Even a physician can't navigate health insurance

Updated: Sep 30, 2020

You might think that doctors have an advantage when it comes to getting their own health insurers to pay for medical care. After all, we operate within the system, understand medical jargon and routinely articulate what constitutes medical necessity. If anyone can maneuver through our dysfunctional insurance system, it’s the clinicians. Right?

From my earliest days of medical education, I recall dire warnings from my instructors about our “broken” healthcare system in the US. It’s not that I didn’t believe them. I saw plenty of supporting evidence. I just always imagined that my inside knowledge as a physician would allow me to make the most of a bad system. Within months of completing my training, however, that illusion was shattered.

The hospital stay

My wife was hospitalized for one night in January of 2017 with an unusual diagnosis – lingual tonsillitis. Like many people, she had her palatine tonsils (the ones visible in the back of your throat) removed as a child. As it turns out, everyone has another set of tonsils at the base on the tongue that do not get removed. For whatever reason – probably a viral or bacterial infection – her lingual tonsils swelled suddenly to the point that she had severe throat pain and difficulty swallowing. This seemed like an emergency to me, so I took her in to a local ER. I even verified on the way that this facility would be in-network with our insurance.

A CT scan of her neck suggested that the swollen tonsils were dangerously close to blocking her airway, so she was given intravenous steroids and admitted to the Intensive Care Unit, in case she required placement of a breathing tube. She also had signs of severe sepsis, including an elevated white blood cell count, high heart rate and elevated lactate level, prompting intravenous antibiotics as well. Fortunately, she made good progress overnight and was able to discharge home the next afternoon. Our momentary relief, however, would soon turn to protracted anger and frustration.


Just 12 days after discharge, we received a notice from our insurance company stating that her inpatient stay would not be covered because “tonsillitis is not an inpatient diagnosis.” The document was shocking, not so much for its medical decision making, but for the fact that the hospital had charged our insurance almost $48,000 for a single night’s stay. No wonder they were reticent to pay up without a fight.

The letter went on to explain that the visit did not warrant payment because my wife did not require intubation or surgery to address the issue of tonsillar swelling. But wait – she didn’t require a breathing tube or surgery because she was admitted, treated aggressively and monitored closely. Clearly, the claims auditor didn’t fully understand this unique situation in which a little-known set of tonsils suddenly swelled in an unusual way. I wrote a letter to clarify the situation and submitted the first of our appeals.

Appeal #1

A month later, I received a letter from our insurer upholding the denial. The report really said nothing to address the content of my letter detailing how my wife’s situation differed from the typical case of tonsillitis. It simply reiterated that, per the terms of our policy, “tonsillitis is not an inpatient diagnosis.” In the meantime, we received a bill from the hospital, which had miraculously decreased to $4,800 simply because it was being billed directly to an individual, rather than an insurance company.

Appeal #2

Undeterred, I moved on to the second level of appeals, which involved review by a physician employed by the insurance company. Surely another physician would appreciate the singular content of this case and reverse the decision? To help the reviewing doctor make a good decision, I even solicited letters from all the physicians involved in my wife’s hospital care, asking them to explain why inpatient admission was necessary. I had letters from an Emergency Medicine physician, an otolaryngologist (ENT) and two intensivists, as well as a revised version of my own letter from an Infectious Disease perspective – all stating that this hospital stay was medically necessary.

A few weeks later, I received a second letter upholding the denial of coverage. Once more, the denial included nothing of substance to refute the claims of five specialists. This time, however, instead of being signed by a claims auditor, it was signed by an Internal Medicine physician employed by the healthcare company. This response turned my stomach a bit. A physician who clearly has a conflict of interest and who has less formal training than the five physicians writing letters of support gets to dismiss the case out of hand without even attempting to address the specific issues at stake? Very well, then – I would just have to move on to my third appeal.

Appeal #3

The third level of appeal involved sending the case out to a third-party physician reviewer, contracted by a medical review company for just such an occasion. Our review was performed by an otolaryngologist in another state who was given a limited portion of the medical record. Unfortunately, it produced the same result – “tonsillitis is not an inpatient diagnosis.” Thanks, random ENT doctor who never evaluated my wife formally. This concluded our available personal appeals, so I contacted the hospital to let them know we were ready to settle.

Appeal #4

Knowing they would never get as much money from individuals, however, the billing battalion at the hospital sprang into action, launching another wave of appeals against the insurance minions. For six months, a team of billers and coders struggled valiantly to convince the insurance company that my wife actually needed to be in the hospital over one year prior, but to no avail. Final ruling: “not medically necessary,” meaning the patient gets to pay the hospital a seemingly arbitrary figure of its choosing.

Resolution (?)

From May of 2017 to August of 2018, our bill increased inexplicably from $4,800 to almost $8,000 when no additional medical services had been rendered in the interim. No itemization of expenses. No explanation offered. The bill just suddenly jumped by $3,200. Tired of being pushed around, I politely declined to pay the bill until it returned to its original amount. To their credit, hospital billing staff did correct accordingly at that point, and we were finally able to resolve the account almost two years after the one-night hospital stay.

Issues raised

This saga highlights several egregious problems with how we pay for healthcare in the United States. If I, as a physician, had this much difficulty navigating the system of appeals, what chance does the average non-medical consumer have? I had the distinct advantages of being able to contact hospital administrators directly and approach my wife’s physicians personally to ask for letters of support. I understood the medical nuances of the case and which issues to argue for reconsideration. And I still lost every appeal.

Second, how can any industry function with billing this opaque? No explanation was ever offered for the increase on our invoice from one year to the next. The hospital billing staff might as well have been pulling numbers out of hat to determine how much we owed when there was no itemization of services. In other contexts, clandestinely charging one party ten times the amount you charge another party for the same service is called a scam. In US healthcare, it’s business as usual. A total lack of transparency in billing, combined with a system that expects healthcare systems to absorb the cost of uninsured patients, allows for bad behavior like this.

Lastly, we have the absurdity of how and where so many healthcare dollars were spent. I can only imagine that everyone involved lost money on our transaction when you consider the labor of dozens of billing staff for both the hospital and the insurance company over many months – not to mention the additional cost of a reviewing physician for the insurance company, a third-party physician review company and the time of five different specialty physicians to review the case and write letters of support. Perhaps that one night in the hospital could have cost a lot less if we didn’t have to offset a huge number of insurance claims going through a costly, time-consuming process of denial and appeal?

Our insurance system is in serious trouble

Sadly, these issues only scratch the surface of our healthcare finance problem. It’s worth noting, for example, that the charges disputed in our case only covered facility fees. We received and paid additional invoices from an Emergency Medicine group, Critical Care group, Radiology group and Otolaryngology group with insurance offering, at best, modest discounts on the charges. Furthermore, we learned after the fact that the available otolaryngologist at the time was out-of-network with our insurance. Never mind that we carefully selected the hospital to make sure we stayed in network. Patients have very little control over who sees them in the hospital, and even when they do have options, it’s highly unusual for either party to know offhand whether the consultant will be covered by the patient’s insurance.

Perhaps the most infuriating part of our ordeal is that there was effectively no way out. Once we saw the ER physician, we had no option to avoid a large medical bill. This doctor exercised his best medical judgement in recommending hospital admission, and we saw how that turned out. Had we declined admission, however, my wife would have been forced to sign out against medical advice. Private insurers, as a general rule, don’t pay when you leave AMA, so we would have been stuck footing the entirety of bills from the ER physician, radiologist and the hospital. Rock, meet hard place.

I wish I could offer a workable solution to our health insurance debacle. For now, the best I can provide is empathy – the ability to tell friends, family and patients that I understand the frustration and discouragement that come with battling a rapacious corporate behemoth who always manages to find some paltry excuse not to pay for your most basic of healthcare needs. I have no kind words for our private health insurance companies. These days, people get medical care in spite of their health insurance – not because of it. Just know that your healthcare providers haven’t been spared, and we’re sick of it, too.

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