Q&A: How Patients Can Get Wise to Bad Billing Practices

It’s no secret that Americans pay too much for medical care and, oftentimes, that care doesn’t necessarily result in better outcomes.

The U.S. spends more money on healthcare than any other country in the world, driving up costs for the patient. Individuals who undergo a procedure or treatment must navigate a complex system, communicating with insurance companies, hospitals, and providers to ensure they can access and afford the care that they need. Critics say that unnecessary treatment, price gouging, and erroneous medical bills increase patient expenses, financially harming millions across the country. One in five U.S. households carry medical debt, according to 2017 data.

But Marshall Allen, an investigative journalist with ProPublica, argues that patients should no longer be forced to accept this reality. In his latest book, Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win, Allen provides patients with resources and strategies to demand fair prices from the medical system and get the care that they need.

MedPage Today spoke to Allen about how patients can fight back when they are overbilled for care, and about kinds of healthcare delivery models are disrupting the current system.

This interview has been edited and condensed for clarity.

What inspired you to write this book?

Allen: I get emails and phone calls almost every day from patients who are getting taken advantage of by the healthcare system. Patients are already at a vulnerable point of their lives, physically, when they undergo some type of care. But then, the billing problems and confusion, the inaccuracies of bills, and the overpriced treatment are causing patients actual harm, and they don’t know what to do about it.

I wanted to write a book that equipped and empowered people to fight back against these issues so that they can win. And by win, I mean get the same great healthcare they need, but at a much lower price.

You state early on in the book that overbilling exists not because the U.S. healthcare system is broken, but because it was designed this way. What do you mean by that?

Allen: I don’t really look at doctors, nurses, or other clinicians as the big problem here. What’s really happened is that the business side of the healthcare industry is glomming on to the trust that we have in our doctors, nurses, and other providers. And it uses that trust to exploit us, frankly. The business side of the industry has created all of these deceptive schemes to take more of our money than they should.

This is becoming more and more apparent, you know, people are becoming more aware of it. I just think we need to identify the medical facilities and providers who treat us fairly, who don’t overcharge us, who correct mistakes when they’re made, and who are transparent with their pricing. We need to give our business to them, and shun the bad actors.

The concept of pushing back against the healthcare system can be daunting for patients. What do you suggest for patients who are overwhelmed by the thought of contesting medical bills?

Allen: First of all, it can be overwhelming. And it’s completely unfair that patients are in this position. But sometimes, it’s a lot easier for patients to push back and win than they might think. I think one of the mistakes we can make is just assuming that it’s always going to be overwhelming and it’s always going to be impossible. In some instances that’s definitely the case, but you don’t really know until you try. So I think getting over our fear is the first step.

Then second, let’s say you get a high medical bill. When I say the title of the book is Never Pay the First Bill, I don’t mean never pay your bills. What I mean is, never pay the first bill until you have analyzed it, understood it, and made sure that it’s accurate and fairly priced. I recommend that people always get an itemized medical bill, for example. Patients should make sure that the bill includes a list of all the charges that add up to the total, as well as all of the billing codes that the hospital used when they filed the insurance claim. Often, when you get those itemized bills with the billing codes, you can look up fair prices. And that’s a really powerful tool.

The process is going to be intimidating, and not everyone will be able to do it. But a lot of people will be able to do it. I know this because I have spoken to hundreds of patients who have been harmed while undergoing medical care, people who have been price gouged or harmed financially. These are really smart people. Patients are way smarter than the big healthcare decision-makers give them credit for.

Many patients receive unnecessary medical care in the U.S. What should patients know about avoiding overtreatment?

Allen: When you look at the studies, they show that maybe up to 25% — or even more — of all medical care is unnecessary. If patients know this in advance, they may better understand how incentives are steering the types of recommendations they get from some doctors and other providers.

Every patient has to give consent for the care they receive. It’s not ultimately the doctor’s decision. So patients need to recognize their own decision-making power. And they need to say, ‘Okay, the doctor is recommending this, but I don’t necessarily have to do it. Maybe I could get a second opinion. Or maybe I could consult the U.S. Preventive Services Task Force.’

What do you suggest for doctors who also are frustrated with billing practices in medicine?

Allen: I really appreciate all the doctors out there who are fighting the system themselves, because they are also victims of it. Many clinicians are trying to do the right thing for their patients, but the business side of medicine is pressuring them to do whatever maximizes revenue — whether it’s good for the patient or not.

I think providers have a lot of power, maybe more power than they think. But they’re up against these massive ‘Titans,’ the big insurance companies that are wasting their time and making them jump through all these hoops to get paid or just to get care approved. That’s a complete nightmare for doctors. And if they’re working in a big hospital system, the revenue model may be constantly pushing and pushing them to provide more care.

Some doctors are breaking out of these traditional models to go to things like direct primary care, or direct-pay relationships for surgery. This is also gaining momentum in the employer-sponsored health plan space. So I do wonder if doctors who are willing to do things a bit differently can partner up with employer-sponsored health plans that are also trying to do things differently? And maybe they can find a way to cut out all the middlemen that aren’t actually doing any of the hands on healthcare.

Doctors would probably get paid more. And I’m sure they would have a much greater sense of satisfaction in the work that they’re doing. I think there is going to be more of this, because there’s been such a complete breakdown of trust in the big healthcare systems and the big insurance companies.

What do you hope readers take away from your book?

Allen: There are 155 million Americans in employer-sponsored health plans, plus an additional 30 million who are uninsured. That’s a big pool of, say, 180 million people. So I think that we have strength in numbers. We all feel overwhelmed, confused, and paralyzed by this. But if each of us were to do this on our own, we would overwhelm the system with our demands for fair treatment. And I think that that would create so much friction for hospitals or other providers who are not treating us fairly, that they would be motivated to change. It would be in their interest to change.

Something like an itemized medical bill, for example, it’s just such a simple ask. Just imagine if millions of people started demanding an itemized bill with the billing codes every time they went to the hospital. It would create so much hassle for that hospital billing department that they might just start providing it. Or if millions of people got engaged, they could insist on legislation, in their states or nationally, ensuring that every hospital bill be itemized.

My hope is that individuals will be more equipped to protect themselves. I’m really hoping that patients will feel equipped and empowered to navigate the healthcare system in a way that avoids the pitfalls, and then also helps them stick up for themselves if they’re getting taken advantage of and bullied.