Real Doctor Speaks

The First Phone Call You Should Never Make After A Massive Medical Bill

• Jim O'Leary • Episode 20

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0:00 | 58:54

I went into the emergency room for a stomach flu. One liter of fluid. A scan I probably didn't need. A few lab tests. A month later, the bill showed up: $10,000. And I had no idea what to do.

That's the moment most Americans give up and pay. Or they get sent to collections. Or they ruin their credit. They believe the bill is real, the hospital is owed the money, and there's nothing they can do about it. All three of those things are wrong.

In this conversation, I sit down with the sharpest medical billing mind I know to walk through the exact step-by-step playbook for fighting back. We talk about the very first move every patient should make before they even look at the bill, the one phone call that quietly costs people thousands of dollars, the hidden code trick hospitals use to triple their charges, and the alternative model that's cutting families' total healthcare costs down to under $4,000 a year.

If you've ever stared at a hospital bill in disbelief, this is the episode that arms you to fight.

In this episode, you'll learn:

  • The single first step every patient should take when a massive medical bill arrives, and why almost everyone gets the order wrong
  • The hidden billing code trick hospitals use to charge ten times what something should cost, and how to spot it
  • The financial setup that's quietly replacing traditional health insurance for thousands of families, and what to know before you switch

Connect with our Christine Price on X: @HEALTHCOSTtruth
 https://x.com/HEALTHCOSTtruth

Chapters:

00:00 – Cold Open
 01:02 – The First Move Most People Get Wrong
 02:11 – How To Request Medical Records The Right Way
 02:48 – Why You Never Call The Hospital
 03:35 – The Financial Aid Screening Loophole
 04:23 – How Hospital Debt Gets Sold For Pennies
 05:32 – The Paperwork Wall Designed To Stop You
 07:05 – Request The Itemized Bill — Only Now
 07:56 – Why AI Cannot Audit Your Bill Alone
 09:45 – CPT Codes Vs ICD-10 Explained
 10:41 – The $2,300 Lab Test With One Match
 11:53 – Why One In Five Claims Gets Denied
 12:51 – The $4,000 Total Healthcare Year
 13:39 – Why HSAs Should Work Like IRAs
 14:53 – The Truth About Health Shares
 17:04 – Why Going Back In Time Is The Answer
 17:51 – Why Congress Will Not Fix This
 19:07 – Inside The Audit Process
 20:42 – Bundled Vs Unbundled Codes
 27:01 – Demand The Best Drug Prices In The World
 27:25 – How To Crosswalk A Claim Yourself
 30:30 – Why The IRS And Congress Will Not Help
 32:25 – The $400 Urgent Care Trap
 35:51 – Why Same Scan, Different Hospital, Different Price
 38:36 – When And How To Report A Hospital
 40:10 – Why Healthcare Belongs With The CFO, Not HR
 41:33 – Why Predictive Modeling Is A Scam
 44:02 – The $800,000 Infusion And How We Beat It
 46:19 – Five Years, Zero Premium Increases
 49:02 – The Mom Who Was Misdiagnosed With COPD
 52:35 – Why Hospital Employment Is Soul Sucking
 53:28 – The Call To Action For Patients
 55:13 – The $2.2 Million Cardiologist
 57:00 – Why The Doctor And The Patient Have To Reunite

SPEAKER_01

Just the other day, I went into the emergency room. I wasn't feeling good. I had a stomach flu. I got one liter of IVE fluid. I had got some sofran in there. They ran a bunch of labs I really didn't need. They got a CAT scan, and then I went home. I felt a little bit better until about a month later. The bill started coming in. It ended up being $10,000. I got this EOB. I'm like, what is an EOB? I couldn't make any sense of it. Called my insurance company, and then that didn't make sense either. I was like, what am I gonna do? And I found out I have a $10,000 deductible plan. This is all me. I have to pay the whole bill. What should I do? I don't think there's anything I can do. Wait a minute, there is something I can do. And today I'm gonna share the solution with you. The solution is Christine Price. She's our guest today. And as always, this podcast is for educational purposes only. It's not medical advice. Please take the advice of a physician if you have a medical problem.

SPEAKER_00

Christine, what should I do with my $9,000 bill? Well, the first thing you need to do is request medical records. The standard advice in the industry is get an itemized bill. You don't want to get an itemized bill before you have the medical records in hand because once you request an itemized bill, that's an indication that there could be a dispute coming. They will alter medical records to match that bill if they have to. I've had it happen on several that I've done. One for a $10,000 procedure. I had the medical bills. I went back and said there's not a justifying diagnosis. And I have an email where the guy from the hospital actually said, we're going to resubmit this and add this diagnosis. I said, you can't do that. That's fraud. No, it's in the medical records. I said, no, it's not in the medical records because I got them first. If you dispute a claim and you don't have a date and time stamped set of medical records, they can and will alter or add to. I don't want to say alter, that sounds criminal. Sometimes it could be, but they will add to a medical record to make it a payable claim.

SPEAKER_01

Is this can I always get the medical records? Is that a right thing?

SPEAKER_00

They're your records, yes. They have to give you your medical records. Okay. You just have to send the request in writing. I always advise that you send the medical request or the medical records request and send it certified mail or priority mail with tracking so you know they've got it. Never, ever, ever, ever make a phone call to the hospital. Do not talk to them. Don't answer text messages, don't answer their phone calls. Every transaction you do after you leave the hospital, once you get a bill, has to be in writing. Otherwise, if it does escalate to court or if it does escalate to collections, you've got a written record of what's happened.

SPEAKER_01

Can you use email? Can you email?

SPEAKER_00

You can use email if they'll give you an email address. You can use fax if you can get a fax number. Okay. But you've got to have a record of how you contacted them, what was said, what transpired. You do not want because they will try to intimidate you by phone. Especially the healthcare system depends on the average American not knowing how the system works. And it was set up like that intentionally because they can bill you, they send you collections. They're not supposed to send you a nonprofit hospitals, should not send you to collections until they have screened you for financial aid eligibility. You shouldn't have to ask them, they're supposed to screen you. So if they send you to a collection agency, dispute the collection agency and say, I wasn't screened for financial aid eligibility, or this claim is in dispute, you always want to dispute a claim, especially a high dollar claim. But nothing can transpire as long as you have everything in writing, you're disputing the claim, or they did not screen you for financial aid eligibility before they sent you to the collection agency. And once you ask a collection agency, explain the legitimacy of this bill, explain to me why everything was medically necessary, they're going to give up because they just bought that bill for pennies on the dollar, and it's not worth their time to go back to the hospital and they don't know how to read a medical bill. They're just all they're after is money.

SPEAKER_01

One thing I read recently, which is fascinating, is when the hospital bills that they can't collect ultimately get sold. They're often selling it at one cent on the dollar, one percent. And I thought, boy, if they're ultimately going to get a penny on that, there's a lot of room for negotiation.

SPEAKER_00

Well, yeah. I mean, that and that's the whole thing. They'll sell it because if they can't collect on it, you know, it's called non-collectible, they'll sell it to a collection agency or an investor. Um, and then they just intimidate you. You can also stop that intimidation by saying, don't call me at work, don't call me between these hours, don't call me repeatedly. There's a lot of rights that people have that they don't know they have, like the they must screen me for financial aid eligibility. You know you're not, you may not qualify for it, but that's beside the point. It is the duty of the nonprofit hospital to screen you for financial aid eligibility before they go to extreme collection actions, which is sending you to a collection agency.

SPEAKER_01

And each nonprofit hospital has a different financial assistance program. Right. So this goes back to, and I love all your proactive comments from the first time. Know what are the policies in your area.

SPEAKER_00

Right. Ask for their financial and it has to be publicly displayed, it has to be on their website. Some nonprofits will consider financial aid eligibility 100% write-off up to 400% of the poverty level. Some are at 200%. But what's happening more and more lately used to, you could bring in your check stub, a tax return, and you prove what your income is. Now, and I just had this recently happen to a family member, they want your tax return, your check stub, copy of your bank statement. No way am I giving a copy of my bank statement to any hospital in this country or another country. And in this particular case, the lady is 84, and they want proof of divorce or a death certificate for somebody that's been not been around for 20 years. They're not supposed to require an abnormal amount of paperwork to prove that you make what you make. But they're making it harder and harder and harder for you to meet their documentation standards for financial aid eligibility.

SPEAKER_01

So that's just the barrier they're putting up because they know people are gonna have to do that. And they're not gonna do it. They're not gonna be able to complete it. And I I did read that some of them have 50 steps that you have to complete.

SPEAKER_00

It's insane. It's actually insane. Trevor Burrus, Jr.

SPEAKER_01

And this is part of the Affordable Care Act that they do that. And the other part, ironically, is physicians can't own hospitals. So it's interesting what's in there. Right. Section 6001. But so now you have your medical records, and then you are supposed to ask for the itemized bill.

SPEAKER_00

After you have the medical records in your hand.

SPEAKER_01

In your hand, okay. And how much time do they have, the hospital have legally to send you them medical records? 30 days. Okay. And you were saying you should really mark that and say, okay, I sent the letter, mark it on your calendar so you know if they don't get it in 30 days, you don't call them. You send them to the code. Don't call them.

SPEAKER_00

Never call them. You send them the second letter, the second email, the second fax. Never ever call them.

SPEAKER_01

Okay. So if they're a nice hospital, they send you all the records, then what's her next step?

SPEAKER_00

Next step is to get an itemized bill.

SPEAKER_01

Okay.

SPEAKER_00

And this is where everything gets confusing and why people are afraid of the healthcare system because you get an itemized bill. You don't need, you don't know that an 80053 is a lab test. You don't know what lab test it is. You don't know if it's medically necessary, so then you try to read the medical records, and it almost takes a doctor to meet the read the medical records. So there's a few ways of doing it. You can upload it to AI and say, act as an expert medical auditor and audit this bill. And it's going to pick out some things that shouldn't be bundled together, shouldn't be charged together. It's going to pick up some things that are way overpriced. But the problem is, you know, years and years ago, when everybody said, get an itemized bill and check for duplicate, they don't duplicate charges anymore. That's too easy to find. So you almost have to find somebody that can crosswalk. And what that means is, is there a diagnosis on the claim that justifies the procedure they did? If it's not on the claim, technically it's not done. It's not a payable claim. Somebody asked me yesterday, did we deny claims that didn't go three digits out on the diagnosis code? The diagnosis code is the diagnosis code, the procedure code is the procedure code based on the correct coding initiative. They have to jive, they have to match. But the average American, again, does not have access to those crosswalks. So you almost have to pay somebody to just crosswalk the claim for you. And that's I'm not trying to sell anything right now, but that's something I do for a very minimal charge because it doesn't take that long, and then draft a letter saying, explain to me why this code is on here when there's no justifying diagnosis. If they can't do that, it's not a payable charge.

SPEAKER_01

And I do want to clarify for everybody there's two sets of codes, and it gets confusing. The first one is CPT codes, current procedural terminology codes. Those are licensed by the AMA, interestingly enough.

SPEAKER_00

Yeah. Right.

SPEAKER_01

And they're usually five-digit codes, and those are the ones that are going to be any procedure you have, any lab test, physician visit x-rays, all that is what that's going to be. The second one is ICD 10, which are the diagnosis codes. So if I come in and they think I have pneumonia and they get a chest x-ray, there should be a code over here saying rule out pneumonia or suspect pneumonia, or something along those lines, as well as the chest x-ray, and they should meet.

SPEAKER_00

Right.

SPEAKER_01

And if the diagnosis says sprain ankle, and if I have a chest x-ray, those aren't going to match.

SPEAKER_00

Right. I just had a claim the other day for I had the only diagnosis on the claim was a fusion of the knee, which is fluid on the knee, and uh $2,300 worth of lab work. No knee x-ray, no drainage of the fluid off the knee. No x-ray, no, just a bunch of lab tests. Interesting. And only one of those lab tests out of $2,350 matched that diagnosis. So we wound up paying, I think, less than $40 on a $2,350 claim. But we as um, and I don't like calling my company a TPA, but there's no other word for it right now. Our members know that if the hospital bills them for a claim that we deny, and it's a legitimate denial if it's not documented, but they'll balance bill the patient anyway. But our members know, call us, and that's where we pivot and work on behalf of the employee to fight that hospital. Because I forget the total number of people that are in collections for medical debt right now, but I would be willing to bet you that 80% of the people that are in collections are in collections for bills that are not payable to start with. But they depend on that. That's how they make their money.

SPEAKER_01

And most of them have health insurance, which is the other part. People think if I have health insurance, I'm okay, I'm safe. You're in You're not safe.

SPEAKER_00

No, you're not safe. One in five claims is denied. Nobody appeals a denial, that's number one. But in my particular case, I opted out. I manage health plans for a living, that's what I've been doing for 30 years. But I've opted out of the traditional insurance cartel, for lack of a better word, for not only myself but my clients. Like I said, we don't use PPO networks, we don't use brokers, we pay RBP, we audit the claims, but on a personal basis, I have a health share, I have a direct primary care, and I have the cost plus prescription card. I'm set. My total health care cost is less than $4,000 a year, and I'm $99. Most people my age are paying $18,000 a year for a $9,000 deductible. And then you have people saying, well, you need a health savings account. Maybe if you're buying that traditional insurance and you have a high deductible health plan, but in my case, I'm not going to pay $18,000 to an insurance company that gives me a $5,000 deductible. So now I'm at $23,000. That's too, that's a mortgage payment for some people, so that the government will allow me to put up $4,500, $4,400 a year tax-free. It makes no sense. They need to take the HSA and the health plan requirement away. Everybody should have an HSA, should be able to open an HSA with the same rules where it rolls over and you can invest it, you can do whatever you want to with it for health care and not have to buy what they call insurance plans.

SPEAKER_01

I agree. An HSA should be just like an IRA.

SPEAKER_00

Exactly.

SPEAKER_01

You have earned income, you should be able to set it up. And I I would just mimic the rules of an IRA and be done with it. And I agree 100%. It doesn't make any sense to have it tied in with a high deductible health plan because now you're forced to pay, overpay for something to get a benefit.

SPEAKER_00

Well, in my case, in in four years, it would be $100,000. Could a $100,000 claim happen? Yeah, but I've got a health share to cover that. And people I love it when people say, but that's not health insurance. It's not health insurance. The reason it's not called health insurance is because the government doesn't let them call it health insurance. It functions just like health insurance did prior to ACA. It doesn't cover pre-existing, which is okay. It's 12, 12 to 24 months. It doesn't cover the normal day-to-day doctor's office visits. Um but it's there if you need it. I pay $207 a month for mine versus $1,800 or $1,500 a month for an insurance plan that's probably gonna tell me who I can see, when I can see them, what test I can have. Um they could deny a test that I really, really need. And you see stories about this all the time where insurance company has denied an MRI or a CAT scan to detect cancer, and then the people people died. And that's why we don't require pre-certs for our members, because if the doctor says, again, we'll look harder if it's a hospital-owned physician, but if an independent physician DPC orders an MRI CAT scan, just go get it, get the results, and let's get treatment underway if you need it.

SPEAKER_01

It is so heartbreaking, and I've seen these stories on X. Somebody needs uh MRI or CT, they're worried about a cancer. And then they fight with the insurance company for three to six months to getting permission, and this test was a $250 test, and people are so caught up in the mindset, I have to go through my insurance. You don't have to go through your insurance, it's your health. The insurance company does not care if you live or die. That's the simple truth. You need to take ownership of this and say, you know, if it's my wife and they're worried about it, I'm getting the scan tomorrow and I'm gonna pay cash and we're gonna find out. It doesn't make any sense that people have gotten caught up into this. Does my insurance company cover this $6 prescription? You pay thousands of dollars so you can have a $6 prescription covered at a $10 copay. You just lose and lose. And what I like what you said with the cost here, which really is interesting to me, is you just brought back health care back to the 1960s when Americans paid 50 percent of their health care out of pocket. They paid for scans, they paid for doctor visits, they paid for medications, they paid for labs, all out of pocket. And our health care costs as a country was about the same as other countries. Exactly. That's the answer. We need to go back in time, and I know everybody says this is an old guy saying we need to go back, but it worked, and it doesn't make sense that we have we have more right now insurance company employees than there are physicians in the country. That tells you the problem.

SPEAKER_00

We have more hospital administrators than we have physicians. That's where I think the the latest I looked up, um, hospital administrators' positions have increased by 3,000 percent. Yes. While physician positions have increased by 32 percent. Those numbers may not be correct. But it just doesn't make sense. And again, it's the vertical integration, it's the government not stepping in, they're not going to, they're paid not to. I told somebody the other day if we can ever buy back Congress, we can get somewhere. Absolutely. But right now they're bought and paid for, and they're not gonna do anything. I've I've sent hospitals to so many different regulatory authorities, nobody touches them. The Transparency Act, great act, it was what 2021? Nobody complies. An executive order issued last year. Nobody complies. Why don't they comply? It doesn't matter. Right now, for a hospital over a hundred beds, the penalty is two point one million dollars a year for noncompliance. That's nothing when they're taking in billions or millions, sometimes billions. They is and it's $2.1 million a year. So a large hospital system, say it has 10 hospitals, that's $20 million a year. It's a drop in the bucket. Yeah. They're not going to comply. One, nobody's gonna look at them, two, nobody's gonna enforce it. And you know, I can write an executive order right here today, and it will be just as effective as the one Donald Trump signed, and nothing against Donald Trump. But it would be just as effective because there's nothing but a piece of paper with a signature on it. If you got data and information without action, you've lost the battle. And that's what's happening right now in America. We are losing the battle because of the government, because of nonprofit hospitals, and because of this vertical integration and a 340B program. I mean, it's ridiculous that we are the richest economy in this country or in the world, but we have the worst quality health care among civilized nations.

SPEAKER_01

The good news, and which I think you agree with, the opportunity here really lies with the employers. It does. Because they can exit the system, use ERISA, and develop their own plans. And you know, that and I think that's where what's going to be the future. But I was just wondering if you could walk me through if I get my this big bill from the ER and I contact you, and how do you look at the claims? Like what is your first step? You know, what are the things you know, do you look at medical necessity and how do you break the claim down?

SPEAKER_00

Well, I break the claim down by medical necessity based on the diagnosis on the claim. I also have the medical records, because there could be a diagnosis on a medical record that did not transfer to the claim. There's clerical errors that happen all the time. But if there's no diagnosis to justify a CT of the neck because you got a head injury, um, then we take that off. After that, if it's even if it's a PPO plan, I look up with the Medicare rates. I've seen rates 40, 45 times Medicare. That that amount is the approved amount by the PPO. We can try to fight that. That's almost an unwinnable fight, and that's why I say it's better to avoid the bill than get the bill and try to fight it. And to avoid the bill, you go to outpatient. But the first thing we do is medical necessity. The second thing we do is bundled or unbundled codes. And AI, again, can help some with that, but it cannot audit a claim. I've tried every LLM out there and they fail miserably.

SPEAKER_01

What is a bundled claim and an unbundled claim?

SPEAKER_00

Um, like a lipid panel, there it runs different, you know, LDL, HDL. Those, the LDL, the HDL, they can have their own codes. Or for a liver panel, the metabolic panel, there's different codes, but those are all bundled into the 80053, and that's uh a bundled code. But now there's modifiers. Like if you go to the emergency room, you've got a broken leg, they run a CAT scan or MRI or X-ray, whatever it is they do, they bill you for that. They add a 2-5 modifier to the emergency room code, and that 2-5 modifier means separate and distinct service. And they charge you $2,000 for walking in the door to be diagnosed with a broken leg and get an x-ray, but because of that 2-5 modifier, that makes it a payable code. It's just it's not as complex as it sounds. Once you know, you know. Once you see it, you see it. And that's that's where we as Americans have to educate ourselves and educate others how to avoid the bill, how to fight the bill, and how to save money. And the first thing is opting out of insurance. Now If you have a chronic condition, if you're gonna undergo a cancer treatment, you have heart issues, you're seeing specialists five or six times a month, stick with the insurance. If not, go to a health share and there's a a zillion out there. Um get a cost plus discount card at the pharmacy. And I actually just did a comparison with cost plus against what I've been paying, and I think I've got a pretty good PBM, which is evil people anyway. But I compared them to my PBM and I just did a short analysis, and the savings were just that they amazed me. So now I have a full in-depth analysis being tak being performed, and I'll I'll put those uh So you're saying the cost plus was lower than the PBM? By far. Yeah. Even including the when you include the shipping.

SPEAKER_01

Okay. And PBM, I'll just break that as a pharmacy benefit manager, and that is a middleman that determines what's on the formulary, which is the approved list of drugs, and what price we pay. So it's a huge amount of power that they have.

SPEAKER_00

Well, and the other thing the PBMs do is put the higher, and it's not their job to do, their job is to control your cost. But they'll put the higher cost drugs, brand name drugs, especially on the second tier instead of the more expensive tier, so more people use that because the rebates are enormous. And that's why, again, on the ERISA plan, the PBM that I have, we design our own formulary, we don't use theirs. Because, and I will go through the formularies usually every two years and see what's going for you know, tier one, tier two, tier three, tier one being generic, tier two being brand name, and tier three being brand name non-formulary. But they're putting the highest rebate drugs on tier two because more people, you know, the copay is lower, more people are gonna use it. And if they watch a television commercial, I don't know how many people are on Ozempic right now. But Ozempic Jardians, any new prescription drug, I go and look at it and say, you know, is there step therapy? And people don't like step therapy. But you shouldn't be taking a $3,000 drug for something that you could would do the same thing for $30.

SPEAKER_01

One of the frustrating things for me is that we are paying so much more than every other country, comparable country, for these brand name drugs. We're paying a huge amount more.

SPEAKER_00

Because we're subsidizing every other country in the world.

SPEAKER_01

Yes, we're subsidizing the RD, and it it's crazy. You know, Zempik is $1,000 here. You can get it, you know, $87 in other countries.

SPEAKER_00

$59 in Germany.

SPEAKER_01

Yeah. And it's in there was a a congressional hearing, it was a Senate hearing, and the senator asked the CEO of Novonordisk if they make money, is it profitable at $87? And I believe at that time it was in Australia, and he said yes. And I'm thinking, then why are we paying $1,000 for it?

SPEAKER_00

Because we cannot buy back Congress.

SPEAKER_01

Yeah. No, I agree. I mean, it's absurd the amount of money wasted.

SPEAKER_00

Well, they do hearings, they do meetings, they do committees, they do there's a breakup big medicine bill in the Senate right now, 30 S 3822. That might not be the right number. But it's to dissolve all these vertical integrations and get medicine back to where it's supposed to be. And it's a great act. But it's sitting in committee, it's been there for almost four months now. Yeah. And again, you can write all you want to, you can meet all you want to, you can have these hearings, and you can make yourself look good on TV by having, you know, these congressional hearings and all these executives in the office. The talking but you don't do anything with it. No. So what you know, you're wasting my money. Right. You're wasting every taxpayer's money, and you're not doing anything to fix it. And even um the Ozimpic, when it came down to what, $299 a couple of months ago, that's not the lowest price in the world. It's still $59 in Germany. And last time I checked, Germany is a civilized nation.

SPEAKER_01

Yes.

SPEAKER_00

So you can't say we're paying the lowest cost of any like nation when it's still five or six times the amount.

SPEAKER_01

Right.

SPEAKER_00

So, I mean, it's just it's education and understanding that our health insurance industry, our health care industry, is not there for patients anymore. It's there for profits.

SPEAKER_01

And we have the largest drug market in the world. Of course we do. And usually, if you have the largest market, you get the best pricing.

SPEAKER_00

Right.

SPEAKER_01

Just like Walmart. Walmart pays less from their vendors than any other company because they have that market.

SPEAKER_00

Amazon as well.

SPEAKER_01

Amazon as well. So there we should have the best prices, not the worst prices, if it wasn't for Congress. So Congress were on to you. We want the best prices. So Christine and I are demanding right now, let's get the best prices in the world for our country.

SPEAKER_00

And pass that breakup Big Medicine Act.

SPEAKER_01

Absolutely.

SPEAKER_00

Absolutely. That is maybe the single most important part of legislation to help us retake our health care system. Without it, as long as they continue to allow these this vertical integration and all these taxes to be avoided and control of your health care. I mean, you have to control your health care. Nobody knows your body like you do.

SPEAKER_01

Correct, correct. So when now I just want to get back to the whole audit process for you, because this is fascinating to me. You know, you go through the medical record, you go through the itemized bill, and then you find out that there's issues, it's not medically necessary, the diagnosis doesn't match the codes, the CPT codes, and then you say, you know what, I'm not accepting this. I'm gonna go ahead and I'm gonna appeal this. How do I do that? As I'm sitting there, I'm nervous about it. I know now after listening to you that I can dispute this, but how do I actually do that?

SPEAKER_00

Unless you have a a lot of knowledge about the laws that you can, and this is not legal advice, but you have to cite the laws because hospitals don't know what they are. Um, you almost have to hire somebody to audit that bill. I would suggest not hiring anybody that does a percentage of savings because to me, if I've got a hundred thousand dollar claim, I pay somebody a thousand dollars to take a look at the claim, and then there's gonna be a percentage of savings additionally due, that's kind of like a PPO discount.

unknown

Yes.

SPEAKER_00

You don't know what you're gonna pay until you know, and I've audited tens of thousands of claims over the course of the last 30 years. It doesn't take any longer to audit a $15,000 claim than it does a hundred thousand dollar claim once you know what you're looking for. But if you if you can find somebody to audit it and draft that initial letter, most of the time the initial letter will clear it because they're not expecting it. Hospitals do not expect disputes, they just don't. The bigger hospitals are more egregious, they may come back to you. But if you've got the facts, you can save on that bill. I've saved um most recently $37,000 with one letter. And it was it took it didn't take that long. I mean, you have to charge for it, people have to charge for it. But those crosswalks where you can do the diagnosis to the procedure, those are kind of underlocking key. You can buy software that has those, but it's really expensive. You know, I'll crosswalk a claim for $50, $75 and compose the letter saying this doesn't, you know, this doesn't match, this doesn't match, this doesn't match. That's the easiest way from point A to point B. If you hire anybody can learn how to do that, you like I said, you you have to pay somebody to crosswalk it. But for the most part, once you learn how to do it, you know how to do it. It's like driving a car. And then you're not paying somebody, you know, three to ten to fifteen to thirty thousand dollars to save you a hundred thousand dollars on a plane, you do it yourself. It's not that difficult. And that's that's my whole point is once you start peeling back the layers and not listening to the hospitals and the brokers and the insurances, it's really not that difficult. But it has been designed by intent to confuse people, so they're afraid of it. A lot of people are more afraid of the healthcare system than they are the IRS.

SPEAKER_01

And ironically, the IRS does regulate a large part of the healthcare system. So they're kind of intertwined now.

SPEAKER_00

They say they do. But they don't regulate anything. The health care industry regulates the health care industry via lobbying. They write the bills and Congress just passes them. And they'll they'll dispute that with me as as long as you want. But you you take any congressman and ask them, what's the what's the discount for this insurance company at this hospital? They can't tell you because they don't care. They're not in our healthcare system. They've got their own. All their health care is paid for. Premier doctors, premier hospitals, they don't have to worry about it. And they don't worry about it. And people ask me, you know, are you conservative or are you liberal? I'm not, I I dislike all politicians the exact amount because they are not helping manage this healthcare system. And that's why people like you, like me, and several others have got to educate and teach people that want to learn, especially employers, to control their health care costs and increase the the likelihood that some of their employees won't suffer a chronic disease because it's called early. It's not about insurance, it's about keeping a person sick, not making them well because as soon as they lose a patient, they lose a reverted stream. And that's just that's my opinion. People are gonna come at me and it's okay. I I've been come at before. It's like saying a health share is not insurance. Well, I'll pay for a health share. I'd pay triple what I'm paying right now for what I have because I get to pick the doctor, I get to pick the test I have, I have control of my health care and nobody else.

SPEAKER_01

You know, it's interesting. I had Andy Schoonover from Crowd Health on here. And it's interesting how there he's able to design a plan that is very patient-focused. And you you could tell the difference, and there's so much transparency. You can go on his site right now and he puts down every claim. It's all on there. So the ones that are denied, the ones that are paid are all listed, the reasons why, and there's no way you're gonna get that from United Health. I can't call them up and say, I want to see, as a company, every claim that you paid in the last month and every claim you denied. They're gonna laugh at me and think I'm crazy.

SPEAKER_00

They won't even give an employer their own claims history, and that's their information.

SPEAKER_01

That they paid for it.

SPEAKER_00

Right. I went to uh this is 20 years ago when I still had insurance. And I was in Temecula, California, had to go to urgent care. I had bronchitis, I knew I had bronchitis, I knew all I needed was an antibiotic before I had my DPC. So I go to urgent care, and there's a sign there that says cash pay $75. My urgent care copay was $100. I wanted to see what they were going to do, so I paid the $100 copay. I saw a nurse practitioner, maybe it was a PA, I don't remember. And he said, Do you want a chest x-ray? Your insurance will pay for it. I said, I don't need a test x ray, I have bronchitis. Do you want us to run some labs, your insurance will pay for it? I said, I don't need any labs, I have bronchitis. Just give me a prescription, let me get out of here. So after all that, he wrote the prescription. I left. I get an EOB a month later with four line items on it. So I called, I think I don't remember which health insurance company it was at the time. But I called the customer service line. I said, look, you need to take a look at this claim because there should only be one line item on it, and that's for the visit itself. And she said, Well, if you have a problem with the claim, you need to contact your doctor. I said, I don't have a problem. I've paid my copay. They're overbilling you by $400 for stuff I didn't get. Well, if you have a problem, you need to call your doctor. And I'm thinking, I you're missing, you're dismissing the whole point. I said, Well, can you tell me what they billed for? I don't have access to that information. I said, You don't have the codes? No. Can you transfer me to a supervisor? Three levels up, nobody could tell me what was billed. And I finally said, Okay, it's your money. You know, I can't do anything about it. But it's, you know, it's $400. And because of the 80-20 rule, they're not gonna buck on that because now, ACA again, the 80-20 rule, the insurance company has to spend 80% of every dollar it receives in premiums for claims. So, real numbers, if you've got a million dollars in claims, they're gonna make $200,000 in profit. If they only pay $500,000 in claims, they only make a $100,000 profit. So they'll pick and choose which claims to pay once they've hit that threshold. I mean, it's a craps game. You might as well go to Las Vegas and put $200 on a rootlet wheel. But everything is designed to increase the costs. And until employers know and individuals know, there's no way to win. We've got to take it back ourselves.

SPEAKER_01

And the interesting thing is you really have two parts of this. So you have the hospitals here, and you have the insurance company here, and the patient's in the middle. The patient wants lower costs, the hospital wants to increase the cost, the insurance company wants to increase the cost just for just what you said, the 80-20 rule. And the patient's sitting in the middle saying, I'm drowning, and that's why they're drowning.

SPEAKER_00

That's exactly why they're drowning. I mean, even in my area, and I did I do analysis, I do research. I I don't sleep at night because this stuff bothers me so bad. But I took a 74177 CT of the abdomen and compared it to four hospitals within 75 miles of me. I took the cash pay, the gross charge cash pay, and what insurance covers. The same insurance carrier, there was a $4,000 difference between the hospitals of what that insurance carrier paid for the same CT scan that I still could have saved, or I didn't have the CT scan, would have saved over $3,000 going to an independent imaging. So why, you know, these PPO discounts to brokers say you're gonna get the best discount there is. No, you're not. You're gonna get whatever they agreed to. So they agreed to why would an insurance company pay $5,000 at hospital A, $4,000 at hospital B, $1,700 at hospital C, and $5,000 at hospital D. They're not even consistent in what they pay. So how can a how can an average person die?

SPEAKER_01

No, you're right. And it's crazy that none of them are anywhere near the cash price. No. So that's one of the big fallacy. If people remember a couple things from this, I want to remember the insurance company isn't there to get you the best price. They don't care about that.

SPEAKER_00

They don't care about it.

SPEAKER_01

They only want to get their stock price up, and that gets them a higher paycheck. That's it. Everything else doesn't really matter. And once you understand that, it all starts to make sense. It does. Now, the other thing that's interesting, you've talked about if you've done your homework, you've gotten your medical records, you've gotten the itemized bill, you wrote a great letter of appeal, you you ask them to audit the claim, you said, I'm, you know, and the first thing you say in there, I'm gonna pay the part that I agree to. So if I agree to paying $40 on a $2,000 claim, because that's what it should have been, uh, here's my check for that. Don't pay any more than that. But if they come back and they refuse to answer your questions, they refuse to audit, they refuse to do anything, you also have the option of reporting them to different agencies.

SPEAKER_00

Yes, you can report them to the state attorney generals, which is the first line of defense, but there again, you got to find an attorney general that's gonna do something. You can report them if you know if they didn't screen you for financial aid eligibility before sending you to collections, you can report them to the Internal Revenue Service for violation of 501R. Um if you ask for a cash price and they sent the claim to your insurance company anyway, that's a HIPAA violation. You can report them for to the DOL for that. But we try not to escalate it to that high because those people aren't going to do anything. So we have to take it upon ourselves to do it. I fight hospitals every day of my life. And knock on wood, so far I haven't lost one. Because they don't have the facts. Once you have the facts, and like I said, it's really, really, really not that hard. I run a TPA, but I don't want any more clients. I had much rather teach an employer how to bring it in-house or a group of employers how to bring it in-house and make because it's their information, it's their money, it's their time. And right now, a lot of them have their HR manager, and nothing against HR managers, but they've got sexual discrimination, they've got all, you know, hours and payroll and everything under the sun that they have to take care of. You almost have to dedicate a benefits manager, a healthcare benefits manager to this process, have them well trained, and that right there will save you 20 percent.

SPEAKER_01

The one thing that's interesting to me is for most companies, health benefits is either second or third largest line benefit. Yet they pawn that off on HR, again, not to say anything bad about HR, but they don't give it to somebody like the chief financial officer who understands finance. They don't assign it to a vice president, but yet they might have their fifth largest line item. They have a senior vice president for that who's on the board. Right. It doesn't make any sense. So all the employers out there, wake up, please get somebody who understands finance, get your CFO in charge of purchasing and managing it, and you can bring in HR if you want to help educate the people how the plan works and where the incentives lie, but you have to be the decision maker for that.

SPEAKER_00

Well, the CEOs and the CFOs, a lot of them don't even know they're the fiduciaries for that plan. They have no clue. And, you know, a CFO has a lot going on, too, and that's why I always say bring in a benefits person to feed the information to the CFO, because he's got a lot on his plate, too, he or she. But you've got to have somebody in that organization that understands. Don't let a broker come in and do your your open enrollment meetings, because you know, if you're offering three plans, they're gonna recommend the most expensive plan. The way I do business is when I tear a plan apart or take it apart, forensically audit it. If you're paying anybody, broker, consultant, TPA, whoever you're paying to manage your health plan, if you cannot measure the return on investment for that person or that company, they need to go away. So if you've got a broker or a consultant that comes in and says, one of my favorite things is predictive modeling. Well, unless you've got a crystal ball or a direct line to God, you cannot predictively model health care. End of story. You can't do it. So, and there are a lot of consultants out there selling the predictive modeling. Let me help you show it, let me show you how to lower your health care costs. Well, if you pay them a million dollars, and a lot of the bigger consulting companies charge a million dollars, um, Elon Musk is paying one a million dollars right now. But at the end of the year, if they cannot point on print on paper where they've saved you two million dollars, they need to go away because they're just adding to your bottom line. And that's the sad part of this entire health care industry is everything is patience over or profit over patience. And that's got to change. And the only way we can affect change is to learn how to do it and do it. I mean, you can learn how to do it, but if you don't put it in action, you've not done anything.

SPEAKER_01

And I'm glad you said the predictive part because one of the things that you learn in healthcare and you live every day is there's averages in healthcare, but there's definitely outliers. You can't predict. You know, all of a sudden somebody needs a bone marrow transplant in a 200-person company, that's going to blow the claims up. So all of a sudden, you know, that's a whole different, and nobody can predict that.

SPEAKER_00

Right.

SPEAKER_01

Or a huge trauma, you know, those sorts of things are just unpredictable and catastrophic. So that's why you have the stop loss. You can't predict that. So anybody's, I agree, anybody says you, you know, or you might need gene therapy or some very expensive biologic to control ulcerative colitis. Right. All these things.

SPEAKER_00

Well, you don't know when another hand dollar drug is going to drop from the pharmacy industry. That's true. I mean, I I'd literally Had a claim it was an infusion uh six, eight months ago. The hospital charged eight hundred thousand dollars for an infusion.

SPEAKER_01

Was that separate from the medication or did I include that was the medication? Oh, that was the medication.

SPEAKER_00

Eight hundred thousand dollars for three little shots infusion. Wow. We didn't pay that, of course. But eight hundred thousand dollars. Yeah now if they had gone with a PPO discount of twenty percent from that hospital, they would have paid what? $640,000. We paid less than $200,000. And it pained me to pay that $200,000. But we got it back from stop loss insurance because we did negotiate it. And that's the other problem. If you have a TPA or anybody administering your plan and you have a stop loss policy in place, you need to follow your claims and see if you hit that spec or if you hit that aggregate and make sure it's reimbursed. Because a lot of them just let it fly by and they never ask for the money back from the stop loss carrier. So I mean there's a lot of moving parts. It sounds complex. It's not.

SPEAKER_01

And the stop loss is also reinsurance. Reinsurance, right? Yeah, sure. The same thing.

SPEAKER_00

And you have a specific deductible, which is $35,000, $50,000, $60,000. So that what that means is the employer is going to pay the first $35,000 of the claims, and then the stop loss will reimburse every claim after that for that individual. And then you have the what it's called attachment point. It's usually $10,000 to $12,000, $15 a month per employee, but they average out what they think the claims are going to come in at. So you have a and that's where the maximum hit is that brokers never explain. Once they set an attachment point where they think all the claims together will total, if they go over that amount, then it's reimbursed at 100% as well. So if you have competent people running your plan, self-funding is just as safe as safer than fully insured because you can design your own plan, you can make your employees happy, it helps with retention, and you're not funding the beast is what I call it, and the beast is the healthcare system.

unknown

Yeah.

SPEAKER_01

And there's a this false sense of security when you're fully insured, because you think, well, I don't have to pay the claims, I just give the money to the health insurance company and they pay it. But it keeps going up and up. Where a lot of people like what you're doing, you come in, you might save a company 30, 40 percent, and it and also all of a sudden it stabilizes.

SPEAKER_00

Right. My clients have not had a premium increase in five years. And I don't know any other anybody that can but it's because we manage the claims.

SPEAKER_01

So five years, no premium increase.

SPEAKER_00

Now, I've got one client right now in 2026 who is playing less in premiums than he did in 2021.

SPEAKER_01

Well, that's not the case on the Affordable Care Act.

SPEAKER_00

There's nothing affordable about the Affordable Care Act. I mean, you have to opt out of the traditional way of doing things, or you're just never I mean, you're never going to get ahead.

SPEAKER_01

Yeah. And the hard part is, and people really don't think about that, but is Americans are paying so much for health insurance, it's becoming another mortgage. Trevor Burrus, Jr.

SPEAKER_00

Well, it is. I mean, even the procedures. If you if you got a $5,000 deductible or $7,000 deductible, and you go get that MRI CAT scan at the hospital and it's $7,000, you're out $7,000. You know, that's car payments, that's groceries for a family of four for what, six months? And Americans, I mean, they're being crushed by this health care system, and some way, somehow, we've got to educate them and as a group take back our health care system. The government's not going to do it for us, insurance companies are not going to do it for us. Hospitals certainly aren't going to do it for us. The brokers aren't do it going to do it for us. You have to put your money where there is a measurable return on investment, whether that be with me or somebody else. But you've got to start measuring it because you cannot control what you can't measure.

SPEAKER_01

And certainly Congress isn't going to fix it. They're paid not to fix it. They created the problem.

SPEAKER_00

Yeah, there's 535 people up there. My per particular, my personal opinion when it comes to health care, 100% worthless.

SPEAKER_01

I would agree. I would agree.

SPEAKER_00

I mean, if they've got a bill or an act, it's all good to write it. But if they're not going to act on it, if they're not going to enforce it, it's nothing but paper. And it's it's it drives me insane. I'm not sure. I maybe it's because I've been in the business for so long. But we've got to find somebody somewhere that will take action.

SPEAKER_01

I'm very excited about the direct primary care because that allows the primary care physicians to opt out of the system, focus on the patients, save them money, and manage their health care. And it's a great way to manage chronic conditions.

SPEAKER_00

Well, it is, and they're, you know, they don't have to have a they don't have extra overhead for a billing person or a CSR because they answer their own phone. Yes. Or an extra nurse because they draw their own blood, or a lab tech because they call Lab Corps to come pick it up, or they do it, you know, spin it down in-house.

SPEAKER_01

Or revenue cycle management. They don't have to have any of that.

SPEAKER_00

I mean, my personal direct primary care physician is a one-man show. I never have to wait. Never, ever. He's always he always answers a text, he always answers a phone call, he always answers an email. And you know, my mom one I took her to him one day because another doctor, a hospital loan physician, had been seeing her for several years and told her she had COPD and was giving her inhalers. And she called me and she said, every time I use one of these inhalers, it gets worse. I said, Enough of anything is enough. I took her to my DPC. Fifteen minutes later, we found out her hem her hem, because he called in a stat order, her hemoglobin was 6.9. 82 years old at the time, and she's still walking around, she shouldn't have been.

SPEAKER_01

That's amazing.

SPEAKER_00

Yeah, the next day, within 24 hours, we were getting a blood and iron infusion. The other doctor would let her die because as long as she came back every week or every month, and as long as he gave her that inhaler every week or every month, that was a continuous revenue stream. The direct primary care cured her of that by doing the necessary tests and ordering the right uh procedures or the process services to get her over that. So again, you know, nothing against doctors in general, but you if if you're gonna go to a hospital-owned physician, you better know him really well.

SPEAKER_01

It it's very tough, and it's tough for the physicians because you allow 15 minutes with the patient. You have to put all this information in the computer, you have to ask people about depression and other things that didn't come in for because you're you're tracked on that, and you don't have the time to think. You don't have the time to really sit there, ask the right questions. You don't know who that person is. Right. You don't have no continuity, and it's very, very difficult and frustrating. And and physicians are burning out and you're leaving. Please don't leave practice. Please get into a direct specialty care practice. And a good friend of mine, Noah Kaufman in Denver is an ER doctor.

SPEAKER_00

ER.

SPEAKER_01

23 years, and he set up his advanced, direct advanced care, which is gonna be great. So it's it's really kind of a mini ER, about he could handle probably 70, 80 percent of what people vote an ER for.

SPEAKER_00

Right.

SPEAKER_01

And it's it's very easy for patients, very cost effective.

SPEAKER_00

They can pay cash and not use the insurance.

SPEAKER_01

Yeah. So I'm hoping his model really catches on. Well uh like wow.

SPEAKER_00

And same thing with Oklahoma, the uh surgery center of Oklahoma. Yes. Um and you know, there are still some physician-owned hospitals around, but and I'm not complaining about all physicians, they've been forced to sell out to be able to survive. And that's the sad part of all of it, because a lot of them most that I know, and I know a lot of physicians, they regret the day they ever sold out to the hospital.

SPEAKER_01

You don't realize how soul-sucking it is to be employed. And as now as I go in, as I'm more of a patient than a doctor now, some days, you go into the hospitals and I look at what's going on there. And I just see the bureaucracy. When I was in my private practice, I first joined. There was I this is a sixth partner, and I knew every employee by name, and I knew exactly what they did, and they all had a role. You go over to the hospital, I have no idea who these people are, I have no idea what they do, but they all slow down the provision of health care.

SPEAKER_00

Exactly.

SPEAKER_01

And they add money to the the career.

SPEAKER_00

They have the hospitalists that know nothing about you when you get to the hospital, and it's just it's not a good situation. And we've got to start now. It's we've almost lost our health care system. If we don't start right now taking it back, we're gonna lose it completely.

SPEAKER_01

I love the call to action. So we've got a lot of call to actions, you know, for patients out there. Find a direct primary care. Find a independent imaging center. Independent imaging center, and really look for options outside the hospital for anything you can schedule. Absolutely. And then find out your hospitals in the area, what their policies are for financial assistance.

SPEAKER_00

Yeah, because you know, it's and the cash pay can vary from a 10 percent discount to I've seen them as high as a 78 percent discount. HCA, which is a for-profit system, if you don't have insurance, you get a 92 percent discount, and they don't care what your income is. It's just because you don't have insurance. Find a nonprofit hospital that does that.

SPEAKER_01

I don't know of any.

SPEAKER_00

There's not any.

SPEAKER_01

Yeah, that's I mean, and there's nonprofit CEOs who are making over $30 million in a year getting paid. I mean, it's it's crazy. And people think Mother Teresa is running these nonprofits. Those days are gone.

SPEAKER_00

Yeah, and and I keep going back because I know more about my local area, of course. I've sure I've done studies on hospitals all over the country, but in my local area, the CEO is a hundred and eighty-one-bed hospital, I believe. CEO makes almost $900,000. In that county, one in five people are in poverty. The average income is around $60,000, $70,000. Family income, $67,000. We've got a cardiologist on staff, $2.2 million. Wow. A cardiologist at Johns Hopkins, which is world renowned for quality, does not make $2 million. Half of his salary is tied to bonuses and incentives. I can't say for sure how those bonuses and incentives are earned, but I do question how many heart casts are ordered that aren't necessary. And there's anytime somebody's got, and it's a sad state of affairs, if there's a monetary advantage to ordering a test that's not necess necessary, I call that medical assault because you're gonna put me through something that I don't need, especially if it involves contrast or something. And there was an article there's a doctor right now in prison for I forgot the number, treating uh cancer patients with chemo. Killed some of them, and they never had cancer.

SPEAKER_01

That's crazy.

SPEAKER_00

It was just revenue generation. That's crazy. There's another uh gynecologist, she's in prison as well, that was performing hysterectomies on younger women that didn't need them. So not only has she done a procedure that wasn't needed, she's taken away the ability of those ladies to have children. You can't pay a price high enough for doing that.

SPEAKER_01

Yeah, no, that that's hard. Well, definitely I I love we have a lot of good call to action. We have a lot of good options for both patients and physicians. And in the end of the whole story in healthcare, we have to bring the patients and the physicians together together, get them in the exam room, everybody else out. That's where it went bad. The whole HMO movement and all that. So I think we've got great things. What I'm gonna do in the show notes is I'm gonna put all your information in there. Okay, and I'm gonna put down all the different terms we've used so people don't have to worry and Google what those are. I'll make it super easy.

SPEAKER_00

Right.

SPEAKER_01

And just make it very educational, very easy. And I want to thank you for all your time. Oh, you're very well.

SPEAKER_00

And I'll put together something, the link for you know the basics, the the good faith estimate request letter. Oh, that'd be great. And the itemized bill letter, because if you just call and say, I want an itemized bill, they're gonna send you the very basics. So you have to tell them what you require on that itemized bill and what you require on the good faith estimate. So I'll put a document together you can link to it. That's the that's the best first start for anybody. That's perfect.

SPEAKER_01

That's perfect. We'll get all that together. It's gonna be fantastic. And please like and follow for more. And if you made it this far, thank you very much for the listeners. And you can always ask any questions.

SPEAKER_00

Absolutely.

SPEAKER_01

And then I I could forward those to Christine, and she is the expert in this. And I will tell you that most physicians, I include this in myself, do not understand medical billing because it's a whole nother area. We focus on treating patients, and most of us, honest to God, hate coding. It's the last thing we want to do. We have to assign codes when we see a patient and we cringe doing it. We're like, I really don't want to spend this time and effort on it. But it's important, but you shouldn't have to.

SPEAKER_00

Your job is to treat patients, in my opinion. I can't know what they're jobing.

SPEAKER_01

I agree.

SPEAKER_00

But it's like, you know, buying a car, a new car from a car salesman, and then expecting them to fix the engine when the check engine light comes on. That's not what they're supposed to do. Everybody has their place in a doctor. Absolutely. You know, I love doctors. I dispens hospitals, hospital systems. So, you know, the less people we can take in out of it, the more people we can take in out of it between the doctor and the physician and the pharmacy, the better off we all are.

SPEAKER_01

Absolutely. And I appreciate all those thoughts. And we're gonna close it out here. Like I said, you know, please let us know if you have any questions, thoughts, and please like and follow for more. Thank you so much.