asked the hospital's billing department, "How much do I have to pay to keep you off my back?" Twenty-five dollars a month. Holly still had a ton of debt. But at $25/month Holly would not be badgered by the collection agencies. "I was paying for peace."


Holly was seeing her hematologist every 3 months. Eventually she just stopped because she felt her disease was being managed and she did not want any more bills.


In 2002, Holly was diagnosed with Crohn's disease. She knows this is another pre-existing condition on her medical records. And she knows she cannot have a lapse of coverage or she could end up uninsurable. "I am more experienced now in playing the game."


Today, Holly is insured through her husband's job. She has been careful to never have a lapse of health insurance coverage. She takes daily medication for the blood clotting condition. She leads a full and productive life.