High Costs of Healthcare: Know When to Take Charge of Your Diagnostic Options

This is part three in Casey Hersch’s articles series about how to defeat chronic illness. Part one was Using Integrative Approaches for Living with Chronic Illness. Part two was Integrative Healing & Becoming An Empowered Patient. 

If you live with a chronic illness or have landed in the Emergency Room, then you know imaging studies and diagnostics are expensive. As a patient who lives with Crohn’s disease — an autoimmune, inflammatory bowel disease — I am very familiar with medical debt. I am also familiar with other stresses associated with diagnostics: excessive testing, reactions to radiation and contrast agents, and generally feeling overwhelmed by my insurance and healthcare system.

Recently, I discovered that for people who rarely use medical services, navigating the system can still be daunting. As I watched my husband agonize in pain late one evening, I took immediate action. However, this one trip to the Emergency Room for kidney stones left our family with a $5,000 bill. Feeling vulnerable and scared, my husband and I understandably trusted and relied upon the on-call physicians to make decisions on his behalf.

While the medical staff compassionately tended to his needs, they also performed numerous scans, even repeating to confirm and then reconfirm what prior scans already showed. We left the Emergency Room exhausted, in debt and with merely an over-the-counter prescription in hand. I could have walked across the street to CVS, bought the same OTC pain medication and saved $4,995.

Inflation is affecting every industry; hospital costs are no exception. Now more than ever, all of us are vulnerable to medical debt and associated healthcare stress. When we are scared or desperate to find answers, we are naturally placed in a vulnerable position and at the mercy of our educated physicians.

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However, all too often, we accept our doctor’s recommendations without question. This passive approach is loaded with consequences when patients accept procedures without knowing the financial, physical and emotional costs. Now is the time to educate ourselves and understand how to navigate the complicated healthcare options.

Many of us learn our lessons after the fact just like I learned from my husband’s unpredictable trip to the ER.  Preventing unpleasant surprises always reduces stress. One of the best ways to cope with unpredictable healthcare stress is to practice your right to self-advocate. When we feel empowered over our health plan and choices, this eases the financial blows and also places power back in our control.

After all, it is your body.

Know Your Insurance Policy

When you receive services in the Emergency Room, staff do not consider if the patient can afford prescribed procedures. They do not consider if you have insurance or not. Their job is strictly to follow protocols and ensure safety.

While this is a noble effort, there are times when doctors perform too many scans, even unnecessary scans, which place burdens on patients’ finances and even patients’ bodies when they are exposed to radiation and contrast agents. It is up to you to understand your needs and your insurance policy.

1. High-Deductible Insurance Plans

To avoid high-insurance premiums, many consumers choose high-deductible plans such as Covered California’s Bronze plan — especially self-employed individuals who may not have the option to participate in a group employer-provided plan. Obamacare greatly eased some of my stress because finally I qualified for insurance regardless of my pre-existing conditions.

However, these plans still have many loopholes and regardless, these plans are still too expensive. High-deductible plans may be tolerable, but this sentiment changes quickly once you use them for imaging or an ER visit. Until you meet your full deductible, you pay everything out of pocket. One visit to the ER, or an MRI and CT scan, can leave you financially depleted.

While patients have the right to file grievances and appeals disputing charges on their outrageous medical bills, the response from these healthcare institutions is often the same: Until you meet your deductible, you will have to make payments until the balance is paid in full. If you fail to make payments, then you receive a daunting letter in the mail threatening that you will be reported to a collection agency.

The best solution is to know your rights and to be prepared for how to respond to unexpected medical needs.

2. Urgent Care Option and the Advice Nurse

Unless you are in a life-threatening situation, before you head to the ER, be aware that you have other after-hour alternatives. For example, calling your insurance plan’s Advice Nurse Telephone number is a good first step. These nurses can help you triage your symptoms and let you know if the ER is unavoidable.

Always know your urgent care options and their hours. In my husband’s situation, he could have gone to the local urgent care, which is open until midnight. This would have saved us thousands of dollars and hours of waiting in the parking lot before he was seen by ER staff. Urgent care visits are markedly less expensive than a trip to the ER, and their physicians are qualified to tell you if you still need emergency services.

3. Document Conversations with Insurance

Sadly, there are too many loopholes involved with health insurance companies these days. Even if you think you know your benefits, take that extra step to contact your health insurance plan’s benefit services before you schedule a procedure. The purpose of this vigilance is documentation, documentation, documentation.

Let your insurance provider know the procedure you are planning and make sure they explain to you and confirm your understanding of your benefits and out-of-pocket responsibilities. If you find out your insurance will not cover your procedure, you still have time to make changes before the debt follows.  Always document these conversations by asking the insurance representative for a reference number. Keep this number.

In the event that you are incorrectly billed, you can refer to this number. Sometimes, insurance representatives will improperly relay your policy benefits to you, and if you make a decision to proceed with a medical intervention based on this incorrect information, you have recourse when you get an unexpected bill. Appeals processes are always an option, first with the insurance company, and second with the Department of Managed Healthcare. Your documentation will serve you well.

4. Ensure Your Primary Physician Is Designated

Always be sure that your chosen primary care physician is known and documented as such by your insurance provider. If you have a policy that requires a designated primary care physician, do not assume the clinic office staff are fully informed. It is up to you to make sure your insurance company has the correct physician listed. If this information is not correct, then you may be surprised when you get bills due to referrals coming from a physician other than who is listed in your insurance records.

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How to Self-Advocate

1. Advocate for Your Medical Needs

Most scans (CT and MRI) are ordered with contrast. This means the doctor injects you with or asks you to drink a substance that reportedly makes the scan more “high definition” and easier to distinguish abnormalities. Physicians order diagnostics thousands of times throughout their careers. Needless to say, they rarely give their patients options. Patients erroneously assume it is the “doctor’s way or the highway.”

The option to use contrast is actually the patient’s choice. You can decline contrast if you feel it is not in your best interests. But expect some resistance from the physician and their office staff. When patients request a deviation from protocol, this behavior usually causes reactions. Healthcare institutions thrive on people following standardized procedures. However, you are not “standard.” You are your own unique person with unique needs. Remember this and make decisions accordingly.

My personal preference is not to use contrast, injected or orally. I have miserable reactions to these substances. However, my physician and insurance company often insist that I am not getting a clear picture of my body unless I use contrast. I have weighed the pros and cons, and I still chose to decline contrast.

After finally finding a radiologist who is a perfect fit for my needs, we customized a unique plan to help me get the best pictures of my body during the MRI enterography. Turns out, there are alternative approaches that serve as natural contrast agents and can enhance the imaging. Had I not explored these options and also insisted that I speak to and collaborate with the radiologist to accommodate my unique needs, I would have felt as though no options existed.

Always advocate for what your body needs and never subject yourself to procedures that you know worsen your symptoms just because a professional insists these are the only options. Even when your doctor implies that they know more than you do, remember no one knows more about your body than you. Once you open the right door, alternative options usually appear.

2. Shop Around for Better Deals

Your doctor has a routine: They order scans all day and typically refer their patients to the same facility for scans regardless of how much the facility charges. There are significant price differences between hospitals, clinics and imaging centers. Recently I was quoted $1500, out of pocket, for a CT of my abdomen at the hospital’s radiology center where my physician referred me.

To my surprise, the same procedure at my local imaging center costs just under $400. When I realized this information, I contacted my insurance company and confirmed that the alternative imaging center is indeed in their network. I then contacted my primary care physician and requested that they send my order for the CT to the location of my choice: the much more affordable center.

Did you know that you can choose a cash pay option at some diagnostic centers? Cash pay means you choose not to have your procedure billed through your insurance; instead, you write a check or pay with a credit card for services. While the cash paid amount will not apply to your insurance deductible, your out-of-pocket burden can be reduced by as much as 50 percent in some cases just for choosing cash pay.

When I learned about this option, I felt financially freed from the chains of my insurance provider. Since I rarely meet my deductible because most of my medical needs are integrative and holistic (not covered by insurance), paying cash for my diagnostics has freed up money for me to use on other medical needs that I must pay for out-of-pocket. This cash option is not for everyone, but certainly knowing you have choices allows you to make choices that are best for you!

3. Healthcare Is a For-Profit Business

Even though your physician is an important relationship in your life, they cannot always have your best interests at heart. They also have competing pressures to meet referral quotas, keep business internal, receive financial incentives, recommend trending pharmaceuticals and ultimately to make a profit for their company. Sometimes they insist you must go through the chain of tests before you can get to the test you really need.

For example, before you can get the CT scan, you may be asked to have multiple X-rays that prove you actually have medical necessity for a CT. This process costs you money and even more radiation exposure. Knowing how the system works allows you to question the process and make decisions that suite your health needs. Be informed and ask questions. When in doubt, as long as you aren’t facing a life-threatening situation, it is okay to hold off, think about your decision, even cancel/postpone a procedure until you have enough information to feel comfortable and proceed.

While you are your own best advocate, even if you end up in the Emergency Room, make sure you have a friend or loved one present and prepared to advocate for your needs. Have appropriate legal paperwork completed so that your preferences are heard and protected. Our medical institutions serve an important place in our lives, but it is up to you to ensure they work for you, not the other way around.

Stay tuned for my next article about these integrative approaches that can help defeat chronic illness.

Casey Hersch, MSW, LCSW, is a licensed clinical social worker, author, and founder of www.lightyoursparkle.life. She specializes in integrative treatment models for chronic illness. Inspired by her own struggles with autoimmune illnesses and trauma, she educates about empowerment and how to build individualized healing plans.