Here is a sobering statistic: it is estimated that up to 80% of medical bills contain errors, and usually not in the patient’s favor. In addition to creating billions of dollars in waste, this issue negatively impacts patient care and outcomes. In fact, financial concerns are the #1 driver of why individuals defer medical care. About 67% of bankruptcies each year are tied to medical issues, impacting more than half a million American families.
Included Health launched member advocacy services in 2018 in recognition of the fact that financial and administrative barriers prevent members from getting the best possible care. Our team helps members decipher explanations of benefits (EOBs), navigate paperwork, and most importantly, fight unfair or excessive bills. Since inception, we have helped members avoid $6.6M in direct medical costs, as well as more than 30,000 hours of research and phone calls. We save members $1,665 on average when we correct a billing error, which is particularly poignant in light of the fact that 40% of Americans do not have adequate savings to cover an unexpected $1,000 expense. Here are some examples of the work that we do every day for our members:
Member Story #1: Keeping a Medical Emergency from Becoming a Financial Disaster
Earlier this year, a member with no prior history of symptoms suddenly began experiencing excruciating stomach pain. She was rushed to the hospital via ambulance, where she was diagnosed with a bowel obstruction and underwent emergency surgery. While recovering from this ordeal, the member began receiving bills for the encounter that totaled more than $25K. She had been in the process of purchasing a home, and these unexpected bills threatened to derail her life. That’s when she turned to Included Health for help.
The first thing we did was to work with the provider to keep the bills from being sent to collections while they were being investigated. Next, we researched each bill to understand why the member was being billed for such a high amount. As it turned out, the ambulance that took the member to the hospital was considered out-of-network, an endemic issue that often results in surprise bills for patients. Furthermore, while the facility that treated the member was considered in-network, the surgeon who performed the procedure was out-of-network. He had been temporarily working at the hospital due to COVID-19 staffing shortages.
We used these extenuating circumstances to advocate repeatedly on the member’s behalf with both the insurance carrier and the provider. Eventually, the two parties agreed to cover the vast majority of the member’s costs, leaving her with just a $60 balance. The member is now fully recovered and back at work, and as a result of our efforts, she was able to move forward with her dream of becoming a homeowner this year!
Member Story #2: Turning a Patient Bill from $93K to $3 (Yes, $3!)
A couple undergoing treatment for infertility was facing a $93K bill after being quoted $7K by their in-network provider. The claim had been denied for lack of documentation around medical necessity and for being excessive in amount. We compiled medical records needed to support the member’s case on the insurance side, while contesting the charge on the provider side using our own research on typical prices for this procedure. After months of negotiations, the carrier reprocessed the claim at the contracted rate for this procedure, while the provider agreed to write off the remaining balance, leaving the member with just a $3 bill. The member was incredibly grateful for the outcome:
“That is truly an amazing outcome and very welcome news. I really would have been lost—and financially damaged—without your steadfast support and guidance. I want to send you a heartfelt thanks for your tireless efforts in this matter.”
We are also happy to share that the couple has since welcomed a healthy baby, and are overjoyed to be new parents who are unburdened by medical debt as they raise their first child.
Both of these member stories highlight the fact that claims issues are often complex and require facilitated dialogue between the carrier and the provider. We take on this challenge on behalf of members because it is incredibly difficult for them to navigate on their own, and because we are able to drive life-changing impact.
Grand Rounds is Now Included Health
Included Health is a new kind of healthcare company, delivering integrated virtual care and navigation. We offer our members care guidance, advocacy, and access to personalized virtual and in-person care for everyday and urgent care, primary care, behavioral health, chronic and specialty care. It’s all included.