- 1 DROM Medical Debt
- 1.1 WHAT IS MEDICAL DEBT?
- 1.2 U.S. PAYS MORE FOR HEALTH CARE, BUT GETS LESS
- 1.3 HOW TO BETTER UNDERSTAND MEDICAL BILLS
- 1.4 CHALLENGING MEDICAL BILLS IN COLLECTIONS
- 1.5 WHAT DO YOU DO IF YOU NEED CARE NOW?
- 1.6 HOW TO CHOOSE A HOSPITAL
- 1.7 DENIED TREATMENT?
- 1.8 END MEDICAL DEBT BY FIGHTING FOR UNIVERSAL HEALTH CARE
- 1.9 RESOURCES
DROM Medical Debt
MEDICAL DEBT: AMERICAS SICK CREATION
WHAT IS MEDICAL DEBT?
If you're having trouble paying medical bills, you are certainly not alone. About 62% of all personal bankruptcies in the United States are linked to medical bills or illness, and three-quarters of those bankrupted had health insurance when they got sick. That's about one medical bankruptcy every ninety seconds.
Medical debt is debt that individuals accrue when they are charged, but don't or can't yet pay for, out-of-pocket health-care-related expenses charged by the hospital, clinic or doctor (provider). As soon as you pull out the plastic and put it on your credit card-something strongly advised against when trying to manage medical bills-it becomes personal or consumer debt.
There are many ways you can incur medical debt. According to the American Journal of Medicine, "Among medical debtors, hospital bills were the largest medical expense for 48%, drug costs for 19%, doctors' bills for 15%, and insurance premiums for 4%."
Dr. David Himmelstein, M.D., founder of Physicians for a National Health Program, states '"private health insurance is akin to an umbrella that melts in the rain. It simply isn't there for you when you most need it."
U.S. PAYS MORE FOR HEALTH CARE, BUT GETS LESS
People in other industrialized countries have no concept of medical debt. That's because they have a system of universal healthcare that spreads risk across the population. U.S. health care does exactly the opposite; the financial burden is placed on the most vulnerable individuals, while the cost of care increases and coverage becomes skimpier.
Health insurance is supposed to guarantee that you get the care you need without going bankrupt, but in the U.S. health system, it may very well do neither.
The World Health Organization places the United States health care system first in spending (per capita) and 37th in quality of care.4 Spending was estimated at over $8,500 per person (or 17.9% of the GDP) last year.5 At the same time, the United States ranked last among "high-income" countries on amenable mortality-that is, deaths that could have been prevented with access to effective health care.
Why does health care cost so much?
One of the largest driving forces of health care cost lies with the high overhead expenses of health insurance companies, such as advertising, underwriting costs and lavish payouts to executives and shareholders. These expenses absorb at least 12% of premiums-amounting to billions of dollars a year that could otherwise be spent on health care. Medicare's overhead, meanwhile, is at 1.42%.
Even with the passage of the new health reform law, the Affordable Care Act, there will be an expansion in the role of private health insurance and for-profit care with an increasingly rapid transfer of public money to private hands leaving patients in the dust.
HOW TO BETTER UNDERSTAND MEDICAL BILLS
'"A few months ago, I was in the hospital for a week. I'm still getting bills. There are so many bills, and they are from different departments in the same hospital! How can I tell them apart?'"
When you receive a medical bill: o Keep every bill. o Separate doctors' bills from the hospital's bills. Not every service provided during your hospital stay will be included in the hospital's bill. o The origin of the bill is a significant factor in determining whether you're entitled to a discount. o Different account numbers on the bills may help indicate the different providers. o Ask the hospital's billing office for an itemized bill. This bill will separately list all hospital charges. You have a right to know what you're being charged for. o If you have trouble understanding which services you're being charged for and by whom, call the telephone number listed on the bill to help clarify. o If you're insured, review your insurance policy to better understand the expenses for which you are responsible versus those covered by the plan. o In addition to making sure you receive coverage that you're eligible for, avoid putting medical bills on your credit card. Doing so converts your medical expenses to consumer debt, which puts you in an even worse place. Having credit card debt instead of medical debt likely means greater fees and penalties, and greater difficulty securing a job or mortgage.
You can challenge your hospital bills for many reasons: o If you believe the bill was not calculated correctly. o If you believe you're being charged twice for a single service. o If you believe your insurance-either public or private-should have covered some or all of the charges for which you are being billed.
PRIVATE INSURANCE BILLS
Be careful about referrals! Sometimes patients admitted to an in-network hospital by their in-network provider incur huge bills as a result of out-ofnetwork referrals during their hospital stay. This is because commercial insurance plans do not require their in-network doctors to refer patients to other in-network doctors.
If you have a plan with limited out-of-network coverage, or with none at all, tell your doctor not to refer you to out-of-network doctors. Ask each specialist who treats you in the hospital whether they accept your health plan. Anesthesia bills can be very costly; request an in-network anesthesiologist who accepts your plan and ask to have this request written in your chart.
Call your doctor right away if you think your bill is wrong. o Find out what the bill is for. You may be responsible for co-pays or deductibles, depending on your plan. o Make sure that the doctor has all of your insurance information. If you have coverage from multiple sources-private insurance, Medicare and/or Medicaid-make sure that the doctor knows about all insurance plans and has sent claims to all. Some insurance sources require payment to be made in a certain order, so if the doctor fails to submit a claim to all sources, your claim may be denied. For example, Medicaid pays last; as a result, Medicaid will deny payment if the claim was not first submitted to your other insurers such as Medicare or commercial plans for payment. o If you receive care from an out-of-network doctor, you may have to pay up front and submit the claim yourself. Clarify this with your doctor. For help submitting a claim, call the Insurer. o Most insurance plans have time limits for submitting claims. Make sure not to miss these deadlines.
Persuading doctors to reduce their bills o Tell your doctors if you're having a hard time paying a bill. You can ask for a discount and offer to send recent financial information such as proof of income, recent bank statements and proof of major expenses. o If you received financial aid for your hospital bill, ask the private doctor if they would be willing to reduce the bill on that basis. o Ask your doctor for an installment plan instead of sending the bill to a collection agency. If the doctor agrees to an installment plan, ask for it in writing. However, if you can no longer afford the payment plan the account may be sent to a collection agency. o
CHALLENGING MEDICAL BILLS IN COLLECTIONS
The best way to challenge a medical bill in collections is to simultaneously ensure that your privacy rights under HIPAA (Health Insurance Portability and Accountability Act of 1996) have not been violated. You can ask for the debt to be validated with a fee breakdown. This is almost impossible to provide without a violation to your rights under HIPAA. See Appendix C for a sample letter for this purpose.
WHAT DO YOU DO IF YOU NEED CARE NOW?
GOING TO THE EMERGENCY ROOM
If you have to go to the hospital, you cannot be turned away from the emergency room. All you can do is get the care you need and figure out how to pay for it later. If you receive a bill that you cannot afford, go as soon as you can to the hospital's financial aid or billing center. Some hospitals can lower your payments based on your level of income. Be persistent.
Stories of lying about identity to avoid emergency room bills have been reported to us confidentially. You could consider changing your identifying information so they cannot track you down to bill you, but use extreme caution to avoid getting caught.
In the New York City area, the Coalition of Concerned Medical Professionals works to connect people who have been denied care with medical professionals who will donate their services. They can be reached only by phone at (718) 469-5817.
In a future version of this manual, we intend to devote considerable space to discuss meeting basic needs at little to no cost, including but not limited to health care.
HOW TO CHOOSE A HOSPITAL
There are different types of hospitals with different types of programs in all fifty states. Many states offer "urgent care" or "free clinics," which provide very basic services, but you may still need insurance to access even these services. Private and public hospitals also have different programs. Public hospitals receive more state and federal funding and should be able to help you find ways to lower your medical bills. If you know this information in advance, you can request which hospital to be taken to if you end up in an ambulance. The National Association of Free and Charitable Clinics (nafcclinics.org) allows you to find free clinics near you.
Protest to get the care you need. Corporations want to avoid bad press. If you are denied health care, you can organize public demonstrations to demand that you're given the care you need. Once public controversy is created, corporations may reverse their decision to withhold care.
END MEDICAL DEBT BY FIGHTING FOR UNIVERSAL HEALTH CARE
The only real solution is to change the system from its current for-profit model to a nonprofit model, which has proved sustainable elsewhere in the world. Of the thirty-three countries with a UN Human Development Index of 0.9 or higher, the United States is the only one without universal healthcare. Half of the remaining thirty-two nations have single-payer healthcare- that is, the state provides insurance and pays for all expenses except co-pays and coinsurance.10 This could happen in the United States by lowering the age of eligibility for Medicare from sixty-five to fifty-five and up, then to forty-five and up and so on, lowering the age every couple of years until everyone has access to comprehensive coverage.
Some states are experimenting with moving to single-payer systems. Vermont is working on implementing a publicly funded universal health care system. This could prove to be a model for the nation in reversing the trend towards greed and profit that dominates our health care.
Join the fight for single-payer universal health care and help build the movement to end medical debt!
o Activists and advocates can contact Healthcare-NOW! at healthcare-now.org. o Health professionals can contact Physicians for a National Health Program at pnhp.org. o If you're in a union, contact National Nurses United at nationalnursesunited.org. o Organize with Occupy Wall Street. Contact Healthcare for the 99% or o Doctors for the 99% at owshealthcare.wordpress.com.
Healthcare-NOW! (healthcare-now.org) National Nurses United (nationalnursesunited.org) Healthcare for the 99% (owshealthcare.wordpress.com) National Association of Free and Charitable Clinics (nafcclinics.org) Physicians for a National Health Program (pnhp.org)
Stephanie Barton, "How to Avoid Medical Debt," Investopedia, May 4, 2011 (tinyurl.com/DROMBarton). Brian Grow and Robert Berner with Jessica Silver-Greenberg, "Fresh Pain for the Uninsured," Bloomberg Businessweek, December 2, 2007 (tinyurl.com/ DROMGrow). "How to Prevent and Fix Medical Debt: A Handbook for Community Advocates Assisting New Yorkers with Medical Debt," Legal Aid Society, February 5, 2010 (tinyurl.com/DROMLAS). Galen Moore, "Mixed Response for Companies that Buy Hospital Debt," Boston Business Journal, November 30, 2009 (tinyurl.com/DROMMoore). Jessica Silver-Greenberg, "Medical Debt Collector to Settle Suit for $2.5 Million," New York Times, July 30, 2012 (tinyurl.com/DROMSilver2).
1. David U. Himmelstein, et al., "Medical Bankruptcy in the United States, 2007: Results of a National Study," American Journal of Medicine 20, no.10 (2009) (tinyurl. com/DROMHimmelstein): 3. 2. Himmelstein, "Medical Bankruptcy," 4. 3. Mark Almberg, "Illness, Medical Bills Linked to Nearly Two-Thirds of Bankruptcies," EurekAlert!, June 4, 2009 (tinyurl.com/DROMAlmberg). 4. The World Health Report 2000: Health Systems: Improving Performance (Geneva: World Health Organization, 2000) (tinyurl.com/DROMWHO), 155. 5. National Health Expenditure Accounts: Methodology Paper, 2010: Definitions, Sources, and Methods (Baltimore: Centers for Medicare and Medicaid Services, 2010) (tinyurl. com/DROMCMS), 5. 6. Ellen Nolte and Martin McKee, "Variations in Amenable Mortality: Trends in 16 High-Income Nations," Health Policy 103, no. 1 (2011) (tinyurl.com/DROMNolte), 47. 7. Medicare Trustees, The 2012 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds (Washington D.C.: Department of the Treasury, 2012) (tinyurl.com/DROMTrustees), 10. 8. The content in this section is primarily modified from: How to Prevent and Fix Medical Debt: A Handbook for Community Advocates Assisting New Yorkers with Medical Debt (New York: Legal Aid Society, 2010) (tinyurl.com/DROMLAS). 9. Stephanie Barton, "How to Avoid Medical Debt," Investopedia, May 4, 2011 (tinyurl.com/DROMBarton). 10. Praveen Ghanta, "List of Countries with Universal Healthcare," True Cost, Au-gust 9, 2009 (tinyurl.com/DROMGhanta).