by Robin Cook
“You mean that Peerless is saying my wife, who had suffered a grand mal seizure, shouldn’t have come to the MMH Inwood ED?”
“That’s exactly what I believe they are saying by denying the claim,” Roger affirmed.
“Well, that’s preposterous,” Brian sputtered. “A grand mal seizure is surely a medical emergency.”
Roger shrugged his narrow shoulders and spread his hands, palms up. “I’m afraid that is going to be between you and your insurance carrier. Meanwhile, there is this sizable bill that needs to be addressed. That is why we need to set up some sort of payment plan going forward, especially now that your wife is an inpatient and using significant resources like an intensive care bed.”
Brian’s thoughts were churning a mile a minute in every conceivable direction. How could this be happening to him? Was his wife’s care now in the balance because of their irresponsible insurance carrier? The whole situation was ridiculous, and mind-boggling.
“Well, what has Peerless said about my wife’s hospitalization?” Brian managed to ask while trying to rein in his thoughts.
“They have said nothing because they have yet to be billed for that,” Roger said. “Here’s what I propose. If you were to, say, pay five thousand a month, we would be willing to accept that without adding interest. We realize that this is an imposition to anyone’s budget.”
“Imposition?” Brian exclaimed. “You don’t understand. I don’t have that kind of money, and certainly not under these circumstances.”
“Well, you tell me what kind of time frame you have in mind,” Roger offered, tenting his fingers, elbows on his desk.
“Well, first, let’s talk about this bill,” Brian snapped. “Twenty-seven-something thousand dollars! How in heaven’s name did the bill come to that? I could buy a new car for that kind of money.”
“That’s easy,” Roger said. “It’s par for the course and certainly not out of line. As I mentioned, Emergency Department care is very expensive. Your wife had multiple radiographic studies, a spinal tap, various consults, expensive pharmacological agents, many sophisticated laboratory tests, and her care tied up a number of highly paid nurses and doctors. She also had a seizure while being attended, which had to be treated. It adds up quickly.”
“I want to see a copy of the bill,” Brian demanded.
“You can request a copy from the billing department. That’s certainly your right.”
“I want to see a copy right here and now,” Brian said. “It’s all computerized, so it can be printed out in minutes.”
“The way it will immediately print out won’t be understandable to you.”
“I don’t care,” Brian countered. “I want to see it.”
“Suit yourself,” Roger said. He picked up the phone and made a quick call. It was obvious that he was now finding the meeting almost as vexing as Brian.
While Roger was on the phone, Brian tried to calm himself. He realized he needed to talk directly to Peerless. It was absurd to think that a health insurance company wouldn’t cover an obviously necessary ED visit even if some other people abused the situation. It had to be some kind of misunderstanding. Maybe they didn’t know there had been several seizures involved, as well as a serious diagnosis thereafter.
“Okay,” Roger told him, hanging up the phone. “I’ll have a copy of the bill in short order.”
“Can the ED bill be added on to the bill that will be generated by my wife’s admission?”
“No, it can’t,” Roger said. “The ED bill must be taken care of separately. Can you give me an idea of what kind of time frame you would be able to propose?”
“I’m even behind on my mortgage,” Brian blurted. “With the pandemic tying the economy in knots, how the hell do you think I can come up with twenty-seven thousand dollars within any conceivable time frame without being a goddamn fortune-teller?”
“Please, calm down,” Roger snapped. “Let’s try to have a civil conversation.”
“You’re right,” Brian said. He had to get himself under control. “You’ll have to excuse me. I’m just blown over by this whole situation. I never thought about any of this. I’ve always had good health insurance. I guess I’ve just taken it for granted. What I need to do is talk directly with Peerless and get them to step up to the plate and take care of this.”
“That is a good plan, but you have to do it right away,” Roger insisted. “You can’t put this off. Talk to your carrier and then get right back to me. As I’m sure you understand, MMH has its own financial responsibilities it has to meet on a daily basis.”
After a knock on Roger’s door, a secretary came in with a small stack of papers and handed them over to him before retreating. Roger briefly glanced at them and then handed them over to Brian. “Good luck,” he said as he did so.
Brian took the papers and glanced through them. It was immediately clear that Roger had been correct. The bill was entirely unintelligible, with every page mostly composed of long lists of alphanumeric entries followed by dollar amounts. Disgusted, Brian tossed the stack onto the desk. “It’s not in English. It’s all in goddamn code!”
“I warned you that it would be incomprehensible.”
“Why is it in code? Why isn’t each procedure or product just listed with a price? This format doesn’t make any sense.”
“Prices are proprietary information,” Roger explained. “We have to keep that information confidential for our negotiations with insurance companies.”
“I don’t follow,” Brian said. “Isn’t there one specific price for every product and procedure?”
Roger scoffed at Brian’s naivete. “There are different prices for different insurance companies. It’s all a matter of bargaining. Surely you must know this.”
“That’s crazy,” Brian said. “I’ve never heard of such a thing. Do I get a chance to bargain?”
Roger genuinely laughed, although he was obviously losing patience. “No, you don’t get a chance to bargain. As an individual, you have to pay full freight.”
“Why is that? Why do I have to pay more than health insurance companies for the same service?”
“This is how American hospital-based medicine works,” Roger snapped. “I don’t have time to explain it to you, nor is it my job. It’s complicated. But, look, I can have a slightly more comprehensible bill drawn up, which I can email to you if you give me your email address.”
“I never had any idea of any of this,” Brian said as he dashed off his email address and handed it over. “I’ll call Peerless as soon as I get home, and I’ll let you know what they say. There has to be a misunderstanding.”
“Fair enough,” Roger said. “And you’ll hear from me as soon as I can get the billing department to expand the bill however much is possible. But I warn you: It still isn’t going to be much more understandable than this one. As I told you, hospital prices are proprietary information.”
“I’ll take my chances.” He then added with mild sarcasm: “Thanks for your time.”
Leaving the administration area, Brian briefly debated whether to try to visit the ICU because he knew where it was on the second floor. He decided against it for two reasons. One was that it might upset the powers that be, and two, if Emma was still disoriented, she wouldn’t even remember he’d visited if he was able to pull it off. Instead, he used one of the courtesy phones in the main lobby and called to see if any of the ICU hospitalists were available, but had no luck.
Brian walked out of the hospital into a warm late summer day, which was beautiful weather-wise but totally lost on him. He walked out to Broadway and turned south as if he were in a trance. Not only was he terrified about the prospects of Emma’s condition, he was now discombobulated and mortified about the possibility that he was facing a horrendous bill he could not pay. All he could hope was that Peerless Health had made a mistake, one that could be rectified by a
phone call. Yet from Roger Dalton’s comments, Brian wasn’t all that optimistic. He felt as if he were caught in the outer edges of a whirlpool that had the power to suck him under and drown him.
CHAPTER 7
August 20
The twenty-minute walk from the hospital to his house on West 217th Street was just long enough for Brian to recover, calm down considerably, and think. He had always been a doer who saw adversity as a challenge. By the time he’d turned onto his street, he was back to giving Peerless Health Insurance the benefit of the doubt. He was now progressively convinced that there had to be a major misunderstanding about the nature of Emma’s condition, and that a simple phone call to point it out would surely clear things up. With that issue possibly solved, he was able to think more about hospital prices and the incredible amount of money involved in healthcare. It seemed preposterous that it could cost more than twenty-seven thousand dollars for a single emergency visit, yet Roger Dalton obviously didn’t think it was at all exceptional. In fact, he had actually said it wasn’t out of line.
Back when Juliette had been born prematurely, Brian was vaguely aware of sky-high hospital bills, but that was for more than a month of neonatal intensive care. But even those bills hadn’t caused a fuss in his personal expenses, since his and Emma’s NYPD health benefits covered it in its entirety. Actually, as Brian turned onto his walkway, what bothered him the most at the moment was Dalton telling him that hospital costs varied depending on which health insurance company was involved and that he, as a nobody, had to pay “full freight.” He couldn’t imagine what people with no insurance at all had to do.
“What a crazy, screwed-up, unfair system,” Brian pondered aloud as he mounted the front steps of his house, one of the very few houses left standing among the myriad of apartment blocks of Inwood, Manhattan.
Once inside, the first thing Brian did was go into the kitchen, where he could hear a cartoon soundtrack. He found Juliette parked in front of the TV and Camila on her laptop at the kitchen table.
“How is everyone?” Brian asked, trying to sound chipper.
“Juliette isn’t hungry,” Camila said. “I’ve tried to tempt her with eggs and bacon, which she usually adores, but she doesn’t want any.”
“How about Bunny?” Brian asked Juliette. Bunny as per usual was tucked in next to her on the banquette. “Is she hungry for bacon and eggs?”
“Bunny has a headache,” Juliette said, without taking her eyes off the screen.
“I forgot about that,” Camila chimed in. “Juliette says she has a headache.”
“I’m sorry,” Brian said. “Maybe Bunny shouldn’t watch so much TV. Do you think that could be causing her headache?”
“I learned something interesting,” Camila said when it was apparent Juliette wasn’t going to respond. She took Brian aside, lowering her voice. “I researched whether young children can be depressed. Apparently, they can, but reactive anxiety is more common a problem. I think we are dealing with significant anxiety here with Miss Juliette.”
“That makes a lot of sense. Witnessing her mother having a seizure and then being kept in the hospital is certainly enough to cause anxiety. Hell, I’m experiencing it myself.”
“I guess we just have to be as supportive as we can,” Camila said. “At the moment it means letting her watch TV.”
“Agreed,” Brian said.
“So, what happened at the hospital? Any word on Emma’s condition?”
“No word on Emma. As for the hospital, they’re demanding to be paid out of pocket for Emma’s ED visit yesterday afternoon.”
“Wow! They don’t waste any time, do they?”
“And you won’t believe the amount they’re asking for,” Brian said. “It’s criminal. As for the speed, I got the sense that MMH Inwood is struggling financially with the coronavirus situation just like we are. Also, it seems the hospital has had a bad relationship with our particular health insurer. True to form, the company already denied the claim. But I’m hoping it’s a misunderstanding. I’ve got to call them and straighten it all out. Are you all right here with Juliette for now?”
“I’m fine,” Camila assured him. “Make your call, and good luck dealing with them. Last year I had a terrible time with my grandmother’s health insurance company.”
Back in the office, Brian searched in the upright file for the Peerless policy to get the policy number and the company’s phone number. When he found it, he noticed it was a Manhattan exchange and a Midtown Manhattan address. Sitting at his desk with the information in front of him, he placed the call. As it went through, he vaguely wondered how many of the Peerless employees were working from home and how many were actually going into the office, as it varied from company to company.
When the line was answered automatically, Brian had to listen to a long list of possible alternatives. He chose one of the last: customer service, which resulted in another extensive list of choices. Five minutes later, when he finally got to speak to a real person and explained that he was calling to contest a denial of claim, he was told that he had to speak to the claims adjustment supervisor on duty. Frustratingly enough, that required another wait of almost thirty minutes while Brian was forced to listen to insipid elevator music. As time passed, he struggled with rising impatience.
“This is Ebony Wilson,” a strong, compelling, yet mellifluous voice suddenly declared, breaking through the background music. “With whom do I have the pleasure of speaking?”
Brian gave his name and then explained why he was calling, namely to discuss the denial of a claim involving a visit to the MMH Inwood Emergency Department. He went on to say that there must have been a misunderstanding and that he wanted to clear up the situation.
“I’m sure I can help,” Ebony said graciously. “Can I please have your Peerless Health Insurance policy number?”
Brian gave the number, enunciating each letter and number so there would be no mistakes and he could get this done as quickly as possible.
“Just a moment, please,” Ebony said. In the next instant Brian found himself back to suffering through more background music. He knew that it was supposed to be calming, but under the circumstances it was having the opposite effect. Just when he was ready to figuratively scream, Ebony’s assertive and pleasant voice returned. “Okay, Mr. Murphy,” she said. “I have the claim here in front of me. It’s from Manhattan Memorial Hospital Inwood concerning an Emergency Department visit for Emma Murphy. Is this correct?”
“Yes, that’s it,” Brian said. In contrast to the elevator music, Ebony’s voice had a welcome and distinctive soothing quality. “Out of curiosity, are you in the Peerless Midtown office or are you working from home?”
“I’m in the office,” Ebony said. “As a supervisor, it works better for me to be here, same with senior management. Most of the secretaries work from home. Why do you ask?”
“No real reason, just curious. It’s such a crazy time, what with most people working from home if they can. I was wondering how the health insurance world was faring.”
“Okay, I have read through the adjuster’s report,” Ebony said, ignoring Brian’s comment. “Everything seems to be in order here. Why do you think there was a misunderstanding?”
“My wife had a grand mal seizure on the Henry Hudson Parkway after feeling ill all day,” Brian told her. “As soon as the seizure was over, we drove directly to the MMH Inwood Emergency Department.”
“Yes, that is documented here in the claim,” Ebony agreed. “But it also says that Emma Murphy walked into the ED without assistance at four-thirty and waited in line to be helped.”
“That may be true, but she was disoriented. I could have called for an ambulance, but that would have taken longer. When she had her seizure, we were in our car fifteen minutes away from the hospital.”
“I agree perfectly with your assessment, Mr. Murphy. An ambulance surely wasn’t n
eeded and would have been an unnecessary expense. But so is the kneejerk reaction to go to a Trauma 1 Emergency Department when your wife should have been seen by her general practitioner, or perhaps an urgent-care center.”
“We don’t have a general practitioner,” Brian interjected. “My wife and I have been in perfect health. We work out every day. For our four-year-old we have a pediatrician, but we haven’t needed a GP.”
“Doesn’t your wife have a gynecologist?”
“Yes, of course she does, for her yearly checkup.”
“GYNs frequently function as general practitioners for young women. Your wife could have gone to her GYN, who could have seen her and admitted her to the hospital if necessary.”
“That’s absurd,” Brian practically shouted.
“Calm down, Mr. Murphy. Anger will get you nowhere. Let me explain something to you. Peerless Health Insurance and our CEO, Heather Williams, are responsible members of our community, our city, and our country. We provide health insurance coverage with the lowest-priced premiums possible, but it comes with responsibility on the part of our members. Let me ask you something, Mr. Murphy. Did you read your Peerless policy as carefully as was recommended by our agent?”
Brian glanced down at the thick stack of papers on his desk. The truth was that he had not read the policy at all and didn’t know if Emma had, either. He’d never read any of the health insurance policies he’d been given, even while an NYPD officer.