Advocating for Yourself in Today’s Healthcare System with Vannessa Ruiz & Kristin Conti

Mike Rankin:

Absolutely. So today we wanted to tackle a really, you know, a critical topic for a lot of us, which is, you know, just navigating health care. And we were talking about with Vannessa and Kristin together and, you know, we’re professionals in the business, been insurance brokers and consultants for, you know, 20, 30 years now.

And we’ve just noticed in the last probably five years, maybe 10 years for sure. But even in the last five, that it is increasingly difficult to, for, you know, the average consumer person that doesn’t know insurance just to navigate the health care system. You know, once you go in, you meet with your doctor and then, you know, the claim gets kind of magically filed with the insurance company.

And then next thing you know, you get a letter back saying that, you know, something went wrong. And I thought maybe we could start just a little bit with you, Kristin, and talking about, you know, as a provider in your history, like all of the time constraints that you guys have and maybe share like a little day in the life or a day, you know, moment in an encounter when somebody comes into the office, like what are all the things that the providers have to go through that I think part of it contributes to, you know, this environment of, you know, confusion and difficulty of getting the claims paid?

Kristin Conti:

Yeah, so I think what people don’t realize a lot of times is that we have metrics to meet, right? So maybe you have to see 20 patients in a day and maybe you have 20 minutes allotted to the encounter, but that includes the time the person checks in to the time that you do intake with the technician and then see the provider. The expectation is then that you would put in potentially all the orders and notes and be done within that a lot of time.

But unfortunately, that’s not realistic. And if you have other people, if you’re booked back to back, let’s say that somebody waited for maybe eight weeks to get in and see you. So now they have a list of things that are a priority in their world.

And you’re trying to, you know, fast track them through the encounter so that you can attempt to address even half of those things. But then you’re or that or you’re deferring and telling them that they need to follow up and book an additional appointment. And again, these things just get drawn out and drawn out and drawn out.

So now you’ve created a situation where somebody’s like, I feel like, you know, my life or my health is in jeopardy. And you feel like you’re you don’t have the time to be heard by the person who should be listening and being able to address those concerns. And again, it’s not that they are careless in that particular circumstance, but just they’re in a bind right there.

Yeah, there’s this, there’s all these outside pressures. And then if you and then imagine to like you’re super busy, right? And you’re out in the waiting room, if you’re waiting two hours to see your provider, now it’s derailed your afternoon, right?

So if I don’t stay on schedule, that has other implications. And you’re kind of caught in this perpetual cycle where, you know, you have all these things that need to be addressed, but not enough time to do it. And then again, imagine, like we go, we always talk about lifestyle interventions, right?

And the thing that’s easiest to give some time, because there’s always the psychology behind an encounter. But let’s say that you have this expectation, you’re going to leave with something, if I have to coach you on how to change your diet and lifestyle, that’s going to take a lot more than 15 minutes.

Mike Rankin:

Yeah, I’d much rather leave with a prescription that I can take to the pharmacy, right? I mean, it’s almost like that’s the expectation. I think these days, it seems like, oh, I’m going to the doctor, I’m going to get a get a prescription, but that’s not always necessarily the right thing.

So when you are then with the notes, and you’re, you know, hitting submit, and the system, you know, sends off a claim to the insurance company, then on our side, the way that it comes to us is sometimes an employee will reach out to us. And so Vannessa, then maybe share, like, some of your experiences in the last few years of just having, you know, some of the difficulties that we’ve run into, it feels like today, you know, back when, you know, humans who were trained and involved, they would look at a claim and, you know, kind of make a decision, it seemed like, you know, much more collegial environment to get somebody to look at a claim, where now so much of it is automated, and they just get kicked back, and then you got to kind of fight the system. So like, you know, how does that sort of present itself from your perspective in your in your day to day?

Vannessa Ruiz:

Most recent days, it’s been pretty much daily. And I guess it just depends on right, the visit and the claim. More recently, it’s been prior authorizations, right authorizations for injections, or maybe they are going to get their MRI, and they think the authorization has been approved.

And that hasn’t happened. But from a pure claim standpoint, I think what we see is a lot of times, most recently in the preventive visits where the labs are getting denied, because they’re not coded correctly, they’re coded as diagnostic instead of preventive. And so people are being billed from that aspect.

Mike Rankin:

So let’s pause on that for a second. So you know, with healthcare reform, preventive care is supposed to be covered at 100%, right with no copay, no deductible, etc. And so what you’re saying is people are, you know, participants, employees, patients are going in for what they think is a preventive care visit, which then should be covered at no cost.

And yet they’re ending up with a bill. Is that correct? Yeah.

And so in from what you’ve seen, what’s what’s happening either at the provider level or the insurance company level that’s ending up kicking out a bill to them, they’re being billed as diagnostic as opposed to preventive.

Vannessa Ruiz:

So right, those labs are not covered. So they’re being denied. And from a member’s perspective, right, I just went in for my preventive should be covered 100%.

Why aren’t they paying anything? So that’s been more recent, even as much so as what I’ve seen more recently and experienced personally, is when you are going for your preventive, right, you’re scheduled visits at certain ages, they want to do a new patient visit. So interesting.

Now you’re no longer getting that preventive at 100%. Because you have to see a totally different provider to get that type of screening. And, you know, you have to shop around, in essence, for providers who are going to honor the full visit being covered at 100%.

Because you’re not really relationship building, you’re just getting your screening, right? But they’re requiring that new patient visit. And it’s being billed as, you know, non preventive, new patient office visit, right?

Mike Rankin:

So your copay or deductible, whatever type of plan you have is then going to kick in. Yep. Interesting.

Kristin Conti:

Yeah. And it might be too that they don’t even realize exactly how it’s impacting the patient, as far as like what their insurance covers or doesn’t cover, because sometimes they’re totally unaware of that.

Mike Rankin:

Right.

Kristin Conti:

I think sometimes what happens is because of these time constraints, so I can’t do all this stuff in 15 minutes, but how do I collect the right information and make sure I can address everything? Oh, I’ll make everyone do this initial intake, right? And instead of having 20 minutes for the encounter, I now have 40 minutes, or same thing with like a procedure, for example, and then you segment all of it, and then you can bill for all of it so that you have a lot of time for each issue.

But you don’t, again, necessarily know how that’s going to impact a patient. So like another example would say, you come in and your blood pressure is elevated. I’m like, oh, okay.

So you might have hypertension. This is going to be our plan. We’re going to do a lipid panel where you want to check and see what your risk of cardiovascular disease is.

That’s going to be diagnostic, right? Because now it’s associated with a condition versus you just coming in and we’re trying to do screening, and then that would be preventative. So if you put like a Z, for example, in front of the annual wellness visit, then that all gets billed as preventative versus having something like a typical 99213, which is basically saying you have moderate level of acuity.

It’s going to take me about 20 minutes to address your concerns, and I’m going to attach that with a diagnostic code, right, like hypertension. Then again, you might be having the exact same conversation, but the way it gets billed is different, and then what’s covered is different as a result.

Mike Rankin:

Right. And I find it so interesting because I often find myself saying, well, often people want to know, well, is it the doctor’s office fault or is the insurance company’s fault, right? And I say, well, in the doctor’s office defense, they have so many patients, so little time, and so many insurance companies that they’re dealing with.

In the insurance company’s defense, if they simply let the guard down and paid everything, they’d all be out of business and we wouldn’t have a financing system, right? I mean, the reason that these systems are in place is to have kind of checks and balances, but for all of us as consumers and patients, it just feels like a giant headache. It’s tough.

Kristin Conti:

It is, even from the provider side, but in some ways, it’s kind of everyone’s responsibility to learn this, right? Because it’s the same thing, like let’s say I pick two antibiotics. Well, I’m just looking at the standards of care and, okay, your culture is positive for this bacteria.

It requires this antibiotic, but then I might look online and realize, oh, okay, well, this antibiotic is going to cost my patient $5. This one’s going to cost them $500. That might change the way I prescribe just by knowing what it’s going to cost them.

Then the same thing with billing for the visits.

Mike Rankin:

Mm-hmm. We were having this conversation the other day. There was something really interesting that happened and you can explain it, but my layman understanding of it is that if we have a patient that’s seeing a doctor for a particular treatment plan, they’ve been going to this doctor for years and years and all of a sudden they’re accustomed to paying one number.

Then next thing you know, it goes up double or triple. Share with me, from your perspective, what happened in that scenario that is just a giant mystery to the participant. All they know is they were paying, I’m picking a number, they were paying $20 and now they’re being billed $300 or whatever.

How do those things happen?

Kristin Conti:

Yeah. In one particular circumstance, I had a client who was going for the same service, same facility, same provider and doing that for a prolonged period of time and then randomly gets a new bill. All of a sudden, they’re thinking like you were saying, what’s happened here?

Same insurance plan, so it’s not like their coverage changed.

Mike Rankin:

Didn’t seem like anything changed. Yeah.

Kristin Conti:

Exactly. We ended up getting some more information and realized that the claim was processed incorrectly. There’s a contracted rate that UnitedHealthcare, for example, would have with a provider or a facility.

The second component of that, once that was adjusted, is that the person or the department processing the bills for that particular clinic had changed. Instead of it being billed as a provider visit, which UnitedHealthcare had contracted at let’s say $60, was now billed as a facility visit. Now that contracted rate for the same service is billed at $280.

That’s a big difference in cost. I guess the other thing that people don’t think about is how is it billed? Diagnostic, preventive, is it a 9921?

There’s all these different codes, right? It’s this whole other language. The other component of that is you also have the place of service.

The reason that happens is because let’s say you go have surgery in Manhattan, the overhead cost to run that facility is going to be a lot more expensive than it is going to be in a small town in the middle of nowhere. Even your rent is exponentially more. Even getting a Tylenol, one tablet, is going to cost you more because the cost to run that facility is going to be factored into every intervention.

Mike Rankin:

All that overhead is baked into it, right? Exactly. When we talk about the place, I think about it.

I remember if you needed an outpatient surgery, if you went to an independent outpatient surgery center, let’s say the facility fee was a thousand dollars, but if you have the same surgeon and the same surgery and they do it in a hospital setting, it’s going to be five thousand dollars just because all that overhead is kind of piled in there. We as consumers, we don’t generally know that level of detail. It can be a lot of surprise at the back end.

I guess while we’re talking about being fair, to be fair, whether it’s UnitedHealthcare, Anthem, or Cigna, all the insurance companies have all those different layers of codes. Vannessa, in terms of some of the other claim issues that you’ve seen and worked on, what are some of the other themes that kind of emerged for you as you think back through this?

Vannessa Ruiz:

All kinds. As I mentioned before, just diagnostic versus preventive. More recently, we did have an authorization in place where the provider must have lost it, misplaced it, didn’t think they had it, obviously didn’t have the time to research for that.

Build a member, contracting provider, build member directly, member paid out of pocket, and I tried to submit that claim to the insurance company, but because they’re contracted, I have to go back to the provider to get them to bill after they’ve gotten the member to sign saying they pay out of pocket. That’s something that’s currently on my plate right now.

Mike Rankin:

One of the others that I know I’ve run into personally, and we’ve had clients that have too, is the insurance companies contract with third-party providers to then go through and say, okay, well we’ve paid all the claims, and now we’re going to send that claim data to this third-party provider who’s then going to go through it with a fine-tooth comb and say, oh, well actually, Kristin, you should have been covered on Medicare or Medicaid or had some other third-party insurance, and if you’re talking about a billion dollars of claims and they’re going to fix two percent of it, well, it turns out to be a lot of money, and so I’ve had some invoices that came over a year later. Sometimes two and three years later. Hey guys, my ability to file this claim is long gone.

You’ve got a, is it usually a year between the date of service and when that claim needs to be filed?

Vannessa Ruiz:

I think it also depends on the state, because usually the insurance company requires a year, but as far as what they’re allowed to bill for, I know I believe here in California it’s four years, so even though your time for filing the claim is a year, that provider can bill you up to four years from that claim.

Mike Rankin:

Yeah, yeah, so lots of mud puddles to get stuck in for sure. And Kristin, in terms of like from the provider’s perspective, I think you said it well, which is, you know, we don’t always know how that’s going to impact, you know, the insurance plan, and maybe as a question to both of you, but what do you think are some of the things that employees and participants can do to sort of, you know, arm themselves a little bit in terms of hopefully avoiding some of these things?

Kristin Conti:

Well, I think one, you know, as health care evolves, I think you have to understand the limitations with that you’re working under, right? So, for example, if you have, you know, you go in and have that initial encounter to establish a relationship, and then you say, okay, I have all these other concerns, how can we set up multiple encounters or subsequent encounters to address each one of these things? And then maybe on the provider’s side, even just knowing like, okay, if I’m going to order labs today under an initial visit, that’s going to be coded a little bit differently than it would be for a preventative encounter, so then I can just start by kind of structuring my time and setting expectations with that person so that they get all of their concerns addressed, but then we can also, you know, not spend two hours in clinic, or make them come back 20 times, or start to do something that makes them feel like they’re constantly being pushed off or deferred.

Mike Rankin:

So, if I hear you correctly, is it from the provider’s perspective, the type of encounter that you have perhaps dictates the amount of time within that visit? Does that change or no?

Kristin Conti:

It can change. It kind of just depends on how it’s set up. Like, sometimes you can advocate for having 40 minutes for a procedure, but most encounters are going to be a 20-minute.

Mike Rankin:

Got it. Okay.

Kristin Conti:

If it’s something simple, then maybe you, you know, would justify having a 10-minute encounter.

Mike Rankin:

Right. Got it.

Kristin Conti:

Okay. It’s like, I have a runny nose. Oh, okay.

Mike Rankin:

Yeah. Here you go. Here you go.

And what about from your perspective, what do you think people can do to?

Vannessa Ruiz:

Well, I would definitely say to recognize that they are consumers, and they need to be aware that in that setting, they’re still a consumer. I think some people think of health care differently. So, they’re going to a contracted provider.

They’re relying on the fact that because this provider’s in network, um, things work a little bit differently. They’re signing forms blindly saying, all right, and what you’re in essence saying is that if this claim is denied for any reason, even if it’s no fault of my own, even if it’s the fault of the provider in some instances, because it does happen, I will be responsible.

Mike Rankin:

Wow.

Vannessa Ruiz:

Um, so, you know, I did have, I did have.

Mike Rankin:

It almost seems like that shouldn’t form shouldn’t be allowed if you’re an in-network provider.

Vannessa Ruiz:

A hundred percent. I don’t, I don’t really understand it. And even when I’m personally in those, um, settings, and I had a member who was having a dependent have some procedure in an in-network facility, and they were adamant about having them sign this document.

And I said, because this person called me, I said, write in that I will not be responsible for the fault of the provider who did not do their due diligence prior to as a contracting provider, you know, and there, there was some back and forth, but ultimately they, they did accept that. And I think when you are going in network, you do, um, expect some sort of protection, right? I’m in an in-network provider.

I’m getting negotiated rates.

Mike Rankin:

That’s what we’re all trained to ask for and trained to do. Right. And then next thing you know, it’s not giving me the protection you need.

Vannessa Ruiz:

Exactly. And this particular person had done their due diligence. They had done it weeks in advance.

They had reached out to me. We kind of, you know, did some steps prior to, and then the day of all of these things came up. So I think, you know, to know that we are consumers, we have a choice, um, and to make sure we, you know, read through what we’re signing.

Kristin Conti:

That’s a good point. I think sometimes too, there’s other things that didn’t even occur to me until recently. Right.

And I’ve been working in healthcare for almost 20 years. You can ask for things like an itemized bill just to see like, did I act, did all of those things actually happen while I was there? And you can actually say, I, you know, I want to dispute this claim.

Can you reprocess it and make sure that it was actually, it went through and everything is correct on here? I mean, those are all things that I think patients realize that they, they might not even have access to the, they don’t even know that they have that as an option, right. As a responsible consumer.

Vannessa Ruiz:

And also a predetermination of benefits. You may not be able to do it for an office visit, right? You’re going for a standard office visit, but if you know you’re having a procedure, you can have them, you know, run that claim through prior to the procedure to know, and that provider should be listing out in an itemized format, what they’re going to do.

The insurance company looks at it, looks at their rates. So you can know what’s applied to my deductible. What’s my out of pocket.

Mike Rankin:

I’m thinking about someone in my family right now that is, you know, probably going to need a procedure done. And I don’t think I gave that advice, which is really going to as soon as we’re done here.

Kristin Conti:

That’s really good.

Mike Rankin:

So, if I’m hearing you, I mean, just a couple of things. One is for the preventive visits or the well visits, make sure that they kind of stick to what’s approved on that menu and don’t bring in a laundry list of issues right to that meeting. Or if you do, which is fine, just be prepared.

You’re going to have your copay or deductible that, that applies to that. But if you’re really just looking at the screening, keep it to the screening and then that should be covered, you know, no copay, no deductible. So, so that’s one.

Two is make sure that you read what it is they’re putting in front of you. Cause I know when we go, it’s like five pages and there’s, you know, HIPAA authorizations and all that other kind of stuff, but there’s definitely patient responsibility. I know I’ve signed off on those as well and probably didn’t read them as closely as I should.

And then the third would be the, you know, predetermination. If you’re going in for a procedure and that way, you know, that provider can run it through the insurance company and they’ll, in essence, give you kind of a forecast of how that, that claim should be paid. So you don’t have any surprises there.

Vannessa Ruiz:

Right. And just know that you have a choice, you know, it’s convenient. I’ve been going to this doctor for 10 years, but right practices grow, people change, you know, is it worth my time waiting two hours to see this provider and signing off that I’m going to be responsible for whatever happens in that or, you know, shopping around in your network to see, you know, who’s going to give me the most bang for my buck, so to speak.

Kristin Conti:

Yeah. It really kind of just depends, right? Everybody has a different set of priorities.

We have a provider who I feel like is very similar to how I was when I was operating in the military, but it might take you forever to get into his clinic. He’s always running behind, but whenever you have him, you have his undivided attention and you don’t leave there without having all your questions answered and feeling like he fully met your needs, right? So, but not everybody has the time and the ability to wait like that.

So maybe you want somebody who’s really concise and punctual, but they’re going to be a little more cutthroat, right? A little more direct and to the point. So like you said, people just need to know that they have a choice and that they should choose somebody that they feel is right for them and can meet them where they’re at.

Mike Rankin:

Yeah. I would say in closing that I do feel like there’s a fatigue, you know, from participants, you know, it’s like, oh my gosh, I’ve got to go through this other hurdle. Can’t they just, you know, pay the claim or get the approval?

And my heart, you know, goes out to them and all of us that are in that situation. And so that fatigue, you know, I think we try to address that and be as, you know, certainly as understanding as we can, but, you know, working really hard in the background to get those, you know, either the approval or the claim paid, because it’s stressful, you know, you’re dealing with your health, you’re dealing with a lot of money and, you know, that’s tough. All right.

So we have learned preventive care visits, pay attention to that, make sure you don’t just sign willy-nilly and read through, do a predetermination, and be a consumer, shop around, advocate for yourself. And I think, you know, when I think about the advocacy side of it, obviously there’s industries that have, you know, grown up and that’s what, you know, what CareGuides does, but also sometimes if it’s really a complex medical issue, maybe bring a family member along, you know, because you only hear a certain amount and sometimes afterwards it’s easier to say, hey, okay, did you hear this? And what they say the next step was and really, really important.

Right.

Vannessa Ruiz:

And just know your resources, right? For our clients and our members, right? We make ourselves available.

We have access to the CareGuides team and just, you know, you can start with human resources, right?

Mike Rankin:

You know, start with your HR team and they’ll be able to, you know, bubble it up and direct where it needs to go.

Kristin Conti:

For a lot of my family members, what I like to do is I pretty much like write out their encounter. This is my past medical history, past surgical history, all of my medications. These are the things I’d like to address.

And then that way, when you’re rushed, you’re not like, you know, getting distracted. You leave there and you’re like, I should have said this.

Mike Rankin:

I wish I asked that question. I’ve done that.

Kristin Conti:

And so you keep everything nice and concise and organized. So, you know, I mean, I know from being a provider what the expectation is. So I can kind of like, okay, here’s the information they need and here’s what you want.

And so now everyone’s happy.

Mike Rankin:

Right. Well, not everyone has a Kristin, but they could have a CareGuide. Awesome.

Well, Kristin, Vannessa, thank you very much. Really appreciate the time. Good insight.

And thank you. Thank you.

Kristin Conti:

Thank you.

Mike Rankin:

Thank you.