Savvy Patient Fought for the Price She Was Quoted − And Didn’t Give Up

Yves here. Sadly California is not a “one party consent” state. But for those of you who are in one party consent states, this story highlights the importance of recording all calls with medical providers about the price of major procedures. I suspect this patient could have truncated the run-around had she had presented evidence that two employees had given her the same quote (the reason for the capitulation may have been that they had recordings of the calls that would be discoverable). But she also had on her side that the cheeky demand for the co-pay before the procedure was again for the lower amount. Yet the hospital dug it with its bait and switch and tried to depict its practice as a “communications breakdown”. Help me.

By Anna Almendrala, Kaiser Health News Correspondent, who covers the business of health care and health care policy. She previously worked at HuffPost for nine years, where she reported on health and lifestyle news and was the creator and host of a podcast about infertility called “IVFML.” Originally published at Kaiser Health News

When Tiffany Qiu heard how much her surgery was going to cost her, she was sure the hospital’s financial department had made a mistake. Qiu, who already knew from a breast cancer scare earlier that year that her plan required a 30% coinsurance payment on operations, pressed the person on the phone several times to make sure she had heard correctly: Her coinsurance payment would be only 20% if she had the procedure at Palomar Medical Center in Poway, California, about 38 miles south of where Qiu lives.

“I was kind of in doubt, so I called them a second time,” said Qiu. “They gave me the exact same amount.”

Qiu had been diagnosed with uterine polyps, a benign condition that was making her periods heavier and more unpredictable. Her OB-GYN proposed removing them but said it was safe to wait. Qiu said that she asked about the possibility of doing it in the doctor’s office under local anesthesia to make the procedure cheaper, but that her doctor rebuffed her suggestion because of her preference for general anesthesia.

Because Qiu thought she was getting a deal on her usual 30% share of the bill, she decided to go ahead with the polyp removal on Nov. 5, 2019. As she sat in the waiting room filling out forms, staffers let her know she needed to pay in full before the surgery.

Unease set in. The hospital asked for the 20% coinsurance — $1,656.10 — that she had been quoted over the phone, but Qiu hadn’t been told she needed to pay on the day of the procedure. As she handed over her credit card, she confirmed one more time that this would be her total patient responsibility, barring complications.

The surgery was over in less than 30 minutes, and she walked out of the hospital with her husband, feeling perfectly fine.

Then the bill came.

Patient: Tiffany Qiu is a 49-year-old real estate agent and mother of two who lives in Temecula, California. Her family of four is covered by a Blue Shield of California policy that she and her husband purchased on the marketplace. Last year, they paid a $1,455 monthly premium, with an individual annual $1,850 deductible and an individual out-of-pocket maximum of $7,550.

Total Bill: Palomar Health billed Blue Shield $22,219.64 for the polyp removal, which the insurer negotiated down to $8,576.79. Blue Shield paid $5,769.72 and stated in an explanation of benefits document that Qiu was responsible for a $334.32 deductible and $2,472.75 coinsurance.

Because Qiu had already paid $1,873.20 on the day of surgery, the hospital billed her an additional $933.87, which meant Qiu was on the hook for the remainder of her 30% coinsurance.

These figures don’t include the fees Qiu paid for anesthesia or her doctor’s services.

Service Provider:Palomar Medical Center in Poway is one of three hospitals in the Palomar Health system. Palomar Healthis a San Diego County public health care district, which means the health care facilities are nonprofit and receive property taxes as a portion of their revenue stream. The system is governed by a board of directors elected from within the district’s boundaries.

What Gives:Hospitals and surgery centers sometimes offer discounts if patients are uninsured and able to pay with cash or a credit card. Physicians may even offer discounts on a patient’s share of the costs if they know the patient is unemployed or has fallen on hard times. But regularly offering discounts to attract patients is not common, and could even be fraudulent if the patients are insured through Medicare, said Paul Ginsburg, director of the USC-Brookings Schaeffer Initiative for Health Policy.

In Qiu’s case, the hospital seemed to be offering a discount on the insurer’s normally required coinsurance.

“The hospital would be in breach of their contract with the insurance if they did not bill her for that amount,” said Martine Brousse, a California-based patient advocate and medical billing consultant for AdvimedPRO. “She owes what the insurance has calculated, and the facility has every right to demand payment.”

Copayments and coinsurance exist, in theory, so patients have “skin in the game.” They have to pay a clearly defined portion of the cost of their care, according to their policy, so they will shop around and use medical care judiciously (though many health experts say coinsurance amounts have gotten so high that many cannot afford them).

Resolution: If she hadn’t been quoted 20%, Qiu said, she would have shopped for a better deal. She flies to China often to visit her mother and was open to getting the surgery done there.

Qiu called the hospital to ask why she was being billed a second time, despite the lack of complications during the surgery. She remembers the back-and-forth over the remaining bill was exhausting, especially because it happened over the holidays.

“I got tired and said, ‘I don’t want to play this game anymore,’” Qiu recalled. “‘If you want to send it to collections, you can do it, but I’m not going to pay for it.’”

The bill landed at a collection agency called IC System. In a May 23 phone call, Qiu said, a representative offered to slash the remaining bill by 25% if she would just pay that day.

But Qiu refused, though she could easily afford to pay. She’s undaunted by the risk the unpaid bill poses to her credit score, preferring instead to fight the hospital on behalf of other patients who may not have the time or luxury to persist.

The experience left her feeling as if the hospital offered her a fake discount to reel in her business.

“I double-checked and tripled-checked with them,” Qiu said. “They have financial departments that should be verifying this with my insurance company.”

Another thing to note is how much the hospital billed Qiu for a simple outpatient procedure: $22,219.64. That amount is “totally laughable,” said Dr. Merrit Quarum, founder of WellRithms, a company that works with self-funded employers and other clients to make sense of complex medical claims.

Not only is the charge far out of line with what that procedure typically costs in that region (around $5,500), but Qiu is now stuck paying a larger amount as her share under the terms of her insurance. This is how those “sticker prices” that few people pay still drive up costs for individuals.

After a reporter’s call, Palomar Health looked back at phone records, confirmed Qiu’s version of events and said a hospital staffer had made a mistake by quoting her a 20% cost-sharing obligation. That percentage then got automatically put into her patient notes and was on the bill of estimated costs she signed and paid on the day of surgery, even though it was incorrect.

They apologized for giving the mistaken impression that Qiu was getting a discount. Staff members are not authorized to offer discounts when providing estimates, said Derryl Acosta, a spokesman for Palomar Health.

Acosta also pointed out other communication breakdowns, like dropping the complaint Qiu phoned in after she received the second bill in late November. Her issue did not get put into the standard customer complaint process, which would have elevated the problem and triggered an investigation into the phone records. That’s why Qiu’s bill was sent to the collection agency.

“We definitely admit that the call should have been handled differently,” Acosta said. “We now have a new call center that we believe will handle this type of call better.”

Because Palomar Health was able to see in their phone records that a staffer had confirmed the erroneous 20% coinsurance amount to Qiu, the health system will change her bill to reflect what she was promised. Qiu will get a statement in the mail saying she has a zero balance, Acosta said.

The Takeaway: Multiple medical billing advocates who reviewed Qiu’s case praised her for her tenacity in calling the hospital financial department twice before the procedure. But as she herself acknowledged, most people don’t have the time or spine to fight.

To avoid such situations, experts advised, patients should check in with their insurer about the discounts offered, as hospital staffers may be poorly trained or ill informed.

If a patient hears conflicting information about charges before a procedure, they need to approach their insurer to confirm the details of their own policy, said Brousse, the patient advocate.

The simple fact that a hospital staffer misinformed a patient isn’t a legal reason to force a hospital to lower a bill, Brousse said.

Also, get promises in writing — before the day of surgery. Make sure the offer is explicit about which services are included and what might count as a complication. Ask whether you’ll have to pay upfront.

Initial estimated bills can be full of asterisks and “weasel words,” said Akshay Gupta, co-founder of CoPatient, a medical bill review and patient advocacy company.

“Even though she tried to be diligent, obviously she still didn’t know that she would need to get something that was legally enforceable,” said Gupta.

Bill of the Month is a crowdsourced investigation by KHN and NPRt hat dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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  1. Abi

    Still cannot get over the fact that some people have decided to use medical care as a way to make profit, I don’t really care your politics or economics, at the very least of being a human being, doesn’t it bother you?

    I’ve had 5 serious medical issues in my short life, I’ve had 3 surgeries, a back brace for my scoliosis and an almost 3 month stay in the hospital. I am so sure my family paid almost zero for all those things, except my brace which cost around £5000 pounds (in 2006 and this is because my family chose to go private so I could have the best technology on offer at the time), just imagining if I lived the US, my medical history may have completely wiped out my family financially.

    Thank the Lord for people like Ms Qui who are fighting the good fight.

    1. Jack

      You have no idea. Becoming a certified medical coding specialist requires advanced training and has one of the hardest certification tests around. I have a RN friend with 30 years experience in medicine and multiple advanced certifications who could not pass the coding certification test (after trying twice). She had to switch careers because she fractured her wrist and could no longer adequately perform CPR, a requirement if you provide any direct patient care.

    2. bruce

      And how about that “patient advocate” Martine Brousse? Reading her (?) statements brought to mind the term “Judas goat”, and in the end she was wrong as Ms. Qiu prevailed.

  2. Maritimer

    I am happy any day I do not have to do a Transaction with the World. If I do have a Transaction of any significance, I keep records. NC recently posted an article on satisfaction with professions and I saw that Medicine was justifiably quite low.

    Bargaining when your health and life are concerned is very stressful. I once had to bargain with a cardiologist over the treatment recommended. (Second opinion was not an option.) He was not pleased but research prior and after verified that his treatment was contradicted in my situation. If I had not protested, I do not think I would be here.

    The best Transaction I have in my life today is with an fine gentleman who maintains and repairs my car. I feel good when I pay him his fair and reasonable charges; that’s what economics should be.

  3. cnchal

    Another thing to note is how much the hospital billed Qiu for a simple outpatient procedure: $22,219.64. That amount is “totally laughable,” said Dr. Merrit Quarum, founder of WellRithms, a company that works with self-funded employers and other clients to make sense of complex medical claims.

    Not only is the charge far out of line with what that procedure typically costs in that region (around $5,500), but Qiu is now stuck paying a larger amount as her share under the terms of her insurance. This is how those “sticker prices” that few people pay still drive up costs for individuals.

    Call the frigging cops, for both ridiculous prices. What’s missing is the “F” word.

  4. carl

    Funny how the “mistakes” always seem to favor the billing party, in this case, the hospital. “When in doubt, bill it out.”

  5. Crazy Horse

    After many years of slow growth the bone spur on my heel reached the size where it needed to be removed. The operation is common and minor enough that sometimes it is performed in an outpatient setting. I was examined by the orthopedic surgeon attached to the small 19 bed hospital that serves our resort/farming valley located 70 miles distant from the first significant city. After he examined the potential surgery I asked how long I should expect to be on crutches and how much it would cost. I have Medicare but the co-pay is still significant for someone on a fixed income. His office refused to estimate a cost after two requests. Finally after I got in their face they handed me a pink post-it with the number $19,700 on it. No indication that it came from the hospital or surgeon, not even a memo pad with the hospital’s name on it. In other words, “lawyer proof.”

    I drove to the nearest regional city and had the operation performed by a orthopedic surgeon affiliated with a small hospital. Because I was driving they recommended an overnight stay in the hospital. I walked out the next morning without aid of crutches. Cost: $3,450 total billed to Medicare, less deductible.

    See why our “health care” system is called the American Medical Extortion System?

    Understand why I keep a rainy day fund sufficient to fly to Costa Rica or Mexico in case I need serious medical care?

    1. CostcoPizza

      You just saved Medicare a non-insignificant sum too. They should cut you a whistleblower check.

      1. Crazy Horse

        The local hospital’s over billing was completely within the scope of approved Medicare procedures. Hospitals with less than 20 beds are exempt from Medicare pricing standards and are allowed to charge any amount they can extort from their customers. So the scam that helps support the local orthopedics’s new $100,000 Tesla is no aberration, but rather a nationally encouraged practice.

  6. timbers

    “We definitely admit that the call should have been handled differently,” Acosta said. “We now have a new call center that we believe will handle this type of call better.”

    Wonder were that new call center is located. India, Philippines, some South American nation? Also wonder if they’ve gotten a new, 3rd call center since this article was published. Most reassuring.

    Have you ever found yourself talking to a customer service person for a minor product you ordered and wondered if that person takes calls only for the company you ordered from or if they are juggling several clients of entirely different companies at once for those employing “call centers”?

  7. timbers

    “If a patient hears conflicting information about charges before a procedure, they need to approach their insurer to confirm the details of their own policy, said Brousse, the patient advocate.”

    Maybe I’m suspicious and misinformed or been healthy far to long with no or little experience in this sort of thing, but it does cross the mind that by sharing this information with the insurance company, it might respond to that kind of data you share with them on what hospitals are willing to charge you directly by contacting them and threatening legal action if they don’t raise their prices offered.

  8. OpenThePodBayDoorsHAL

    Reading this from Australia is quite amazing and depressing, the people who prevented Bernie from gaining any power to bring First World health care to the U.S. should be shot

      1. KLG

        Tempting, very tempting. But I’d be OK with them just disappearing, back to their second homes or wherever, never to return as public figures of any kind. Let the Duchess of Pacific Heights eat her high-end ice cream in peace. Anyway, it is clear that Pelosi Schumer Clinton Obama & Biden LLC will be the death of us all, one way or another.

      2. Ford Prefect

        It will be interesting to see what happens if the Supremes kill the ACA and Biden gets elected with a Democratic Senate.

        There will be no ACA to build off of then. Would the Dems just go full on Bernie Bro and put in single payer, since the Heritage Foundation option (ACA) is no longer acceptable to the conservatives?

        If the Supremes also kill Roe v. Wade, then the Dems could just make Medicare eligibility at the age of conception instead of 65 as part of the “Right to Life”. It would be interesting to see how a fetus would select between the various Part Bs and Ds as well as sign-up 3 months before or after conception. Otherwise, they could change age 65 to “at birth”.

  9. Prosaic Iowa

    The beatings will continue until morale improves! I can think of no other business that operates in the same way as the US medical system. With byzantine billing codes, third party billing, and unverified procedure rates the patient (or the consumer or “mark” if you prefer) is left with very little leverage. It’s not really a functioning market in the true sense of the word. A working market starts with the presumption of some symmetry of knowledge and reasonable competition. That is clearly not what we have with the US medical market.

    1. Ford Prefect

      The Mafia protection rackets operate in a similar fashion.

      The used car industry used to as well, but they got regulated.

  10. Oh

    Hospitals, Clinics and Group Practices all play the same game. They’re worse than the used car dealer. The insurance companies are in cahoots with these crooks. When you pay an insurance premium you have a contract with the insurance company, not the hospital or other companies providing the service. The providers have a contract with the insurance company. Why the hell do they guys want you to pay them your copayment? The insurance company should be the one to collect that. Besides, in most states the crooked medical providers have gotten a law passed that you are liable if the insurance company does not pay them. What kind of a law is that? Add to this the other parts of the wretched system – the billing companies, the collection agencies, the billing consultants and others who feed off this system. Now I heard that Medical in CA has a clawback on services paid for people over 55. How about a clawback on corporations that don’t fulfil their contracts with the consumer? Kameleon, are you listening?

    I have an occasion several years ago where the hospital billed me over and above the amount that the insurance paid them. I talked to the insurance company and they told me that they had not received their permission for the extra service they were billing me for and therefore I didn’t have to pay it. I therefore refused to pay the hospital which then sent it to the collection agency, who kept bugging me. Eventually, they stopped calling me but I found out that they had reported it to the credit agency (another POS in the system). I wrote to all three agencies and said that it was a fradulent bill and asked them to remove it from my credit report. They did.

    My advice to all is to act like Ms. Qiu and fight every fradulent bill. Make sure you correspond with them in writing. Confirm every phone call in writing. We should also join together and fight for our rights as consumers and patients.

    1. Howard Beale IV

      Try working for a Fortune 500 company, who self-funds their healthcare, and uses a for-profit administrator (UHC), and live in an area where many providers are ‘out-of-network’ (the only provider of anesthesia in the area.) And god forbid if I need a joint replacement or cancer treatment, where I’m forced to go to a so-called ‘Center of Excellence’ to have those procedures done.

  11. Bob

    “The best Transaction I have in my life today is with an fine gentleman who maintains and repairs my car. I feel good when I pay him his fair and reasonable charges; that’s what economics should be.”

    Isn’t this what all of us should expect ? Simply a fair shake in the market place ?

    This is the sort of billing practice that causes the 30% admin cost for American healthcare.

  12. Rory

    I try to pay some attention to politics and to what is going on in the world. I am aware of the dominant influence of money in politics, but I simply don’t understand why the massive public dissatisfaction with the way we currently have to get medical care isn’t enough to overcome that and to lead us to universal health care as a matter of right. It affects everyone’s lives. How can we ignore it?

    1. Jeff

      How can we ignore it?

      Easy, the power is on, the internet works and the trash is getting picked up.

      It’s really hard to get people to give a shit.

      1. troublemecca

        If you have the money, you just pay without blinking. That people can’t afford a 5k bill is surprising to many… and after the surprise, comes the disgust at others’ misfortune (as opposed to ones’ own obscene wealth). Then comes the victim blaming, with nebulous references to meritocratic values, the A-dream, and the virtues of capitalism.

        I’ve come to understand that power really can justify anything, especially itself.

      2. Ford Prefect

        The US is working on making those things non-functional since they are leading to an elevated degree of satisfaction of the populace which implies these services have not been economically optimized yet.

  13. juno mas

    Although California is a two-party consent state, it can be wise to record the content of phone calls; as a way to “refresh” your recollection of the conversation contents, if necessary at some future date. You can submit those written recollections as ”text” in any future discussions.

    1. Martin Cohen

      In California, make sure to say “This call is being recorded for quantity assurance.” The quantity that is being assured is the amount that you pay.

    2. bruce

      You might be surprised how many calls get taped anyway in a two-party consent state. Decades ago I was practicing law and scheduled to phone a lawyer I didn’t trust in San Francisco. Ten minutes into the convo, he goes “Oh by the way, do I have your permission to tape this call?” I grinned and looked over at my own tape recorder.

  14. CatmanPNW

    I had this happen a few years ago. Started calling before a procedure – maybe a month and a half. Was told they’d get the cost info to me two weeks before. I still hadn’t heard, despite calling several times. The day before they gave me an estimate, of course leaving out anesthesiologist, the cost of the room, and another bill I cannot remember. I called them, asked for the total, paid, and then kept getting more bills from different billing departments – the anesthesiologist had one, so did the facility. Each time I said, “I just want to pay off all of these. Are there any more?” Each time, yep, you are done. Then a year and a half later I got a bill and a threatening letter saying I owed them $1.34 for a test. I’m baffled by how anyone could argue we have a good system.

  15. Dave_in_Austin

    On the “one party consent” states and the two-party rule in states like CA.

    Every phone call to a provider begins with the obligatory warning “…this call may be recorded for purposes of…”

    Notice the passive tense. There is no statement on who has the right to record the call, only that it “may be” recorded. My guess is some many people getting the calls subcontract out the work of answering that they are covering the bases. subcontractor in Manila can do it and the organization getting the call (in this case a medical provider) is safe from suit.

    But you- the caller- appear to be safe too. An assertion that you the caller know when calling that the people on the other end of the line aas a routine practice approves of recording these calls (“this call may”) coupled with the failure to say who may record the call, seems to allow either party to record the call without any further notice. No “every few seconds a beep’ is requireed because both parties are on notice that the call is being recorded..

    Am I missing something?

    1. Yves Smith Post author

      No, this is not correct. You do not have to inform anyone else on a call if you are in a one party state. Your consent to recording yourself is enough!

      The reason financial institutions issue warnings to everyone is they’d have to pay a ton more money to balkanize their call center ops to have the calls from people in one party states routed to one set of call center types and the ones from two party states handled otherwise. Plus it’s not even clear they could discriminate accurately. If you have a CA phone number, that isn’t what’s dispositive, it’s where you are when you call.

      Moreover, I do not recommend announcing you are recording. You have the legal right to do without notification if you are in a one party state plus many organizations will immediately terminate the call if you tell them you are recording. Cigna is one and I suspect most insurers behave the same way.

  16. Tim

    My kids were both born at this hospital and I also have California BC/BS.

    I reviewed the bill for my first child line item by line item, and it didn’t add up properly (being overcharged of course), so I confronted the billing desk lady about it for quite a while showing her, she finally went into the back room and came back a few minutes later with a revised total that still didn’t match how it should actually have tallied up, but it was close enough I took the deal and made my final payment.

    I assume while in the back room the lady played a game of solitaire, put a note in my records of being “difficult to bill,” typed a random number total down on the revised bill and sent me on my way.

    Two years later for my second child, the amount billed was more reasonable and made sense. Go figure.

  17. Bob Hertz

    Thanks for posting a great article.

    The hard part of reform is that if hospital billing is controlled, say by a binding national fee schedule, then some hospitals will go broke,

    Just when we need them most for the pandemic!

    The typical American hospital is a phenomenally expensive place– and this has many causes — construction costs, borrowing costs, equipment costs, drug costs, generally high salaries.

    If we want to stop hospitals from extorting from patients, we must find a way to get hospitals the money the need to survive. This will require higher taxes.

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