#278 | Inside Medical Billing: The Complexities, Ethical Concerns and Tips for Reducing Your Bill

Always ask for your itemized bill. And if you see something that makes no sense, ask for your medical record, so that you've got something to say when you call billing now and say, I got charged for this, this, this, and I looked at my records, they didn't do it. I don't see where it's supported, that type of thing. And usually they will start taking off some of those charges, and they will say, you can say, I can't afford this. Now, they have a lot of programs too, that if you can't afford it, ask, because you could get put in some programs based upon your income, where they lower it or completely take it off. But you gotta ask.

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

All right. Sue Chamberlain from Cincinnati, Ohio. Thank you so much for joining us on down to birth show today. Trisha and I have never done an episode like this before, and we're really excited about it. We posted women's stories and anecdotes in april 2024 on our Instagram stories, and we do have all those in a highlight right now of pretty outrageous things they were billed for, and one of our followers said, Oh, you need to speak to my mother. She works in this field. So thank you for coming on the show and welcome - my pleasure. Thank you for having me.

So it's our understanding you have served as Director of revenue cycle. I just love that the word revenue is just right out there. Let's remind everyone this is a corporate system in the United States, yes, which oversees hospital billing. And one of the reasons this conversation is so salient is that it gets really the emotions riled in the United States, because this is a lifestyle for all of us, but our our international followers, those who are outside of the US, are just flabbergasted at the things we're billed for over here. They just they really can't even believe how it's all run Absolutely So just before we get into answering some of our listeners questions, I just want to share just a few of the things that women have found on their hospital bills, multiple women reported that they were being charged for skin to skin contact. You've heard of that, right? Absolutely, okay. This one was a kicker. Labor without anesthesia. Labor without anesthesia. What the heck is that all about? The absence of doing something, the absence of using something. How does that incur any fee for the hospital? Do you have a can you have their explanation for that before we go on with the list?

I can do you want me to give it to you quick now? Yeah, give it to us quick now. Okay, so basically, what you're looking at is they're putting charges in. So that staff that has to put charges in. Can have a description that makes sense to them. There's going to be also a code for labor with anesthesia that's going to be more money. This one is labor without anesthesia, which is still for the nursing care, and if the physician care and that type of stuff is needed, but without the anesthetic, add on code without the anesthesiologist. So it's still that labor charge, but there's they're differentiating the whether or not you wanted anesthesia or not. Now it's usually going to be less because you don't have the anesthetic cost, but sometimes it could be more nursing time, but usually that's going to mean a little bit less, but still charging for the labor. So there won't be a redundant there shouldn't be a redundant item that also says labor and delivery somewhere. This should be the one and only one correct, but it could be a subcategory, depending how it's put in. So, and we can go into a lot of detail about that, but basically it's going to come down to what is actually the charging code, so they want to keep track of by department, even what the charges are, what, how many staff hours are needed, all the things that's going on. But what goes to the insurance company is a code that everybody in the United States uses. So. That has $1 amount assigned to it by the individual hospital. So sometimes they put funky things in that are only specific to that hospital. So when I answer some of these questions, it's going to be in general, you're going to see some weird things. This is what I want you to do to look at it, and part of it's going to be kind of reading between the lines and looking at that whole bill and looking for an actual what you should see is a code that's either a CPT or a DRG. You're looking for something that says, This is how much is being charged.

So the CPT in the diagnosis codes are two different things. The CPT code is the actual code that gets reimbursed for $1 amount. And you can have to have certain diagnoses in order to achieve a level of a CPT code. So if you're billing for a higher service, you have to have justification that the diagnosis that the person is receiving justifies a higher level of care --

correct, and not only the diagnosis, but the documentation to support it, which is the other thing. So let me go really high. So basically, what happens the patient comes in, they're registered, and as soon as they're registered, people start adding services by each department for what was done. So there's a reason why a lot of people say, just tell me how much it's going to cost for me to deliver my baby. Well, nobody can really do that because it depends. Are you going to have a normal delivery, or are you going to possibly tear or are you going to have issues? We have to do an emergency C section versus versus the vaginal, uncomplicated birth, that type of thing. So in talking before I gave the example, in my case, I gave birth with one contraction of my son. I shot that nine pound, 12 ounce baby out really, really fast. So really, this should be a birth story episode,

because remarkable, it was coded as an expedited instead of a normal. So there was an additional charge, because he came out fast. Oh, come on, versus Yes, because it was more of a complicated Now, part of the complication was his face was very bruised, and, you know, there were some issues that they had to check him out because of that. But yeah, it took it from a natural birth to a complicated birth by putting that expedited on there.

Do you buy that Sue? Um, not really, because it's still less charges, but the problem is, is that you still have to take what the codes are, and it goes to a DRG. Now the expedited Okay, so let me take it a little bit more. So once all those things happen, all those services are put in, and they're going to put in the Tylenol that you were given, because they have to show that it was given by this department. But it's not going to have a code assigned to it. It's going to be included. Now, if the person becomes impatient, which is what most births are, they end up versus observation. So observation, you come in, you go into labor, the labor slows down your set home. That's observation. Everything's going to be coded with what we call CPT code. It's an outpatient code. Come back in and now you deliver. Now they're going to code it with a different coding system, and it turns into one charge, DRG. Now you can have multiple different types of deliveries that all go to the same DRG that DRG then is sent to the insurance company, and the insurance company decides what they're going to pay for just that DRG. You have a different DRG for a C section. You have a different DRG for a complicated delivery. So everything's a little bit different, and it's just extremely complicated in the United States on how they do the billing. So to go to skin on skin as an example, the only time you should see where anybody charges for that skin on skin time should be if you have to have extra nursing there. So for an example, the one that you sent was skin on skin after C section after C section. A lot of times, women are very unstable. They they're shaking. They have IVs in their arms. Their arms are out to the side. And if they want to do that, skin on skin while they're still sewing them up, they're doing all that kind of stuff, they have to have nursing staff there, additional nursing staff there to help them with that.

Okay, but we did hear from one woman whose husband did skin on skin, and they got that line item on their bill. That's where you want to look at the documentation, because what happens is, you get a person in the department, they start looking through all the charges. They can click on and they're going to click on that that's not justified unless you have additional documentation to support the need.

So can you explain what a DRG is? Absolutely.

So a DRG stands for diagnostic related groups. So they take diagnoses that are related and they put them all together to be in one DRG, it's only for inpatients. So for example, if you come in and end up having a totally normal vaginal birth, it's one DRG, it's a number. If you end up having a C section, it goes to another, a different number, and within each one of those groups. So say you have just a normal C section. It's a Plan C section. It might be DRG, and I don't know it off the top of my head, so I'm going to say 123, now, if you had a C section, but it was an emergency C section, and they had to do fast anesthesia, they had to do all kinds of stuff. It's a complicated so it's a DRG with a complicated condition. It's going to go to a higher DRG, which is more payment. Let's go through some of the other things on the list. So the next one was that a woman said she was charged for quote labor, and it was only 30 minutes from her arrival till the baby was born. Do you think that is one of those situations where it theoretically should have said labor without anesthesia? I mean, it doesn't make sense to have a line item that just says labor.

So this comes back to the each hospital will put a description in there that makes sense to the department to grab. All right. So that may be different per hospital, and that's the description that's on there, whereas another hospital has the labor with anesthesia or without anesthesia, or whatever data they may want to be coming to but it should still be the same overall code for both of those. Oh, I understand the line. They might have used a different descriptor, but it should be the same code as the hospital that says, let's say labor without anesthesia. This one I really take very great issue with, and I'm curious to hear what you say. And I've heard this before from clients of mine. This couple was charged for counseling because they declined vitamin K, and the hospital started ushering in people to try to change their mind. I take issue with this, first of all, because they have the right to decline it. But second, they didn't ask for such counseling. They're really just being coerced and pressured into something they don't want. And then, on top of it, to add insult to injury, to pressure, to coercion, they're billed for that. I think that's really extremely unethical on many levels. What's your explanation for that?

So the explanation of why they do it is because doctors bring in consultants and nurses bring in consultants as a regular thing. It's just kind of their habit. Do they need to? Should they absolutely not what they're trying to justify? And I agree with you. I have a problem with that. What they're trying to justify is they're trying to cover their bases, but they're justifying it by bringing in somebody else, because a consultant charge actually is an additional charge that pays more.

It's an additional charge that they could charge for absolutely now, it may be included with some payers, but other payers, it's a line item that they're going to charge separate, especially if you're self pay. So again, if your self pay or your insurance company doesn't cover that, I would be calling and saying, I did not request this, and look at the medical records to see why they even did it. So a lot of times, there's arguments for I did not ask for this person to come in. I should not be charged for that service. Now, the doctors are going to come back and go, Yeah, but I wanted you to talk to them. You know, that's something that's not you weren't asking the doctor question. The doctor brought in a consultant to talk about it, or the doctor didn't see a problem and decide she wanted to bring somebody else in to talk to you about it.

It's not uncommon to hear stories of what appears to be a hospital or doctor sticking it to a woman. Just yesterday, I heard, not for the first time in my work experience, a woman who switched providers and in her final conversation with the provider because she was opting for a home birth or a different kind of birth, got this new bill. In this case, it was $2,000 highest I've ever heard of to date, where the insurance wouldn't cover it. It was the doctor just saying, Oh yeah, well, I'm billing you for the counseling of our last conversation when you told me you were leaving me, it's like, well, you know what note to self, I'm not going to be doing the breakup with you anymore. I'm not going to have the you know, conversation about why I'm leaving you. I'm just not going to show up again to my net, you know, my 32 week prenatal or whatever it is, I find it very passive aggressive, and it certainly appears here, I think, to any rational person, that because they can't bill for the vitamin K, it looks like they're finding a workaround. But even if they have the best intentions, I think an ethical person would still be able to argue this woman did not ask for counseling. She did not ask for that like you just said she didn't ask for it, right?

If she went in for her normal office visit and then said, I'm not coming to you anymore. Yeah? It's not a that is not counseling? Yeah, right, that could happen. Able to justify that, that is an office visit that's included in the full prenatal and wouldn't counseling have to be a separate person coming in a consultation with another provider, or the purpose of the visit was a consultation. You can't have an office visit and a consultation in the same so it's a difference between Counseling and Consultation. So a physician can go into a counseling mode where they're talking to you about all your options, blah, blah, blah, blah, blah, and that can take over the where they're doing the full exam. And that is just absolutely unbelievable. I mean, come on, this is what they're saying, that the physician can, like, put on this counselor hat, this invisible hat, by the way, that nobody sees but in their mind, I'm putting on my counseling hat, and now I'm billing you differently, a special billing item that your insurance may not even pay for because I'm wearing my invisible counseling hat. I mean, what professional doesn't have counseling included in their some kind of counseling or advising included in their work well, and here's where I'll throw out sometimes it it makes sense. So for example, I would have some physicians going over to counseling and and along that way, if, say, an elderly mother brought in her child, elderly could be too but that they were asking a lot of questions about what care they should have for their mom, and they end up talking to them for an hour and a half because the daughter is asking a lot of questions, and they're trying to determine what care that person needs. That makes sense, that that may go from a normal visit to now we're going to be in a counseling visit, but in this particular case, and again, this is where I'd say, get the medical records and look to see what the records say, because technically, that patient should be asking for advice, and if that patient is not asking for advice, just going in for their normal prenatal, and the doctor decides they're going to say why I'm The best. And you should stay with me. That's not a billable service. That's absolutely not, and I would fight it.

So Sue. One of the biggest things that happens in billing in prenatal care and obstetric care is the excess charges that are added on for a woman who has a C section. Now, we've heard from some sources that fees are flat, global fees. There's a, you know, there's a global fee for prenatal care, which includes the labor and delivery, and then there's like, a global fee for a C section birth. Can you explain? Do you is there enough of a money incentive difference between a vaginal birth and a cesarean birth for that to sometimes be a motivating factor in the decision making process. The truth is, I had doctors that didn't want to stick around and wait for the woman to fully labor, so they just took them in to do the C section. And there were all kinds of things put in place to try to make it so that it wasn't a huge difference, because they didn't want to have the financial incentive, but there was still a convenience incentive for the providers that they were trying to take away. And I will tell you, I had a provider who said, because we had to go back to him and say, what's the justification for the C section? There's nothing in the record. He said, I had a tea time stories like that. Yes. So the difference in the financial reimbursement may not be that significant between a vaginal birth and a cesarean. However, when a woman has a cesarean, you may have additional nursing time, the skin to skin charges, the anesthesia charges, potential NICU charges, those are all ways in which a surgical birth can bring up the bills significantly. I mean, we've seen mothers reported to us. They've showed us their vaginal vaginal birth bills, which are, you know, maybe 10 to 15,000 and then some cesarean births that exceed 30,000 as soon as you go into a surgical an operating room, your charges automatically go up, and there's actually a room charge that's kind of set, so you're absolutely going to have that, the big question. So what they've done over the years of my career, so I've been doing this for over 30 years. They started putting a lot of quality indicators out there, though, so if a hospital has too many C sections. They're they're looking at that hospital and looking for justification. It raises a lot of red flags of, why are you doing this? The other part I will throw out to play devil's advocate is there were so, so so many lawsuits against OB gyns for a while there.

It's very common in. Obstetric world, the saying that you will never be sued for the C section that you did perform, you will only ever be sued for the one that you didn't. So that is the liability incentive. All right, let's ask you some of the questions that women submitted to us through Instagram in preparation for this episode, and see see what advice you might have for us just, I'm sure you understand this Sue well, did you speak to patients much when they had billing complaints? Or were you just way too many levels above that and overseeing everything the really complicated cases that weren't black and white all came to me that were usually the weird ones.

I just think it's worth acknowledging that this is a sort, first of all, it's the top reason for bankruptcy in the United States, but it is an incredible source of anxiety. You're going somewhere and you don't know they're, they're recommending things, or they're pushing things, and they're, they're telling you to do things under this no questions asked, vibe, but you have no idea what the bill will be for. I had an MRI years ago, when my son was little. I did an MRI, and it was $1,000 and my insurance paid for 80% and I remember thinking, Oh my gosh. I What is this like for people don't have insurance? The doctor wanted a follow up exactly three months later, I went exactly three months later, and I did a follow up, and the bill was $5,000 and my 80% covered 4000 and I paid 1000 out of pocket. Yep, they just changed their price, yep. And I thought that, like first of all, again, what the kind of anxiety people have when they don't have insurance, but even when they do the whole thing that then now it's up to the insurance company whether they will pay for it. So I just, I just think it's, I think at a minimum, it's not our culture, and it'll never happen, but they should say, This is what I recommend. This is the charge for it, and this is, we don't know whether your insurance will cover, but this is the amount that's going to show up on the bill. I can't believe we have any industry in this country where that isn't happening, correct, 10s of 1000s of dollars, in many cases, right?

So one of the things that has been pushed in the last about 10 years, but nobody's been able to get it figured out completely, is they expect hospitals to put what services they can on their website with the probable cost for it so people can compare. Now, as I said, the problem is you go in and expect a normal delivery, and then suddenly it switches over to something else, and then there's complications with the baby, and now the baby has their own bill. Yeah, all of that going on, it's not included in the delivery.

But why weren't you surprised when I said three months later, the price had just changed from 1000 to 5000 How come you just said, Yep. Is it that arbitrary? I know Stephen Brill wrote a fabulous book on this bitter little pill, but he says it's arbitrary. They can really just put any price they want in there. Do they absolutely can. What they will do is they will review all the prices at least once a year. But usually it's more than that, and somebody goes in and looks at what all the payers pay. So they're going to look at what Blue Cross, what Aetna, what everybody else pays for this particular service. And in my career, they take the top payer, which may be including other services and stuff, but say that Medicaid pays $20 but the top payer pays $2,000 for the same service, and unfortunately, that is not an unlikely scenario. Then what the hospital does is they chart put the charge on there. And in my career, it's been 140% to 180% of that top charge.

So now wait a minute, that's over. That's over the top charge. That's $2,800 140% that they will put that much. What about the Medicare patient? Would they just accept the $20 they'll bill for overseas we have, they have to accept reimbursement at the rate that the insurance company that they have the contract with your MRI Could your the person who performed the MRI could charge $5,000 and the insurance can pay $75 and they cannot charge you for the difference. Charge they have a difference.

I had to pay the 20% difference. So, so that's a difference between your deductible, your co pay, and the contract that they have. So so the contracts that in the in and I will say 1015, years ago, the hospital could bill the patient for what the insurance company didn't pay. Now they don't do that. Now this was about, this was about 16 to 18 years ago, okay, so you would have gotten paid billed by the hospital for what your insurance company didn't pay. Now they set up the contracts, because what happened is the patients called the insurance company and come to. Explained, why aren't you paying this? Because my doctor said I needed it, so the insurance companies put in the contract that you can't build the patients anymore from for what's left over, other than your deductibles and your co pays.

Was that the 2012 Affordable Care Act at play that kind of but no, it was mostly the insurance companies who didn't want patients complaining to them. So they make their own individual contracts with the hospital. So they will. So in the case of the MRI, they may say, we'll pay the one insurance company said we'll pay $2,000 so because the the hospitals now going to make that that charge is 100 and say 150% more. So now if you're a private pay patient, you're going to be charged 5000 for that same service that they're going to accept, 2000 from this payer and $75 from this other payer.

Okay, this leads me to one of the questions women asked our self, pay patients, build less. It sounds like you're saying they're billed more because they cast this they cast this wide net. They intentionally charge more than the top top payer so they don't miss out on a penny of potentiality, on what they can collect correct that's exactly why they do it. And then the sound of them, and then the self pay. Patients who don't have insurance are stuck with those outrageous high bills.

Yes and no, they're going to get they're going to get sent that bill. Now, a lot of hospitals, because they realize how ridiculous it is, and more importantly, it's a PR issue, because some of those patients will go and say, Look at this. This is how much as a private patient, private pay patient, I'm getting charged for it. So some hospitals will automatically do a charge down. It's going to be way more than what they accept from Medicaid, but it will be, it'll be in the top end of what they would accept from a lot of their payers, or slightly more. But if they don't do that, I'm telling your entire audience. You call them and ask them to make adjustments, they will make adjustments if you ask 99% of the time if they don't push it to somebody else and ask for an appeal to that.

So let's talk about why do medical facilities and hospitals do this? Is it because they are just greedy, or is it because insurance pays crappy reimbursements, or is it because they both or, or in, what you know, in how, like, unethical, is it really, I mean, is that? Is that the argument that this is really unethical, what's going on? So the one thing is, remember that there's two different kinds of hospital systems. There's the not for profit. So any profit it's made, it's not going to any individuals. There's no investors. All the money that's made for that hospital is going back to the hospital to service the community, and those hospitals still need to get every penny they can possibly get, because if you don't get payment, and you don't get the money coming in, you can't buy the more advanced equipment, you can't hire the more elite providers, all of that kind of stuff. Now, when I started, that's all most hospitals were, and it was all about treating the patient, and you do whatever you can, but it's become more of a business and more of a we can't have this many people in this department. We need to have fewer billers. We need to have fewer coders. We need to have make it work well. The only way you can do that is to make it be the same all the way across and do things as quick and easy as possible.

I want to comment on this because I personally am not aware of any of these small non profit hospitals, maybe because I live in the New York metropolitan area. They're all corporate conglomerates. And I want the listener to know I have mentioned this on occasion over the years on the podcast, but it's definitely worth mentioning in this episode that you must not be fooled by the.org these are still corporate conglomerates, and the only reason there is any sliver of arguing that they are nonprofits is that in the in around 1987 hospital the hospital pharmaceutical lobby appealed to Ronald Reagan's Congress, and they agreed to stop requiring hospital systems to pay federal income tax, Which in the 80s was between 45 and 51% so it was a major financial win, and that's when the conflicts of interest really started to skyrocket. That just so happens to be the safest year it was ever to give birth. Birth, maternal mortality rates really started to skyrocket after that terrible legislation. So we must not be fooled by the. Dot org, if you're listening to this episode and you're thinking, Oh, hopefully my hospital is one of those nonprofits. It almost definitely isn't. And there's really no way to know by their website domain. How would a woman know if her hospital is, in fact, a nonprofit? Because I should mention that was the only criterion that they applied to it, they said you don't have to pay federal income tax anymore, but you can have multi million dollar salaries at the high level. You can have multi million dollar advertising budgets, and you're nodding and nodding because you know all this. How would someone know if she actually is at a nonprofit hospital and not that we're recommending that or not? But it's just such an interesting dichotomy in this country. Hello, and there's, we'll add to that is that's where it kind of split off to the not not for profit. But as time has gone on, even the the not for profit hospitals have become more of a business. So you almost have now where you still have that business that we need to get this much money, we need to get as much as we can, versus the for profit that are trying to send money back to investors and that kind of stuff. So, I mean, you can look to see if there's investors within the organization or not, but it's the same thing. As you said, we got CEOs coming into hospital systems that they're all about cutting and they get paid multi million dollar income, and they're all about cutting staff, which then you have nurses going on strike because you have such low patient to nursing ratios.

Because what's happening is even the nonprofits are now following the for profit model, correct.

Okay. Is this driven by the hospitals trying to go for the highest profit possible, or is this in part because insurance companies make it really difficult to get paid? Well, insurance companies, to me, in my experience, the biggest problem is the insurance companies. That's what I was so you have the for profit, but the the hospitals now, even the not for profit, have to try to keep they have to keep up with the best technology, the best whatever. But what the insurance companies are reimbursing, and this is the part that just flabbergast me, what the companies now the insurance companies are reimbursing compared to even 510 years ago, is way less. Okay, Medicare has gone up in some areas, but in other areas, even Medicare and Medicaid is paying less, because, again, most Medicare is controlled by for profit insurance companies that have a contract with Medicare, so they're paying less and less, they're denying more and more, but yet, the amount of money people are paying for their insurance benefits every month is still going up.

So my personal, my personal belief on this is that the insurance companies are the greedy party here, and they make it very difficult for providers and even the larger institutions to provide good care, because they have to become profit driven, because they barely get reimbursed, and insurance companies they they randomly just deny claims. Correct. If they receive 100 claims, they will randomly just deny five of them or lose them, or whatever. And so it's part of their system. I think that the insurance companies are the most devious part of this whole process. And they make, they make the most money, and remember that they are for profits. So I worked for a short time for a payer. It was, it was a HMO. And I will tell you, I sat in on meetings where they literally said that this particular thing, even though we know it should be paid 80% of the time, 20% of it, it shouldn't, so just go ahead and deny all of them, and we'll pay Dr A, because Dr a appeals all the time, so just put in the system to go ahead and pay Dr A, but everybody else gets an automatic denial. And for years, what hospital systems did is they accepted the denial. Now you have to have staff, more staff, going back trying to fight the insurance companies because they denied stuff for absolutely no reason. But you also have people that are asking. So for example, I've had people in the office. We had a person that had hemorrhoids. As an example, they had hemorrhoids and they were going to go in and get them ligated, very basic, but what they did was call for pre approval for an anal for an anal lesion, and when I said, but that's not what it was. It was hemorrhoids, they said, Well, yeah, but we don't get paid for hemorrhoids. So we told them we're going to do this. Well, the documentation doesn't support. That. So that's a devil's advocate, but there is a lot of fraud out there as well. Yeah, people all trying to play the system. All right, let me ask. Let me tell you one more anecdote from a woman, and then let's ask you some questions that our listeners wanted us to ask you. Okay, so let me hear what you say about this Sue. A couple of women wrote to us. So numerous women, two or three women, at least, wrote to us, and they said, baby was born in the car. Hospital charged us for quote, out of hospital birth. Please explain that one to me.

So there's actually code for hospital out of hospital birth, because they still have to check out the mom, check out the baby. Well, then charge for checking out the mom and baby. Why don't they just charge for the postpartum care? Why should there be a line item for something that didn't happen?

It's, it's not it shouldn't be the same amount as doing a full birth.

It shouldn't be, well, sometimes they still have to deliver the afterbirth. Sometimes they're, you know, baby's out, but the baby's still stuck on the umbilical or, you know, they may also have to do suturing well, that they should bill for what they have to do is all I'm saying, right? And I'm going to say, though, a lot of that comes down to the title again, versus what they actually did. So look at the documentation.

Okay, here are some quick questions we had that we didn't already cover in this discussion. Do you think competition is a factor? This woman says there's just one NICU in her entire area, and it charges 10,000 daily, and she thinks that's because they have a monopoly in the area. I think that sounds certainly likely. What's your opinion, or what's your knowledge about that?

Absolutely, you have a lot of places that will have a specialized like, if you have a child, a children's hospital, all the babies go there, yeah? So they've got a monopoly, so they're taking advantage of the monopoly that they have. Okay? Will insurance pay if I leave against medical advice.

It depends. It depends why you're leaving, what was covered. That's going to be one of those cases where I guarantee you, the insurance property is probably going to ask for the medical records.

Yeah, I researched that myself over the years, and it did. It was, it was a sort of that depends, like this insurance company does about 95% of the time. It's frightening for someone to be in the hospital and not to be able to leave. We have this from a lot of our NICU followers, babies in the NICU, and I swear, countless of these couples say I could not get my baby out. They said it would be two days, and we were like having panic attacks five, six days later, baby seemed perfect, and they just wouldn't let that baby go. How do you grab your baby and run and then have this threat? Well, then none of this will be paid for. Yeah, and that's if that's even a remote possibility that's financially devastating to a family. They could lose their house over such a thing, absolutely and there, what higher stress is there in the world than not having your baby and having this looming possibility so unethical? This whole system just needs an overhaul. So, and I would say, if you're in that situation, definitely talk to billing, because it's possible that it will be a DRG, and so two days will be the same amount of money as six days. So you want to talk to the billing department if that is occurring, because it depends upon what's going on with that child. Because we have had cases that I've been involved in where they bring in Child Protective Services when people want to take the baby home, and so you got to be careful of that too. Okay, but did you ever see CPS actually successfully remove a baby for any of these normal reasons, like parents not wanting to do a vitamin K shot, we see a lot of threats. You've never seen.

I'm talking about NICU, where the patient, the parents, want to take the baby, but the baby's on a respirator. But did you ever see the C What did you see CPS do in the most extreme case, they just came in and talked to the patient and with social work to explain, I'm sorry, the parents to explain why, in detail, they need to still be there. And then they even brought billing in because it was that reason that they wanted to okay, what's the best way to get to make sure the bill is accurate and to get the bill down? We had one woman share with us that she called to get the bill down, and this wonderful human being on the other end of the phone, and the billing department said, Listen, let us send you three bills. Don't pay anything. Then call to negotiate after we've sent you three, which gives her, which actually gives the patient leverage, because now the hospital is afraid they go, they're going to have to send it off to collections. Then she got it reduced by 40% so can you corroborate any of this, or have any advice so it's going to be a different policy by hospital? So when that one person said that it's not going to be beneficial in another hospital, now, remember how it's going to go into effect? We don't know, but where. Health care cannot be used against you on your credit score. So that will be hopefully beneficial with with for a lot of people like this. But yes, you absolutely can call billing negotiate. Not everybody's going to tell you that was something that that person could have probably gotten fired for in some hospitals for saying, but there is, they will negotiate with you. But other places, if you haven't paid your first bill, they automatically send you to collections because they don't want to bother with it. Now you got so what tip do?

What? What advice do you have? Then I would say number one, always ask your itemized bill, and if you see something that makes no sense, ask for your medical record from that particular stay, and kind of compare so that you've got something to say when you call billing now and say, I got charged for this, this, this, and I looked at my records, they didn't do it. I don't see where it supported that type of thing. And usually they will start taking off some of those charges, and they will say, you can, say, I can't afford this. Now they have a lot of programs too, that if you can't afford it, ask, because you could get put in some programs based upon your income, where they lower it or completely take it off. But you gotta ask you just reminded me one more question we got a woman said that, what happens if you go into the hospital on December, 30 or 31st and you're not discharged until January, 2 or third. How does it get allocated as far as the calendar year?

It usually goes off of your admission date.

Okay, all right. And the final thing I would just say is that you know mothers who don't have insurance, or if there's a job change and a loss of insurance, they're always look to your state for state supported insurance. There are usually good programs for pregnant moms to be covered, and actually they provide quite good coverage for pregnancy and birth absolutely Well Sue. Thank you so much for lending all of your fantastic experience and knowledge and advice. This is one of those conversations that we have, more questions, the more we learn. It's complex, as you said, and I'm sure you can see that from working in the industry for decades, and that it's also ever changing. We've seen it change a lot over the years, haven't you? I absolutely, yeah.

Thank you. Sue. Unfortunately, over the years, it looks like things are not really working in the favor of pregnant moms and babies, but it's getting more challenging. So this information will hopefully be really helpful to guide moms to find the best coverage for themselves and fight those bills when they come in if they don't agree with them, absolutely my number one advice, just call and ask questions.

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But there's some people that have very little training, and they're put in charge of trying to figure this out. And many of them, the patient calls and said, I have, you know, I preeclampsia. They have no idea what preeclampsia is, and they're trying to help you figure out your bill without even understanding what some of that stuff is. So that's because I was over revenue. I mean, I did a lot of training for my admitting people and my billing people, just so that they understood basic anatomy and treatments and all that kind of stuff. So to me, because we pay, I think last stat I saw, we pay nine times more than most other people in other countries, and people complain about it, but our outcomes are worse. So you can say, you know, they have to go and wait 10 months before they can get seen for a heart attack. No, that's not what happens. But if you look at the outcomes, our outcomes in the United States are not good compared to a lot of the other countries, plus you get a huge bill.