It was still a pretty bad experience. I was in the dark for weeks on which expenses would be covered, and I didn’t understand the explanation when I finally got it.

Getting pneumonia while teaching English in Bosnia, I learned that in many eastern European countries patients slip doctors cash to get better or faster care. In India, I learned I didn’t even have to pay. I spent the night in a large shared hospital room, my boyfriend at my side, and staff waved me away when I tried to offer up my travel insurance.

In my country, the US, I didn’t really have to learn. I just knew. It’s so, so expensive, often even when you have insurance, and especially if you don’t know the right questions to ask in advance to “make” the system work like it should.

• The first year of the pandemic, it was cheaper to pay for a flu shot out of pocket at Walgreens than use my insurance because I’d have to go to a primary care provider and pay a $50 visit fee. I only turned up at Walgreens, though, because I’d called my insurance to ask about flu shots, and they directed me to Walgreens specifically.

• I also got burned when, after checking with my insurance AND the provider I’d located via my their site that my annual women’s health exam would be covered, the claim was later denied. The Explanation of Benefits – which inconveniently only displayed sideways on my screen – said “Misc unlisted codes cannot be processed w o description report” and “out-of-network provider not covered by HMO policy”.

• Now providers are required to make good faith estimates, when asked, including the cost of the primary service, and any other services that are part of that same experience. So I thought I had my bases covered.  Nope. Lab fees were left off the estimate, and they cost more than the services provided at the doctor’s office. Unfortunately, you can only dispute a bill if the amount from one single provider is more than $400 over the estimate.

The time my insurance mostly worked

Most recently: the happy ending! the one where my insurance worked! In October 2021, I got food poisoning – or something. My stomach was not well, my temperature was nearly 103, and I had chills that didn’t stop. I called an ambulance because I worried too much about losing consciousness to drive myself.

I spent under two hours in the ER. My records said I was “presenting with sepsis” – infection that has spread to the blood and can be fatal if untreated…so it was genuinely an emergency, or the hospital staff thought so, which is good, because insurance companies have denied claims for people going to the ER if the situation turns out not to be as urgent as they thought (the NPR series Bill of the Month details medical bill nightmares like this). The ER treated me with IV fluids and ibuprofen, and as they worked to rule out anything else, did an EKG and CT scan. I got a prescription for a strong antibiotic to fill the next morning at Walgreens, and went home.

It was an uncomfortable week. I had to give up most of my yoga teaching work, meaning most of my income as an independent contractor with no sick time. But I got better and then held my breath waiting for the charges to show up on my insurance webpage. It would be weeks before the claims were processed and I’d learn what my insurance was covering or having removed, and what I was responsible for. The first round of info was the “billed amount”:

$2381 for the ambulance. The City of Chicago billed me shortly after my hospital visit for the full amount, stating it had been over 45 days since the incident and they had not heard back from my insurance.  In fact, they had post-dated the bill and sent it sooner than 45 days. Once my insurance had addressed the claim weeks later, the online version of my bill went down to $500, but I never got an updated paper bill.

Roughly $16,500 for all the little pieces of the ER visit. This was scary, in and of itself, but also because it is approximately half my current annual income. As I waited and waited for my insurance company’s verdict, I visited a food bank and canceled my wifi to save a little money. I looked into second and third jobs. I suppose in the back of my mind I knew that I’d never wind up paying this inflated amount, but knowing that my bill would be somewhere between zero and half my annual income was still unsettling.

The happy ending

Finally I got a verdict from my insurance company in the form of an Explanation of Benefits … and I didn’t understand it. Initially I thought I was responsible for the bulk of the bills, and in that panic, I came across one very valuable resource via a neighborhood facebook group: a neighbor named Morgan who is passionate about healthcare reform and knows all about billing. Morgan offered to help me just because. She looked at my bills (she told me I could black out personal info) and explanation of benefits, talked me through them, and was the real bearer of the best news: it seemed like my insurance had actually worked much like it is supposed to and I was responsible for just around $2500 total.

Tips from my neighbor

Morgan gave me some tips, which I’ve done my best to paraphrase here. They are mostly relevant to people with insurance. That’s not to say no one else needs help, just that even those of us who have insurance do too!

Should tips from my neighbor be your only resource? No! You should be able to google many of these tips on your own…or use all the other resources you got in high school to understand health insurance! Just kidding – I got sex ed, drivers ed, home ec, and physics, but no insurance ed. The people best situated to understand how things work, and how consumers (patients) can save money or avoid being taken advantage of, are the people working for insurance companies or in billing. Plenty of these people probably do see problems with the system, and like Morgan, help those they can – but it’s not really anyone’s job in this system to look out for the person paying.

• Hospitals are either “in network” or “out of network” with your insurance, and req your nearest in network hospital may save you money in an emergency if you can request to be taken to an in network hospital. In network hospitals have legal agreements or contracts with your insurance company limiting how much the hospital can bill for any particular service (an “allowed amount”), and out of network hospitals do not. I just got lucky – I had no idea that the hospital I was taken to was in network.

• Once you receive an actual hospital bill, compare it to the Explanation of Benefits your insurance company provides. Make sure the charges from the hospital match the allowed amounts. If not, contact the hospital and politely point out the discrepancy. Charges called “disallowed” (or “contract discount” or “write off” depending on the insurance company) are those that the insurer doesn’t pay, and neither do you.

• If a charge is denied in the Explanation of Benefits, that means the insurance company isn’t paying it but the hospital may still bill you. The Explanation of Benefits will have a code and explanation for the denial reason. Read it. For instance, it’s possible that the provider needed to submit additional paperwork and did not, so the charge was denied and pushed to the patient. This could potentially be remedied so you do not need to pay.

• There are ways to appeal your insurance company’s decision on coverage and they should be detailed in your Explanation of Benefits or elsewhere. They are likely lengthy processes much like “charity” financial aid from the hospital itself – see below.

• Under Obama’s Affordable Care Act, non-profit hospitals are legally required to offer “charity” financial aid for folks within certain income brackets in order to maintain their non-profit status. Surprise: it’s not a quick or easy process. They also offer payment plans so if you aren’t eligible for “charity” aid, or you can pay but just not all at once, you should be able to talk to the hospital and arrange a payment plan, often without interest. Read my experience of and tips for successfully applying for and receiving “charity” aid.

Part of me keeps thinking I shouldn’t be complaining about this, since ultimately my insurance worked.  But things could have turned out very differently if I’d wound up at a different hospital – or if I hadn’t spent hours applying for “charity” financial aid over the course of weeks, submitting and re-submitting documents, running back and forth to Kinko’s. And while I’m pretty broke right now, I do still have access to resources that a lot of people don’t. I live on the north side of Chicago with a car. I have regular income, I’m computer literate, and I only need to take care of one cat, not any kids.  I have plenty of experience writing in the process of getting my BA and MA.

Also, as much as I knew my experience was stressful and overwhelming, it was daunting to put it into words, in an organized form like this article, in language that doesn’t sound, quite honestly, dumb or uniformed. Popular online publications are less interested in lengthy articles about “boring” topics like this than articles about yoga or sex, and often don’t want to include links to resources as the author might be selling something.

I think that’s at least partly why more people don’t talk about this – we know things are bad, but we don’t know what to say or how to frame the problem, or we think it’s our fault for not knowing more about insurance. We need to talk about things though. Things need to change, policies need to change, but people at large also need to get educated and vocal about the problems in this system.