186. Stop Overpaying for Your Health Insurance: EOBs, Tiers & Avoiding Bad Bills

0:00 Welcome to Medicine Redefined, a podcast focusing on helping you reclaim ownership of your health. I'm Dr. Darsha, and I'm Dr. Ultima Shraja, where your hosts, hair to challenge conventional practices and uncover the stories behind pioneers shaping the future of medicine. Our conversations not only focus on the individual level to dissect common practices for health optimization, but also zoom out to enhance systemic change. Join us as we look to break the status quo, move the needle forward, and put the help back in health care. Hey guys, before we dive into today's conversation, I have an exciting update.

0:41 My new practice, refining health and performance, is officially launching soon. It's a practice built around health, longevity, and performance. The Medicine 3.0 approach we talk about every week here on this podcast. And here's the best part. So you can work with me from the comfort of your home. Our founding member in Rome is now live. So if you'd like to learn more or join the weight list, visit refininghealthrx.com. All right. That's going to be episode. All right. Ladies and gentlemen, back here with another progress note. This one is Ultima Shraja's idea, talking about insurance negotiations. Ultima Shraja. Take this off, man. Why are we talking about this? Yeah, buckle in, man. I'm pissed off. So I guess I'll start with a little bit of a story.

1:24 And then I initially wanted to just kind of complain about this. I did complain about it to my better half. And I thought, well, listen, if I'm having difficulties with this, maybe a lot of people who are not in the industry or not on behind the curtains. And how can we make it actionable for people? So the story goes like this, right? My wife and I, we both have employer-sponsored plans, health insurance, this is. And we all know how much we live health insurance. And this is all going to be about. And my plan for my institution was something that I was on for a while for myself for the last year and a half. My daughter and my wife until she finished her training until June 30th were on her plan.

2:05 It was more economical, it would be more sense. The benefits worked out better that way. As a June 30th, she switched over the entire family is now on my plan. So just for context, her plan was blew off through the shield, I'm on that note. Now there is an allergist that we had to get our daughter into sea and we had never seen her part of June 30th. We were actually waiting for July 1st for her to be on my plan to be able to see that because this allergist was tier one in my plan. And we'll talk about all of this stuff, why that makes sense and why that matters. And she was tier three on the prior plan. And so at tier three, the out of cost was too much, it didn't quite make sense. So we made sure we waited till July 1st and we saw them. And so we had a couple of visits at this point they've treated us. And I get these bills coming the last couple of months at home.

2:47 You know, I'm just ignoring them because it's $180 per visit. And I say, no, I can't be at my specialist co-paste $30. I know what the visits cost is completely covered. And so I'm just ignoring them. At one point, Amelia, my wife says, hey, can you look into this, please, they keep sending it. I was like, no, they'll figure it out. No, I gave them the insurance. I'm the one who went to that first visit. I explicitly communicated with the front office staff, so I didn't figure it out. Well, I don't know why I did this. But anyways, I was driving to the gym and I was like, I'm going to go ahead and call them anyway. And so I get to the billing office and I speak to them and say, listen, your wife is not covered under Edna. She's covered in her Blue Cross Blue Shield. No, that's not true. That ended you in 30th. We switched over. It's like, no, it's showing her she has active coverage of Blue Cross.

3:29 And they actually paid for this claim. And then this is your responsibility, right? Because it's against tier three. And so this is your out of pocket cost. It's like, well, that makes no sense. We eliminated it. She has Edna coverage. And so this lady on the other side tells me, hey, listen, you need to call Blue Cross and figure it out. Because if she has two active coverages with two separate systems, and that's really the only way this could probably happen is you have two completely parties who are not communicating with each other, right? Edna, Blue Cross, two big players. And she's actually not covered by Blue Cross. Blue Cross is actually going to try to recoup the payment from us because nobody wants to pay. And we have to pay them back because they paid us. And then Edna actually has to pay out the claim, which is us.

4:12 It's like, okay, well, that's how it's great. Take care of it. And she's like, no, actually, you have to call Blue Cross and let them know at the mistake. I was like, why do I have to call Blue Cross? You want money from me? You call Blue Cross, right? And it was well, no, actually, it's a, if we can't communicate with them. At that point, I was like, is he serious? Wait, so the man can't, they can't take, they can't talk due to hip-hop, but they can take money. Right. Right. Right. And this is going to come back to him. I just, at some point, you know, like, when you're having a communication, I don't like often playing the physician card. At that point, I had to and I was like, man, this doesn't make any sense.

4:54 I understand what you have to do. So can you please just run this claim and just like, no, sir, like, I will take the information from you for your insurance company, but you have to call. And I said, okay, let me understand that you want money from me. I have to settle claim for you. Some other random company paid you who I care nothing about, right? So you have to give their money back illegally. Otherwise, they're going to come after you, not me, but you want me to call them. And she was like, yeah, because you have to. And I was like, okay, how about this? How about you just take my right information and you bill it and then we'll figure it all out. And so my wife being the, the gentle soul she is and doesn't like any conflict and controversy and she's from Southern California, she decided Blue Cross and she took care of it. So we, we solved that problem. But I thought about all the people who, anybody else who would have been in my situation and you mentioned, you don't have a lot of this.

5:38 And I actually have four or five stories of these were last decade that have had these types of experiences where they would have just taken that. Now you know that time is really our most valuable asset. And so that took time that pissed me off. And I think it was somebody else. They might not even had the idea to call and say, look, actually, this is not my responsibility. Even though the other person kept saying and you have the incorrect insurance. So that's where we are. I'm going to try to make lemonade out of this situation, hopefully for people as I say. So I like it. I like it. Man. Rough. Sounds rough. I think I'm one of those in the camp where I see that and I'm like, man, is this worth the energy, right?

6:18 And I think we're like, we're at a point now as attendings where how do we reconcile the principle behind it? Because I would probably still call it because there's a lot of principle behind it versus being like, you know what, I just not going to, I'm not going to deal with the same worth it. Yeah. But okay. So let's go through this because we, what was it? Maybe five, maybe a little bit more six, seven episodes ago. We had, oh my god, what was the name of it? Thank you, bit. Yeah. Yes. Yes. Yes. Yeah. We had him come on, talk about insurance. Beautifully kind of took us through it. But we're going to go even more in depth now. I think and talk about more about nuance and relate it back to this story. So you know, I can never get these terms straight. And so I think any of the pre-med and medical students out there, this would be a good refresher hopefully if they did learn it.

7:04 But take us through, you know, insurance 101, what are some of those terms that we have to know about when it comes to the co-pay and money and understanding, meeting a certain amount of money before you can then do XYZ? What does all that mean? Sure. Yeah. Any consumer of healthcare, right? So I think important terms, just so you can speak the language, we always talk about terminology, you have to be able to understand it. So when you call and you try to advocate on your behalf, you know exactly what it is that they're saying on the other side and you can actually have a clear conversation. So premium is the term that most people think about. This is what you have to pay monthly to have insurance. Everybody has a premium, you know, whether there's, if it's employer-sponsored or not, it's, there's a portion that you're paying, maybe the employer is paying, if you're paying 100% by yourself, that's your monthly premium.

7:53 And this applies to all insurances, car insurance, home insurance, all that stuff. Your deductible is what you pay first before the insurance starts sharing and contributing to your plan. And so people might have heard of something called a high deductible healthcare plan and those might be something that people who don't need a lot of healthcare resources, young people might engage in where they have a $5,000 deductible. They're like, hey, the first $5,000 of pretty much everything except emergency services, I'm going to pay out a pocket that includes doctors, vids, and so on and so forth. Co-pays, it's a fixed fee per visit and that might be, so the specialist, your, your primary care, it might be 20 bucks for your co-pay.

8:37 And it doesn't matter whether or not you've met your deductible. This is something you're paying every single time and other procedures can have co-pays as well. Not to be confused with co-insurance, which is a certain percentage of the cost that you have to pay after you meet your deductible. So if you have a $500 or $1,000 family deductible and then you can have your co-pay, which might be 20 bucks for that primary care, well, usually we'll just, let's say $50 co-pay, you still might have a 20% co-insurance. So if that visit costs $200, you're still paying $40 on top of your co-pay. So that's another important one. Other ones out of pocket, maximum, as the phrase suggests, this is your annual ceiling after this is all the money you'll pay out after that, all the cover services are at 100%.

9:26 So you have to be really sick or really use your healthcare resources in order to get this. These numbers are in the 15s or 20,000 somewhere in that range, sometimes a little bit lower, but rarely. And then last, the important one kind of will suggest is your network. The network is important. So people might have heard in network, out of network, and I think, you know, even within network, tiers, as I alluded to in that first story that I said, that's really important. So your tiers are your preferred providers that you have to see. So somebody might be in network, but they might be a tier three provider. And a tier three provider, you are taking a lot more of the cost as the patient, whereas a tier one provider is a preferred provider and you want to go say that it's going to be less out of pocket costs.

10:07 That every system is tier based on in network, but there are horizon being the classic New Jersey. It's the largest health and sure for most patients and they're often have tier based system. So those are some of the main ones. Anything that I miss that you could think of that that you always have a question about? No, I think those are red. I think those are the ones that most of us hear about, you know, when we go to these visits or when we talk to patients, I think, yeah, thinking there's up. Yeah. And it's really important to, I think, really understand that because I think when you're not only when you're picking a plan, but also when you're choosing who to go see, like for you, this doesn't matter as much because, you know, patients really get to pick that they're getting to see you. I mean, maybe they heard they were so awesome.

10:47 That's the inpatient rehab they picked. But oftentimes when you're going to see an outpatient clinician, you need to understand these things before you go see that doctor, certainly the in network and out of network stuff. And I think Vince talked a lot about most of his stuff as out of network and we can talk about reimbursement if that's necessary. So I think that's an important one other things that come to mind that people need to understand is something called an EOB, the explanation of benefits. Anytime you utilize healthcare resources, you go to a doctor, you have a procedure you go to a hospital, you're going to get an EOB in the mail. And that is not a bill, right? And Bill and his invoice that you have to pay out an EOB is not that, even though it might look like an invoice.

11:31 So this is a receipt from your insurer. It shows what was billed, what the plan allowed, what they paid and what you might owe. But that's not, they're not asking you for money. It's just breaking down the charges and like a lot of times you'll see like contracted charges, waived off, reduced, etc. But it's in detail of everything that happened. This is an important thing for people to look at because this is where you can catch mistakes. This is where you can pick up poor billing practices, you know, refer back to with Leah Houston talked about. These are things that are important for you to look at at least a couple of times before we just kind of shred them. So you can make a or you can have an informed discussion debate to your point about energy and principle.

12:17 I've shared this story before, I think with Peter Venezuelan when he came back way back in the day about when I was at Hopkins and we had the institution sponsored plan. And do you remember this? Does it talk about that? I think I did. This is during pregnancy and for those who don't know, during pregnancy, prenatal visits are covered 100%. I remember Amelia went to her routine. I think prenatal maybe 12 week follow up or something where the visit, they asked us if anything was wrong and she said, hey, listen, I've been a little nauseated lately, totally part of the process. That's not what she went to the doctor for. And then the way they coded it, nausea was a primary diagnosis. And so the whole visit kick back and I think I had to pay 110 bucks or something.

13:00 And I was like, yeah, that makes sense. This should be 100% covered. And it was maybe nearly 11 months of fighting back and forth until eventually I had to broker a call between like management and the insurance company to try to understand that the codes needed to be just swapped. First had to go a second, second had to be first. And that's not something that I think, well, it definitely is not something that should have taken all that energy. This is a principle thing that I just, you know, and I was a really important lesson for me to learn because I think that's where I kind of learned on how to communicate and how to cover your ass, so to speak. Yeah. But one thing I'll say is anytime you have an issue where you think that something's in dispute, ask them to put your account in hold.

13:42 People are often concerned they're going to send it to collections, just say, hey, listen, this is being debated. This is something they're working through. Can you just request to put the account in hold? They should do that for you. As long as you're actively making a good faith effort towards doing that, and if you're calling and you're speaking and you're advocating and you have meticulous notes, that's something that's really important to do. Gotcha. Nice. Okay. Do you, how do people figure out these numbers for their premium deductible? Let's say they signed up for something and they're like, shoot, okay, I don't know. I want to go see the kind of colleges I'm going to see a sportsman doc. How do I know? How do I find out this information? Is it through the insurance website? Do you recommend artificial intelligence at this point?

14:22 What do you suggest? Now, AI probably wouldn't have unique stuff for their plans. I don't think that AI is going to have access to them, I mean, especially not the employer sponsor plans. That type of data and those are discounter rates a lot. So for the monthly premium is going to be something that when you signed up, you're going to have a good sense of what that's supposed to be. So if you're going to help care.gov, if it's going through your employer, you've gotten that information at a time. If not, you can ask your human resources person or go back to healthcare.gov and just look up to what that initial plan that you agree to. The seeing different doctors, which are copays are, so this is important.

15:02 Every single person, when they're signing up, it's required by law to have something called a summary of benefits and coverage. It's a booklet that has all the information and all the details about all the things that we just talked about. And you have to walk through this before you're actually comparing plans to see what's going to be more suitable and what's going to be appropriate for you and your family. This is where you're going to see all those copays. What it's going to cost you to go see a PCP, primary care versus specialist in those copays, what your co-insurance is going to be, deductibles out of pocket max. It's also going to have if it's tier-based system, every single one of those numbers for tier one, tier two, tier three. And if there are out of network benefits, how much is that?

15:44 Oftentimes, if there are out of network benefits, unless it's a really good plan, they're going to be at a much more reduced to reimbursement rate from the insurance company. So, for instance, tier three might be where the insurance company pays only 70 percent of the visit and an out of network might be only 50 percent, right? But now you can go, now you can go see events. You can see people like Dr. Marquesi and Reimbursed and get a super bill. So that's a document that every single person gets, and you have to look at that. And I recommend people to kind of just save it, save it on your computer, save it on your phone. It's just, it's such a long document. It's hard to kind of remember, right, or take screenshots of it, and just those key points.

16:26 So, when you go to the doctor's office and say, oh, your copay is actually $70 and it's like, oh, no, actually, like, this is my specialist copay, what's going on? And you'll find out that maybe that's not what they are. A classic example comes to mind is some of my colleagues that I practice with, they're family medicine trained, but then subspecialize in OMM. And so if they're billing as OMM clinicians, they become specialists. They're no longer primary care doctors. So even if somebody's seeing them as a family medicine doctor, if they're seeing them in that wrong location where they're practicing osteopathy, now their copay, seeing the same doctor can be $25 in one family medicine clinic where they're the primary care doctors, but in a different clinic where they're serving where the clinician is wearing a different hat, it could be completely different.

17:08 So you got to, you got to really know that stuff. Gotcha. Okay. And then when it comes to requesting a hold on the account, does that mean you then actually can't use your insurance? What if you have to go to a follow-up appointment or something a week after that's a great question. No, no, no, it would be for that specific account with that specific clinician. So let's just say you came to see me in clinic and we had a bill with us at dispute, you'll say, hey, just put this hold on account. So my billers, my companies that you outsource to, they're not sending it to collections. No collections rarely ever affects your debt. You have to really not make a good effort for a long, long time for something like that to happen, but that would be the purpose of that. It doesn't affect your insurance at all.

17:49 Like it would not affect at the level of lacrosse or anything. So it would, it's not like putting a pause on that at all. Cool. All right. Awesome. Let's move down then to plantites, right? So oftentimes on this podcast, we're talking about DPC, DPS, these are just like cash-based practices, right? But within the insurance model, there is each of them. There's PPL, right? So let's go through those. What do each of those, what are the different plant types and what benefit is there to each of those? Yeah. So yeah. So PPL was a preferred provider organization. This is, so I'm going to go with, from most flexibility to least. This is the one that's going to typically have outdoor network benefits or are usually going to be covered at lower rates.

18:29 These are the types of plants like Medicare, it's typically a PPL, I think about that. Even though that's a federally funded program, they have state plants as well. So PPLs are favored, they are a little bit more expensive, you're paying a bit of a premium to not have, or have a wider network and see whoever you want. And EPO is an exclusive provider organization, slightly more restrictions. It's typically, you can only see people in network, but they have a larger network. And you don't need referrals from a primary care doctor. POS, point of service, is an HMO like, but you can go out of network with referrals. It has somewhat mixed rules, again, slightly restrictive, but not as much as something called an HMO, a health care managed organization.

19:16 This is the one that's classic, you have to stay in network. You often, if not always, have to pick a primary care provider. And every single time you want to go see a specialist, you have to reach out to your primary care provider who has to get a referral. This happens with us all the time where patients come to see us and like we're hunting down their primary care doctor five minutes before the appointment. But we can't see you, even if you're setting in the office, because you didn't get a referral. And that's the most, like it's a gatekeeper type model. The big systems on the west coast, Kaiser, comes to mind, they have an HMO based system, and they have this network where you can only go within the Kaiser model. It's really frustrating for a lot of people. Gotcha. Cool. Great explanation there.

19:56 Yeah. I actually never really heard of EPO and POS. I'm guessing those aren't as common or I don't know if all insurancees, do they offer those? Like, or is that specific unique bootie? They're insured. No. Far less common. Far less common. POS is probably a little bit more common. EPO is far less common. Sometimes EPO and PPO can be interchangeable. People will just look at that. And because EPO is so wide, people might not recognize that, hey, this is just a really large in network as opposed to a their outer network benefits and people might not even pay attention to that. Got it. Okay. Cool. All right. Let's move on to how to essentially read your plan. Are the specifics that you're looking for? Obviously, this is going to be case-to-case basis, but I think you have a good general outline here as far as, you know, what the, what the ordinary average show should really be looking at.

20:42 Yeah. So, coming back to that, the summary, the benefit summary that I talked about, again, saving that, putting it on your computer, oftentimes now, especially in 2025, all of the big players are going to have online portals as well. I think that's really important is that if you can create an online portal, this is a great place. If you have access to computer, which most people do, if not phone, they have apps as well. The apps tend to be a little bit clunky, but the online portals are pretty good because well, one, you can access the summary of benefits coverage if you don't have it. Two, all the EOBs should automatically route to there, even though they're going to send it to you at home. But if you ever had a question about a claim, you can just go take a look at the EOB and exactly what happened and then compare that to the bill that you're actually getting from your clinician or your provider.

21:27 This is also a great place. A lot of times I know Edna has a good portal, Blue Cross has a decent portal too, where you can search providers. So if you had a question to see if somebody's covered in network or outer network, this is a great place to check that. Now caveat with that is oftentimes they are not updating or a doc might work at multiple locations and only one of the locations is showing in network and another location for just the way that they structure their billing. It could be that that's one doctor in a or one provider that you're seeing in a large practice and it's actually being being billed at an NPI number, which is a provider identification number on a different NPI and that's why your doc is now considered out of network.

22:13 These are also things that's happened to me. So it's really that summary of benefits coverage that is going to give you all the information that you need, whether it's preventative visits, labs and imaging, mental health benefits, PT, OT, pharmacy, well pharmacy formulae is a little bit different and we could talk about that if you want to, but I think that setting up the portal is important. Oftentimes it'll give people ID cards as well and having those electronic ID cards, I think is also important because sometimes the ID snapshot also has just really high yield, out of pocket, maximum deductible, copays, people think people can reference those quickly. Gotcha. Cool.

22:53 Awesome. Anything else? What else? I know you have labs on here, DME, which is something that's up our alley as rehab docs that we look at. Mental health services. I think that's something more and more people are looking into as well. Are these things that are usually typically covered or? Yes, so the mental health service, when I was thinking about that example of, so if you think about a lot of times, mental health providers can be licensed social workers and they might be, it could be part of a bigger practice where the psychiatrist's NPI is being used to build the, or the whole practice has a one NPI and you might be seeing a certain clinician who might be in different practices and they're not directly peeling.

23:39 The other one that actually comes to mind is if you're seeing PAs, PAs often build under physicians. So your PAs might have a certain provider ID and you keep putting that person's provider ID and it's showing up as covered, but if the billing is actually happening under the physician who has not covered, that could be a challenge for you because now you're getting a bill because that's how it's happening even though you're seeing a certain doctor. So I don't know how often PAs are in the mental health field. I don't think this, I think the licensed social worker is something that comes to mind. They're very, very common. It's nearly impossible to get psychiatrist these days, the rush practitioners typically have their own, their license to practice independently, at least in the state of New Jersey.

24:23 Is that the case in Florida as well, yeah. But I mean, when in doubt, pick up the phone and I know I gave a little bit of love to the portal's online, but pick up the phone and call and get that information ahead of time. I think as annoying as this is, the safest way to do it is it's always better to call the doctor and find out with a doctor if they're accepting your insurance or not. They should have the most updated information. If not, the doctor should do the work for you and this is not exclusive just to the physician. This could be for physical therapy, occupational therapy. The reality is they want your business.

25:05 They should look into your insurance benefit to see what tier you are and what your responsibility is going to be. The same thing with dentists. When you call, you say, hey, are you guys covered? If they really don't care, they'll punt and say, you have to call your insurance and find out. I have noticed that. I've gotten that from patients sometimes they just don't care. They're so busy or you just get somebody really nasty at the front desk and they're not interested in doing their work, but it is their responsibility to kind of check. I shouldn't say it's the responsibility. Secondly, your responsibility as the consumer because at the end of the day, it's on you when something doesn't cover it, but they should be doing that because that's kind of just the way that things at least work in this country to my knowledge.

25:48 Have you ever had that experience where you've called and tried to see if somebody's covered and they said, now you got to call the insurance company and find out yourself? I don't. I haven't called. I have case management. With the inpatient. So a lot of it. I mean, as a consumer, like with your parents, anything like that, no, they take care of it. Or, you know, I think a lot of these larger networks will have now in service case management or in service, like people that will do more billing, like and Jack maltraden that sense when it comes to health insurance, admit types of stuff, yeah, I haven't had that. Yeah. Yeah, it's important to think it's like, remember, it is still a business and you're still a customer.

26:28 And so if they don't do a good job there, one that could be actually a red flag, if they're not even willing to do a little bit of legwork for them to figure out if, you know, what your responsibilities and you're going to get bad service off the gecko, maybe you need to go to somebody else and they lose that patient. They lose that customer. I hate saying it that way, but that's what it is, right? This whole situation is just a business. Absolutely is, man, going through that right now with a couple of patients as we speak, I'm getting emails, but phone about it comes for service and trying to make things happy even though they're not going to react candidates and stuff. Like you said, it is a business in the end and unfortunately that's how it is, but the tough thing to say on the inpatient side, what do you mean, give me some, give us some cases.

27:11 Yeah, so you know, our hospital is known to be one of the best down here in Florida, especially the one specific one that I work at, some of the best therapists that we work at. And so when it comes to rehab hospitals, just like any other hospital, the goal is to fill beds, right? The goal is to try to maximize the number of beds because that keeps your admissions up that you have more discharges and keeps revenue flowing and keeps money flowing. When you sound a lot of the times or rehab patients are actually, if they're second or third times through that door, eventually there comes a point though where that rehab patient no longer will benefit from our services, right? I mean, they've just plateaued in function or they get sent out to the hospital.

27:54 They're just not a good candidate overall. But to the families, it's, oh, bring them to rehab because there's always that hope. They can always try, but let's be honest, sometimes it's a, it's almost like a vacation for the family where they don't have to take care of their loved one at home. And so sometimes they get a break, the therapist and our staff will kind of take over and, you know, whether it's a week or two, but what we have to, when I deny those patients, right? Because a lot of times we have liaisons and a marketing team that will go out and say, hey, this patient, are they a good candidate? My eyes, they're not. And this is a, a decision that I make alongside the therapy team after talking to them.

28:34 But then the family gets upset, right? And so now it's really a customer service type thing. So in the back of my head is, do we accept a patient that's not actually a great candidate? It quote, unquote, saves face for us. They're also good marketers and they are a good word of mouth family to go and tell other families, hey, this is why you go to this hospital because they take care of you and they're nice and et cetera, right? So I mean, in the end, it's still heavily, heavily, heavily a business. And we're just trying to work our magic within that system, essentially, but yeah, that's kind of what, what I've gotten through right now, so. Yeah. You know, the upside there is, at least I think, correct me for wrong.

29:16 I often talk about the business of medicine on the outpatient side sometimes, well, oftentimes drives to practice medicine here, aside from admitting a patient, I don't think that's going to be the case, right? Because they're still going to get good quality care if they're there. Correct. Yeah. Regardless, if they're going to come, we're going to still provide the best care, right? But then there's also metrics we work about, send out rates, patient satisfaction, discharge admissions. You know, there's just a lot of other metrics within the metrics that we try to hit. That physicians have to hit that our leadership, each and every one of the roles has to hit. And obviously, these are measuring like a quarterly basis, monthly basis, yearly basis, right?

29:59 So those are all things that are on the back of our minds when we look at the specific job that we do. Give an example of some metrics from the inpatient rehab unit that you might have to pay attention to. Yes. People don't know. So for me, probably the two most important are the patient satisfaction. And so, you know, patients get a survey at the end, just rating their experience. A lot of the influence comes from the physician because of, you know, obviously where they take care of, did we solve their issues, but also the rest of the staff, the therapy team, all of that goes into the engagement of the physician or sorry to the patient. Secondly, acute transfers, right? So we want, this is across the board of anywhere any in patient system is acute transfers.

30:41 So when a patient gets sick from a rehab hospital, because remember for the, for the audience of rehab hospital, yes, it's still a hospital, just like any other, but it has less resources. So we are not ACLS certified, right? So we do not, we can, we can, we're BLS certified, so we can do CPR, but when it comes to heavy cardiac meds and full resuscitation, we're unable to do that. So we have to send the patient out. So keeping our send out rate low is another good metric of knowing like, hey, we're doing everything we can for this patient. We're actually taking good patients for rehab. Now that's also monitored again, something called CMI, which is, which is case mix index.

31:22 And that, the higher the number, that is the more sick a patient is, you know? So a patient, let's say, a 1.6 or 1.8 CMI is somebody with diabetes, COPD, maybe a leg amputation, heart failure, all these things. Whereas somebody with a 1.3 might just be a fever fracture, let's say obesity and hypertension. That's it, right? So, yeah, less complexity from medical, less complex, exactly. So the higher your CMI in a hospital, the more of a budget you essentially get for a send out rate. Because now you're expected to have some patients that have to go back to the hospital and after they come to rehab. So these are kind of the metrics of the numbers that are always in flux that we kind of have to keep in mind.

32:04 Re-emission rates are always a big thing too, right? So you discharge a patient in what, in the next 30 days, how likely are they to actually go back to the hospital? So, you know, from anything we do, from a mission to discharge, our metrics are getting influenced in some sort of way. Yeah. Yeah, it's interesting. It is all interesting. You know, we try to do the best that we can within the system that we are. So, you're talking about acute transfers. That actually reminds me of something I didn't talk about that I think is important is emergency visits. So, oftentimes, you know, in the case of an emergency, people will know that anything, anytime you, it doesn't matter where you are, in network, out of network, if you go to the ER, it is their responsibility.

32:46 But the ER is, you're going to get good care. They have to, these are the laws, at least in this country, they have to take care. That doesn't mean that you're not going to get a bill for it later. So, network doesn't matter almost exclusively, it's going to be covered. Here's the catch, though. And I think Marty McCarrick talks about in his book is, is, let's say, you have an emergency. So that code situation they're talking about, somebody's got a code blue, your heart's literally stopping. And they're getting taken by the ambulance to the hospital. Well, just that night, the anesthesiologist who's going to intubate, you happens to be out of network. And all of a sudden, you're going to get a really large bill for the code and the intubation that came down, hopefully you've recovered and bounced back and went to rehab and now you're home and thriving.

33:33 And you got this massive bill because somebody to lose a moonlighting was the physician fees and the consultation fees for that specific clinician and maybe the ER doc and the team were out of network, even though the hospital's up to street from you and network. And so these are things that are really important, you know, ground versus air is another really big thing. I think oftentimes, so I work in there, you know, Cooper trauma is, is a regionally phenomenal trauma center here. And oftentimes a really big traumatic case is something like a spinal cord injury or massive brain injury from down the shore. They're getting flown in that helicopter bill, which is not necessarily in network. And especially if your plan doesn't cover helicopter flights, I could be $25,000 flight that was necessary to save your life.

34:18 But, you know, these are all things to kind of think about and, you know, I come back to Vince's point. I mean, these are things that you're going to have to, I mean, that sucks. I don't really have a work around that other than wear helmet, I suppose. But, you know, safe for responsible driving, no texting, et cetera. But yeah, those are arguments that you're going to have to make. Those are things that you're going to have to try to prevent for. But in all seriousness, even having conversations with your loved ones, you know, you don't have kids yet. But when we had our daughter, one of the first things that we thought about, okay, all right, what are all the hospitals? Which hospital do we want to go to in case we have an emergency, like JSM allergies? And if we ever have antiflexus, where are we taking her?

35:00 You know, we consider, okay, listen, chop is here. Yes, we want to balance coverage and, you know, whether something is in network with also excellent care. And you know, think about all these things. This has happened with my family members, my parents, like they've had to go to the ER. We had a really bad visit at where my mom ended up in the hospital one time. And I remember telling the rest of my family, do not ever go to that hospital again. Not because it was not covered and because of those reasons, because the quality of care that we got. And if you ever have an emergency, go to this hospital because, you know, they have better services and they have a better trauma team and they have better cardiovascular treatment. If they need to convert a non-surgical case into a surgical case, they can do that more easily.

35:41 They don't have to transfer out. So these are conversations that people should be having and be attacking it from multiple lens. Again, from a financial lens, probably more so even than the actual health lens because the number one reason for bankruptcy in this country is medical debt. And we got to try to avoid that where you can. So I think this co-cumst of mine from Martin Rooney talks about, you know, if you failed to plan, you plan to fail. So you can only do so much here. And so that's one of the things you could do. I like that, man, because I mean, we all have control if we want. I think the issue is we're told by a system like, hey, you're never going to figure it out anyways. So what's the point?

36:21 Right? And I feel like I'm almost victim of that, too. It's kind of like, whatever, like I'm healthy right now. But again, this is all the knowledge for a rainy day, for when that day ever comes. And so always important, just kind of learn it now. And it's coming. Yeah. Right. For every single person, it's coming if it's not for you, it's for a loved one, your parent, your kid. I hate to say it, but it's coming. Yeah. It's a great point, man. And I think that's where that, that the principle of principle, right? And actually, you know, even if it is $100 and we can easily afford that, it's going through it the first time, because if you can do it once, then you know you can do it forever. You're more knowledgeable. You can handle when it gets worse and you can just navigate the system a lot more easily.

37:04 So totally agree. Yeah. I did what I was going to say to kind of build off that. Yeah. As much as, you know, for the last five years, we've been talking about improving healthcare practices and brought amazing people on here to reflect policy change. That stuff is going to take a long, long time. But taking agency of your health, that's really easy to do now. I shouldn't say easy. That's much simpler to do. And then so that's my hope is people walk away from this and it's like, okay, listen, yeah, I can sit here and wait for the system to get better, which is going to take a very long time. Maybe it never does. But here's what I can do today. Here's action look for me. Yeah. Agreed.

37:44 I did want to ask you about tears, right? Because at the start of this episode, you mentioned how, you know, you're supposed to be tier one, but they were tier three. What are the tears? Why does it matter? Yeah. It's all contracting based stuff. So it's really interesting how this happens, especially on the limelight a lot. Because Medicare is actually under a crossfire because they're cutting their reimbursement costs for a lot of different procedures, which is a big problem. A lot of the folks who are proceduralists in my specific field that they're doing, Medicare is just not paying enough to even cover the cost of goods. So to speak, forget even the physician's professional fee. And so oftentimes, you know, physicians aren't taking that specific insurance company.

38:27 So why does that matter? Well, at tier one, you have better, the insurance company has contracted with certain practices, certain organizations, certain groups that, hey, we are going to funnel all our patients into you by having their lease out of pocket costs. And then the reimbursement rates sometime reflect that. Oftentimes, I actually reflect that. I think Vince talked about this too, which is it's such a honestly bullshit way to do this. And oftentimes it's interesting. I think that so when we talked about PBMs, you have this, you know, vertical alignment and it's the same idea is, Optum Pharmacy is owned by United Health Care.

39:10 And so anybody who's in United Health Care, you have to go to Optum Pharmacy to get special medication, a credo, you have to get a special specialty medication from a credo, which is a blue crush product. And so you're paying that. So it's the same idea in a sense that you contract with certain people, you give them slightly better reimbursement rates and then most of the patients end up going to that. And they keep more money in their pocket. And then tier two, you disincentivize the patient to go in for some tier two, even if they're a world class clinicians or out of network world class clinicians and they're going to get best possible care because you don't have good contracts or reimbursements for them. And so what you see is a lot of people who physicians are stepping out of network.

39:52 They're not taking insurance anymore. In fact, I mean, my prior practice, we're going to be out of network for everybody. And so Vince, Sassy, who've been on here, they talked about this as well, they're out of network. So if you have out of network benefits, well, you're one of the fortunate people who can potentially reimburse this with something called the super bill and get some of that money back. If you're not, then you either have to kind of pay out a pocket and hopefully you find value in that or you're going to be unable to see. So it's a similar idea that like, you know, maybe tier three, you can almost look like borderline out of network. Got it. Cool. Awesome. What? What now? Where do you want to go from here? Yeah.

40:33 Well, I'll just recap, right? So I think important things. So I think first and foremost, the most important thing is to know your plan essentials. So get that booklet, the summary of benefits coverage, save it, have it accessible, have it on your phone, set up an online portal if you don't have that just so you can quickly reference and find providers oftentimes that's really helpful. But it's not going to be even if you find somebody that's a good step in, but pick up the phone and call, start with calling the actual provider you want to see before you call the insurance company. If you have extra time and poor, you're really, really cautious, then you can do that. Download the ID cards. Have your ID card. So I have actually running a, like a shared note on my Apple notes with my wife where I have, I don't want to tell people this, but maybe my password during there, maybe you're not, I don't know.

41:14 But our ID cards are in there. Our prescription cards are in there. And if you want to put your summary belt and you can put all that stuff in there, you know, pre-visit verification. I'll be talked about that. Remember that the explanation of benefits is not a bill, but you should reconcile that if you are saving your EOBs with a bill before you pay. Oftentimes, and remember Chris Hutchins talking about this is, you know, they'll catch up where you have like a level five visit here or in a level three here. And if you know the insurance paid something, so let me, let me get actual tactical example for that. Let's say a provider billed $300 for a visit, but legally, they're only allowed to build 150 for that visit. And that didn't get adjusted on the end on all of a sudden, you know, they're allowed to build 150 and the insurance pays 80%.

41:59 Maybe let me use these are numbers. They allowed to build 100. The insurance pays 80% while your responsibility is 20%. If you look at that in the EOB, you know that you owe 20 bucks when that bill comes in mail. But if they forgot to make that adjustment from 300, well, 20% is all of a sudden they're going to send you bill for 60 because, you know, the adjustment didn't happen or something like that didn't happen. So that's how you can potentially reconcile that and these mistakes happen all the time. People don't check them and that's why they just automatically pay it, you know, vendors and pharmacies.

43:30 So that's like these are kind of things that happen all the time and you can expect the people on the other side who are just picking up the baton to be smart or honestly, I hate to say that or care about, give a shit about how much, you know, medical debt is robbing you. So in that note, every single time you call for every single call, every bill, keep a claim action log, date time, person named department that you spoke to get a case reference if you can, what they promise your next step follow up date, save all that stuff. So you'll oftentimes people will call and they'll say, oh, I'm just looking at my internal notes.

44:10 Well, now you got your internal notes running here. So when you call back and he said, I spoke to Chris this on this day and we said this and he said, this was going to happen all of a sudden, they're taking you seriously and you can just expedite that call, no when to take the escalation ladder. So there are times where you just, you know, the first person, they're oftentimes just trying to beat you down. I feel like and eventually people do give up, just know when you have to escalate it to the billing supervisor to the practice manager, same thing with the insurance company, you know, take it to your supervisor manager and say, listen, hear my notes. This is my sixth call about this issue. I think it's time for us to escalate this. And if you need to, you can three way call like to resolve an issue.

44:50 I think I already mentioned having insurance kit. I think the last one I let people say is like, don't let them gaslight you. Just like this person on my phone call, they will try to do that all the time. They will say, hip I has something to do with it, which absolutely doesn't. So you know, I'm tempted to have this person if she even knows what the hell hip I is and what it means and what stands for. And they will assume that you do not understand and you are less educated than them. And they will try to gaslight you about the situation when in fact, that's not true. I think if you follow this action plan that we talked about and you have meticulous notes and you understand your own situation, you are going to be the expert of your plan, not them. And if you don't get it, ask them to explain it over and over and over again, because you have the most to lose in this situation.

45:32 Yeah. I like that. Is there a common theme that you see with your patients that come into the office that you kind of just wish which people knew every time they came into their office that you would see more of that, you know, that they aren't doing unawareness of what their plan is, what it offers. I like, I'll give the court later to that. The ones that are the most successful come in like I'll say, hey, listen, I think, I think I can do this procedure. I just want to make sure if I need a prior off to say no, I already called the insurance company. We're good. We don't need a prior off. Amazing. That's made my life so much easier because I'm happy to do the procedure. I just don't want you to get a bill for it or if there's an advanced procedure where they actually pick up the phone and call the insurance company and advocate on their behalf.

46:16 One time the insurance, when we talked about this in daily of care, getting a test approved, getting a procedure approved, they'll just wait, wait, wait, and things just fall off. The patients who advocate for themselves, they do so much better and again, it's just the coming back to they don't anticipate people are going to be knowledgeable enough or have the time and energy to pick that up, but it's actually once you really understand your plan, you can kind of cut right to the chase. I think that's the biggest thing that I would just wish people did more. Yeah. Perfect. Love that. Well, I hope this helps. I don't know if I'm more riled up or less riled up at the end of this, but I'm sure I'm going to have lots more stories as type of shit happens, but I hope that really helps people.

47:01 If you've had a bad situation like this where that you've successfully been able to overcome, we'd love to hear your story. So shoot us a message, hit us up on social media, and hopefully people can maximize and leverage the insurance for them. I think this is helpful. Let me tell you what I got on this at least because as a provider who's even like, nothing is transparent to me. And I also struggle with this is one, obviously, the terms make sense, right? Two is when you're signing up for insurance, understanding the terms now and seeing what best fits your budget, your lifestyle, your conditions, all that, right? So having a better understanding of that now when I go into the portal, when I look for a physician, I can understand in network, first out of network, what would make the most sense out of it and what those co-pays and all that would be.

47:46 So now I just have a whole financial picture ahead of me and I can probably map out too or they're going to be follow ups, labs, just go to the booklet and see exactly what might be covered. And then from there, once you get the EOB, the explanation of benefits, really just going through it now that I have a better understanding and saying, hey, is it accurate? Is it not? If it isn't accurate, making that phone call, not letting them gaslight you, telling them what you know, you know? And then I think the key thing here, like you said, is keeping a detailed list of who you talk to the time, all the details. I think that's very huge because like you said, unfortunately, we live in a world where serious people will only take other people seriously if they are serious.

48:26 So that's definitely key. But yeah, no, I think this was an awesome man. I learned a lot myself and I think other people will do. Awesome. All right, man. Until next time. All right. See you. Peace. Thanks for listening to the other episode of Medicine Redefined. If you enjoyed this episode, please be sure to check out some of the additional resources in the show notes. Please also check out our social media platforms where you can find more content like this. You can follow us on Instagram, Twitter, and TikTok at Med Redefined. We also want to thank our team for the production of this podcast, specifically Ethan Jewel and video, Harita Yapuri on social media, Zanablegmani on research, and Sarah Hahn for newsletter.

49:07 Also, if you enjoyed the show, please be sure to subscribe, review, and share with anyone who you think will gain value from this as well. Now, time for the ever so important disclaimer. This podcast is intended for general public use and is for educational purposes only. It does not constitute the practice of medicine, nor should be construed as medical advice. No physician patient relationship is formed, and anything discussed in this podcast does not represent the views of our employers. We recommend that you seek the guidance of your personal physician regarding any specific health related issues.