Got a Medical Bill in the Mail? Don't Pay It Until You Read This Book

One mark of a good how-to book is the number of Post-it notes sticking out from its pages afterward.

That would make “Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win” a must-read for anyone who’s up against a health insurance company or medical billing department. Investigative journalist Marshall Allen has distilled 15 years of reporting on the state of healthcare in America into both a manifesto and manual about why and how patients (and their employers) should stand up for themselves.

Chock full of step-by-step instructions, sample letters, and even the words to say when speaking to a customer service representative or government agency, the book aims to empower consumers and companies. But Allen doesn’t pretend his tips and advice will make it easy to win an insurance appeal or turn the tables on a debt collector -- just easier.

As he put it, “If all of us are more skeptical and take more care to put some of these steps into practice, we can be savvier consumers, we can save a lot of money, and possibly stop a lot of harm.”

Allen is so serious about those goals that he’s left the nonprofit newsroom ProPublica and signed on with the Office of Inspector General at the U.S. Department of Health and Human Services, where he’ll continue to look into patient mistreatment and financial malfeasance in another context. (Allen stresses that he’s speaking as an author and not a new government employee.) 

Allen spoke with NPLB executive editor Lynda Gorov from his home in Fanwood, N.J. Here is a lightly edited and condensed version of their conversation.

NPLB: In the book, you tell some personal horror stories and talk about some personal triumphs dealing with your own health insurer. Did those spur you to cover these issues, or was it that you brought your tenacity as an investigative reporter to your dealings with insurance?‍

Allen: I definitely started with no knowledge. I’ve been fortunate to be healthy so I haven’t had to interact with the healthcare system a lot on my own. I learned about the system by covering it. I would write stories about patients who had gotten an outrageous medical bill and that’s how I learned how the billing process works and how insurance companies work. 

NPLB: Do you worry with the book out that people will start calling you for help directly?‍

Allen: I want them to call me. They can go to my website and reach out to me there. A lot of people write to me with problems and now I can just say, ‘Oh that’s in Chapter 3.’ I want to equip people to take on these challenges themselves. People don’t realize the power they have. You can’t win every time but often you can -- and you don’t really know until you go down that road of pushing back. 

NPLB: What kind of money can people save using your tips? ‍

Allen: That number is going to be different for everyone. I have a whole chapter on how sometimes you can save money by paying cash. I have a friend who asked if she should pay cash at the pharmacy and saved $30 every month. For some people that’s not that much money, but it’s nice to have an extra $30 in your pocket. 

One of the craziest stories I tell is about [a man] who needed an MRI. It was $11,000 if he ran it through insurance, $9,000 out of pocket. Lots of studies have shown that things like CT scans and MRIs are a lot cheaper if you go to an independent imaging center and not a hospital. He paid about $900. He saved around $8,000 just by going to an independent imaging center. 

Sometimes it’s really easy and you can save huge amounts of money. Sometimes it’s a big fight. You never quite know until you start. That’s why you have to try all the strategies. 

NPLB: How do you empower people to step up on their own behalf when they are already suffering or scared or in pain?‍

Allen: This is like learning financial wellness. You want to do it before you need it. I don’t expect everyone to be able to apply this knowledge right away but hopefully a lot of people will.  

NPLB: The way you write about the terms we use -- calling insurers payers, for instance, when we are the ones paying for our own care through our premiums -- really struck me. Do you think changing the way people think of the system means changing the language around it?‍

Allen: The industry creates the lexicon they want us to use. Payers is a perfect example. We are the payers -- the taxpaying public is one payer, the employer is another payer, and the working American is another payer. Through the book I’m trying to reframe the conversation. No one else is paying for this. We are paying for this. And we have a right to stand up for ourselves when we are being taken advantage of.

NPLB: Is there one story that sticks out as the most egregious? 

Allen: There are too many stories. I have read a lot of good books on healthcare and they are chock full of anecdotes. The most important words in my title are ‘and win.’ That’s what I’m really focused on. That’s why I love hearing these victory stories from patients and employers. Sadly this is such a persistent problem. I talk to people about this and every person has a story about how they have been ripped off by the healthcare system.

NPLB: Do you think insurance companies make it difficult on purpose in the hope that some patients will just go away?

Allen: I don’t know if it’s intentional or not. But it ends up being the practical result. That is how it plays out often. I know they also do that when it comes to paying claims. Some insurance companies have much higher rejection rates. There’s very little accountability for the insurance companies. That’s why we need to stick up for ourselves. 

NPLB: So how do we start reforming the insurance system?‍

Allen: We equip people to navigate it. Also, employers are a huge stakeholder that hasn’t been engaged. We have to get employees and employers to push back.  

NPLB: What does a good system look like?‍

Allen: I don’t make any policy recommendations in the book and I’ve stayed away from that. I think that distracts us. We wish and hope someone will come in and fix it and that hasn’t happened for us. We’ve been waiting decades. I don’t put my trust in policymakers to come up with something sensible. That’s why we as individuals need to learn to apply these principles --  so we can stand up for ourselves whenever possible.

NPLB: What’s the best tip you can give people who are facing down medical bills besides to take a deep breath?‍

Allen: Any time you get a medical bill, get an itemized one. Make them itemize that bill so you can see every charge and make sure that everything that you’re charged for is stuff that actually happened. Once you have the billing codes, you can check the prices in your zip code. That’s one way to do a price check. The other is on the hospital’s website. They’re required by federal rule to post them. They’re supposed to make it easy to find. If you can’t, call and ask them. 

NPLB: You’re asking people to build a detailed case in their favor and against their insurer’s decision. Calling state regulators is a great tip. So is telling people exactly what to say: ‘I need to ask a question about a specific health insurance regulation.’ Do you genuinely believe these agencies will help patients do the work?‍

Allen: I’ve often found with the real policy wonks that they enjoy helping people. How many opportunities do they have where people are actually interested in insurance regulations? Not at parties and not at home with their significant others, I can guarantee that. And they are public servants and I appreciate that a lot of them are working away and not being appreciated. It doesn’t mean it’s going to be easy to find them. You’re going to have to do some sleuthing.

NPLB: Lately I've been dealing with a lot of customer service reps, in part because we changed insurance and they require prior authorizations for medicines we’ve been taking forever. Do you think people inside insurance companies really want to help, or that they just feel they’ve got a job to do? ‍

Allen: I think you see both. I definitely do not think there is one universal mindset that’s present in any hospital billing department or any insurance company customer service department. That’s why when we engage with them, especially if we’ve taken the time to understand what’s going on with our bills, each individual story carries a tremendous amount of moral force. When we are standing up and asking that they treat us in the way that’s fair, we can cause change to come about. It won’t work every time, but it will never work if we never try. So those of us who can try need to try. 

We’re not just fighting back for ourselves. These are injustices that have been built into our system and we need to all stand up collectively and say this is wrong. And I do think that if enough of us do that we can bring about a tremendous amount of change.

Let’s look at surprise billing – the leading cause of medical debt and bankruptcy. What if 1 percent of us filed in small claims court? It would cause so much pain and expense for those unethical surprise billers that it would not be in their best interest to continue.  

NPLB: I want to take Laurie the Insurance Warrior in your book to lunch and hire her so I never have to think about any of this again. When do you suggest people get an outsider involved? ‍

Allen: If it’s a complicated hospital stay, or really expensive, or life or death insurance company denial, you may need to bring in a patient advocate. I have very high regard for patient advocates. You may have to pay them a fee but they are worth their weight in gold because they can maybe get your care improved, or your bill covered. You have to be able to afford it, though.  

NPLB: Our Out-of-Pocket Report did a story on Go Fund Me as America’s national healthcare system and we are currently looking into debt collectors. So many Americans owe so much. Again, the tips you have about having people ask for the paper trail of debt: perfect. But how do we make people actually do this when confrontation goes against so many people’s instincts?‍

Allen: Again, how do you teach motivation? People have to be motivated already. They have to be at that point where they are willing to learn a new skill or take on an administrative challenge. I have a template in the book but they still have to fill it out and send it certified mail. This is not convenient. It can be a hassle. That’s why in the beginning of the book I tried to show how this is their money and if they follow these steps they can save money with every healthcare interaction.  

NPLB: If, as you write, this isn’t an error but in fact the healthcare system and health insurance industry were built this way, what do we do to unbuild them and then rebuild them to our better advantage and satisfaction?‍

Allen: Employers need to start getting engaged and using the leverage they have. That would be transformative. I have eight chapters for individuals, three for companies. I hope people will go to their board, CFO, CEO, and ask, ‘What are you doing to address this problem because my compensation is being sucked out of my paycheck and my wallet because of this healthcare system?’ I am hoping the employees will motivate the employers to change. So far employers have been sitting on the sideline. They haven’t done things to be disruptive but they could.

NPLB: My teenager is having surgery this week, and I have to admit reading your book right beforehand made me nervous. I am better than most at this, but suddenly I’m worried about looming surprise expenses. How could I have better prepared for this? ‍

Allen: First thing, and you may already have done this, always make sure whatever is being done is necessary. Sometimes doctors are paid when they do stuff, so sometimes they do stuff whether the patient actually needs it or not. When it’s discretionary or they’re recommending something you aren’t sure you need, it’s important to get a second opinion.. The one question I tell people to ask is: ‘What will happen if we do nothing? Am I going to infect someone, am I going to die?’ Reframe it. Let’s not assume we are going to do it, let’s assume we are not going to. Sometimes watchful waiting is a good thing. You can save money that way, too.‍

Lynda Gorov is executive editor of No Patient Left Behind.‍

Allen: First thing, and you may already have done this, always make sure whatever is being done is necessary. Sometimes doctors are paid when they do stuff, so sometimes they do stuff whether the patient actually needs it or not. When it’s discretionary or they’re recommending something you aren’t sure you need, it’s important to get a second opinion.. The one question I tell people to ask is: ‘What will happen if we do nothing? Am I going to infect someone, am I going to die?’ Reframe it. Let’s not assume we are going to do it, let’s assume we are not going to. Sometimes watchful waiting is a good thing. You can save money that way, too.

NPLB: Is there one story that sticks out as the most egregious? 

Allen: There are too many stories. I have read a lot of good books on healthcare and they are chock full of anecdotes. The most important words in my title are ‘and win.’ That’s what I’m really focused on. That’s why I love hearing these victory stories from patients and employers. Sadly this is such a persistent problem. I talk to people about this and every person has a story about how they have been ripped off by the healthcare system.

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