I think we’re getting to a tipping point

This last year has exposed what forty years of unrestrained brutal capitalism has done to this country

Today we have an interview with a fella who works in medical billing. He’s the type of guy who is the conduit between your doctor and your insurance company and you who figures out what stupid imaginary amount of money you end up on the hook for. “My job shouldn’t exist,” he said. That’s right buddy.

First check this shit out.

I have covered this sort of thing in here so many times it’s become a cliche at this point to keep complaining about it. It’s practically the platonic ideal of a Hell World story. Nonetheless it goes without saying to anyone not afflicted with chronic and debilitating local news website mindset that there is nothing to feel good about here. Stories like this one above and the dozens of others like it we see every month should in fact make us feel the exact opposite of good. Feel shitty stories.

This piece from WHNT in Alabama has an extra layer of sick-making to it though because of the way it was written. They actually did the fucking thing. They risked it all:

BIRMINGHAM, Ala. (WIAT) — Savage’s Bakery in Homewood is now serving a new kind of lemonade–a special concoction customers won’t find on their regular menu.

Liza Scott, the 7-year-old daughter of owner Elizabeth Scott, has set up a lemonade stand inside the bakery. Because when life gave her lemons…

She made lemonade.

It goes on:

It was less than a month ago that Liza began having Grand Mal seizures. Weeks later, doctors learned this “spunky, loving, fearless, bright, happy girl” has an “extra special brain.”

Don’t think she’s the only one here who does.

“I can’t handle it. So, I hope I make it,” Liza said. “My mom keeps saying I’m going to, but I feel like I’m not.”

Jesus Christ.

Elsewhere in here previously I wrote about the history of the iconic lemonade stand and how it teaches children all sorts of meaningful lessons about capitalism.

I just saw a GoFundMe started by a seven year old boy named Cayden asking people to help him with his goal of selling lemonade to raise money for kids with cancer. Peruse your Facebook events and you’ll find dozens of similar efforts like this one in Texas last year hoping to sell $400 worth of lemonade for children with cancer. The local TV news in Arkansas featured two little girls who raised $3,000 for breast cancer last year because one of their mothers is suffering from it. 

Whenever you see pieces like those in the news they’re covered as a feel good inspirational stories. Look at the pluck of these young kids doing their part they say. What a bunch of good kids the news guy says, and then we share them ourselves on social media because it makes us feel good. It really shouldn’t. 

Lawrence Ferlinghetti died the other day and this poem of his “The world is a beautiful place” seems appropriate at the moment. It starts like this:

The previous two issues of Hell World were paid-only and I thought the second one here was at least “pretty good.”

This coming Sunday is the anniversary of the first American death from the pandemic. The first of 500,000. How do you feel about that number? It just kind of sits there in its grandiose heft for me. Like if you saw a dinosaur come to life emerging over a hill into a clearing its immense stupid body unfurling in front of you you wouldn’t go oh look at its little nose you’d behold it all in its uncanny size at once and be struck dumb. I can’t personally make much sense out of it. 500,000 dead now in under a year. What is that? It makes my brain feel slow and dry like when you’re struggling with an especially dense philosophical text or something or like when your fight or flight reflexes kick in and you instinctively know that you’re somewhere you shouldn’t be. It’s when you go down in the basement. It’s an ejector button for comprehension. You cannot hold the deaths of 500,000 individuals from a pandemic in one country in your brain all at once it overloads the system. It’s Lovecraftian and just as if not more racist.

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The even grimmer thing to think about the young girl with brain cancer is that things "worked out well" for her because she got the news to cover her story and all of us to share it and chip in because it's so exceptionally miserable. So many people whose stories are merely baseline miserable but without a catchy hook don't go viral and we just never hear about them so it’s not our problem.

Read this old piece if you never did for more on that.

The advice for best practices most of these sites share are to tell a good story and spin a narrative and appeal to people’s interests which becomes almost absurdly macabre when the subject is human lives. McFarland is a unique case in that she proved an especially effective advocate for herself: She’s young and photogenic and internet-savvy and has a heartbreaking story having lost both her parents at a young age. Many others are much less fortunate.

On top of managing your health and your expenses now you have to make sure you present your malady with authenticity. Think of your cancer as the origin story a tech startup tells about itself on the About section of its website. And then start hoping a celebrity takes an interest in your plight online. It might be a shorter wait for that than a doctor anyway.

Ok here’s the interview with the guy.

For about ten years our man here today has worked in medical billing. What is that? Basically he’s the guy who takes the bill from your doctor for your medical care, presents it to the insurance company to try to get money out of them to cover it, then comes back to you with whatever stupid amount you now owe. Along the way all manner of mystical bullshit transpires that he almost doesn’t even understand himself. It’s essentially alchemy. Turning medicine into money. 

He’s worked for single practice providers and nursing facilities and doctors with a variety of specialties including ones whose clientele are regular assholes like us and ones who cater to the rich and famous in California. 

“I make a solidly middle class salary, and it’s supported me living in Los Angeles,” he said. But ultimately “my job shouldn’t exist.” 

I agree!

Tell us why your job shouldn’t exist. 

In my lifetime I’ve seen a demonstrative decrease in how satisfied people are with the care they receive, and a lack of trust in physicians. That to me is all driven by the profit motive. I think that there’s a real lack of understanding, by design, of how the business of healthcare operates, and how insurance companies make money. I think the real driver of discontent with healthcare is the move into for-profit health insurance. Anybody who has had any kind of insurance company has gotten one of those explanations of benefits... 

I have no idea what it means when I get one. 

Exactly. And that’s by design. I am not a licensed coder, and I was hired for that reason. The people who hired me wanted me to be trained by doctors rather than insurance companies. I think that if people understood... The way that for-profit insurance makes money is this: You pay your premium, and then they hold that in an account that gains interest. Maybe they invest it. The point is they are making money off of holding it. You go to see your doctor, they write down why you were there, the length of the appointment, then I code it and submit it out. The insurance company gets it and they say, oh we didn’t actually get it. They say the claim was lost in the mail. Then I have to go, no, no, it was sent on this day. Then they go, oh, ok we did get it, but actually, you needed a pre-authorization for this. Ok, let’s go back and do that. All of these things are to really delay and hold onto that money so it gains interest. That’s why you get pre-authorizations, and ticky-tack denials, these things that really make it more difficult for you the consumer, while the insurance company makes more money. 

Is that a well established conclusion for why they do it, to hold onto the money, or is it just your reading of things?  

If you were to ask somebody who works for an insurance company they would say, no, we do this to reduce fraud, etc. But if you asked someone who works in medicine they would agree with me. 

I write in here a lot about some of my injuries and stuff. A couple of months ago I was trying to go get one of these shots I get where they inject my abdominal with whatever it is, steroids or something, and the hospital said, well, no you can’t just come in and do it, we have to get it pre-authorized by the insurance. So you have to come here first and we’ll look at you for five minutes, then schedule another real appointment to actually do something for you after we ask the insurance company if it’s ok. It would have been like two months of waiting. Meanwhile this is in the peak of the pandemic, I don’t want to go to a hospital if I don’t absolutely have to just for some insurance company bullshit when it’s something the doctor has done for me multiple times now and agrees is a proper course of care for me.

So I just didn’t go and sucked it up with the pain. So many people that have pain or are sick avoid care like that because of the fucking paper work and all the hoops to jump through that are just maddening and morale-killing. And it’s just so they can deny care and hold onto the money we’ve already paid? It makes a person insane to think about. 

What they’re doing is to make sure you’re not “abusing your coverage.” Of course you’re not. I had to deal with this personally. They didn’t want to authorize adderall, which I take for ADHD. They said I had to get authorization from my doctor. Fine. I had my psychiatrist fill out the pre-authorization and they still denied it. I’ve been taking adderall for sixteen years at the same dosage. They played me against my doctor. They said this is your doctor’s job. I said, no, my doctor’s job is to say I need this stuff. Your job is to approve it. I sent them a copy of an approved prescription from another insurance company. I said I have your formulary, this covers it. If you don’t I’m going to file a bad faith claim, which they don’t want. 

That’s something you can do to your insurance? Accuse them of denying you something for bullshit reasons? 

It has to be something expressly in your plan. So if your plan covers it, and they say you need to get it pre-authorized, you can say, no, you cover this. But you have to be some kind of lawyer and billing expert to figure it all out. A lot of times it’s easier for people to say fuck it and pay out of pocket because they don’t want the headache. 

Well that’s what I’m thinking right now. When I talk about people walking around in pain... Obviously if your leg is hanging off you’re going to go get it taken care of no matter what, but there’s so many things, little things people have, and when you start hearing all this shit, pre-authorization, go here, talk to this guy, send this paper work here, I feel like so many people just say fuck it. They say I don’t have the time, or the inclination, to become a full time clerk for my own health. 

Isn’t that in the insurance company’s interest? To make it such a pain in the ass to get care that we don’t avail ourselves of the services we’re already paying for? 

Absolutely. Then you might just pay out of pocket. You pay for your premium and you’re not using it. They make the most money from people who are healthy and don’t use their insurance. And that’s why the individual mandate was so important in the ACA. The people who don’t use the system heavily supplement the people who do. 

Which is what insurance is supposed to be!

Exactly. When I first moved out here I herniated a disc in my neck. I had a $2,000 deductible. I couldn't afford to go and get an MRI and get physical therapy. I had to wait until I had new health insurance with my new job through the California exchange. Meanwhile I’m not sleeping. I’m smoking weed five nights a week so that I can sleep. If not I’m waking up with tingling numbness in my arm. My neck felt like when the pads get real low on your car brakes. That’s how it felt. 

Eventually I got my new insurance, and I worked out a payment plan with the hospital I got an MRI at. Then my insurance came in and I had to pay $120 for my co-pays for physical therapy. That’s the other thing, these deductibles. Paul Ryan, years ago, said what we need are health savings accounts. This idea that people have money to put into that! Am I gonna sell my unicorn? Some of these solutions that I hear from Republicans are nonsense. 

This for-profit predatory shit is relatively new right? Within my lifetime?

Health insurance couldn’t be for-profit before Nixon. It started to expand under Reagan, then exploded under Clinton. The idea was free markets, freer people. Like I said, how insurance companies make money is delaying and denying care. That’s the crux of it. 

That’s the bottom line?

Yes. If you delay and deny payment you make more profit. 

It’s infuriating and kind of short-circuits my ability to think right now. 

It’s the same thing we saw with the financial crisis. When you layer things and make them so dry and boring, the average person can’t understand it. It was the same with like credit swap derivatives.  

Ok back to the fucked up bills we get. So when you get your explanation of benefits and it says this MRI would’ve cost $8,000, but we’re charging you $1,200, that’s because they're gambling that some rich guy is gonna pay the full price?

Yes. If we both go into Cedars-Sinai and we both need an MRI, they can’t go, ok, you’re 43 we’re gonna charge you $5,000, and you’re 34, we’re gonna charge you $2,000. They can’t do that. They have to charge the same across the board legally. The cash rate then is inflated. The idea is you would get somebody that is very wealthy that says ok, here’s $10,000 for the MRI. I’ll pay.

And where do those prices even come from?

Insurance companies base reimbursement rates off of what Medicare reimburses. By the way, if you have a doctor that’s in network, these kids come out of college, six figures in debt, making as much as a waiter. The insurance company makes more money the less they pay out to the doctor. What happens then is your doctor has to start seeing way more patients. That’s the other aspect of it. For the physicians, the more people you can get in and get out, the less time you spend, the better. Generally at this point doctors aren’t getting into this to make money. They’re doing it to help people. That’s another reason doctors go out of network now. It allows them to spend more time with a patient. 

Going out of network means you stop accepting insurance? 

Yes. To be in network you have to agree to a contract that’s like, ok, I’ll bill $5,000 for that MRI, but I will accept $2,500 from the insurance, and I will adjust off the other $2,500. 

When you’re accepting insurance and you have to shuffle big numbers of patients through it’s like… You get worse service at McDonald’s than you do at a fancy restaurant. So this is turning healthcare into a churn and burn type of thing right? 

Yeah it is, but… I am very pro-doctor. This current system we have now is so detrimental to the provider and the patient. It only benefits insurance companies. 

I do have a degree of sympathy for doctors. If they’re being fucked by insurance companies too it hurts both of us. And it’s all just so some insurance company motherfucker can get rich. 

There used to be a single payer advocacy group that put out a list of what insurance company CEOs make in compensation. At one point half of them made more in a day than the median yearly income of the United States. It’s obscene.

So did the ACA make this all better or worse? 

The ACA was a good starting point. None of these programs like Medicare are silver bullets. The ACA should’ve been amended and evolved. That’s part of why the Republicans have had a hard time coming up with a replacement. Even Ann Coulter talked about at one point that Romney-care should’ve been adopted in all fifty states, which is what the ACA was. 

I think there are good things about the ACA. Pre-existing conditions. Covering yearly physicals, which is good because it gets you in there, and should catch stuff theoretically. Keeping kids on their parents’ plans until twenty six. Those are all good things. But overall it’s neutral. I think insurance companies liked it because people had to sign up or pay a penalty. Insurance companies don’t want it to go away now. They spent a shit load of money to get ready for it, so when the Republicans were trying to repeal it they were very unhappy. I think it was 2012 or 2013 when the Supreme Court ruled on it. Insurance companies were panicked. 

It was a good starting point but was never meant to be the finish line. 

You’ve worked for some high end type of doctors. How different is the care the rich people get?

The doctors I worked for on the higher end, I thought, were high end because they cared so much. Having those people who paid a lot of money meant they could take care of people we were floating on a $5 a month payment plan. 

Really? 

That was explicit. The doctors were insistent on not knowing who had insurance, who was paying what, because they didn’t want to have the appearance of bias. The difference is at the higher end places there was less of an obsession with money. The lower end places I felt like the emphasis was on money, and there was a lack of concern for patients. If you’re only in it for money you’re going to be miserable because there isn’t a whole lot to be made. Maybe compared to a regular person, but not for the amount of work they’re putting in.

Did you deal directly with patients helping them handle bills? 

I would work with patients. I want to make sure that a bill gets paid obviously, but I don’t like private for-profit insurance, so I want to see them pay it. I’ve had money problems like everyone. The anxiety of making ends meet. Most doctors’ offices will work with you. The best advice I can give is to be upfront and say, listen, I don’t know if I can pay this. I’d like to set up a payment plan. Most hospitals will do that. You hear about these $100,000 bills. If you're in that situation, these places are often required to offer payment plans. If you say, look, I can’t afford $80,000, they’ll knock off most of it. It will end up at like $8,000, which is still a shit load, don’t get me wrong, but then you can set up a payment plan that reasonably allows you to pay without bankrupting you. 

Why can a hospital say you owe me $80,000, and when I say I can’t pay that they can say, ok just kidding how about $8,000? Why can they do that? I don’t understand. Did the thing cost $80,000 or not? Did you put in $80,000 of work on my body or did you put in $8,000 of work? What is going on?

That’s another issue. The decision for what a procedure costs is kind of witchcraft. 

I know it’s related to what Medicare can charge...

Yeah but even how they do it… What Medicare would allow for a procedure in Boston is different in LA. It goes by what is charged by most physicians in LA. I don’t know how you put a dollar value on a medical procedure. Medicare doesn’t 100% elucidate how they make these decisions, but it’s something like they talk to fifty orthopedists in LA, and determine this is the average of what they charge for, say, knee reconstruction. 

Maybe this is because the last interview I did for Hell World on a topic I don’t really understand was about the stock market, but this all reminds me of that. It’s just like these vagaries on the wind, and somebody’s job is to divine hard data out of essentially vapor? 

A lot of it is like that. I don’t know why I’m doing what I’m doing, but I know the process. I know that the insurance company is supposed to do this, and that they’re supposed to pay this, but I don’t know how they come up with the number. For example, deductibles don’t make any sense to me. Aside from deductibles you see an out of pocket amount, which is a second, slower deductible. 

I never understand what’s out of pocket and what's deductible. And the co-pay? What is that, just like a door charge to get into the building? 

Kind of. Let’s say you go see a doctor and then I charge the insurance company $125 for the visit. They’ll say we allow $100, the patients has a $25 co-pay, so we’ll pay the doctor $75, and the patient then has $25 more left over to pay. Out of pocket is another way for insurance companies to not have to pay for anything. 

I don’t know if this is helping me understand! I hear all this stuff and just think fuck it who cares I’ll just die. Ok besides asking for knocking down the bill is there anything else people can do to get help?

The people who I was really sympathetic to were the ones who said straight up they were having money issues and needed help. 

And people don’t generally know they can do that?

They don’t. You’re gonna call your insurance company and you're gonna get a different person every time, possibly outsourced. But if you call your doctor it’s going to be one of three people who work for the doctor. Generally the person billing from the doctor or hospital is on your side. 

Some more of it is just general debt advice I’ve gotten. Don’t run away from a bill, it’s not going to go away, but most places will work with you. They will give you a payment plan. Like I said some of them are required to if you ask. They don’t have to offer it though. 

Does your job exist in many other countries? 

I would assume on a much smaller scale. I’m sure there’s stuff that gets denied through bureaucracy. 

You’re skeptical about Medicare for All for some reason?

Honestly the system would be shocked if we jumped right to it. That said, a lot of the issues you hear from critics of Medicare for All on the right: That it’s a two-tiered system that’s going to favor the rich. We’re gonna have these long wait times that lead to people dying. We’re gonna have faceless bureaucrats making your health decisions… That’s our system now! That’s all built in. The difference with single payer is a lot fewer people are going to go bankrupt. Also a lot fewer people are going to get rich.

This last year has exposed what forty years of unrestrained brutal capitalism has done to this country. I think we’re getting to a tipping point. I would be surprised if there isn’t at least a push for a public option in the next four years, which is the next step on the path to single payer. I just don’t think the current climate is tenable. 

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