For those who went to the Cleveland Clinic… did they do this to you?

[KarenK]

In 2 days I’m supposed to be flying to the CC, BUT how I have been treated is unlawful and unacceptable.

I feel like I have been badgered by a number of people in the Surgeon’s office and in Surgical Registration. They all say one thing about the financial arrangement but they won’t put it in writing. They want me to sign a document that obligates me to signing the equivalent of a blank check and ignore what the document says!

The document states, “I agree to be financially responsible and obligated to pay CC for any balance not paid by a Third Party Payer.”
They claim I won’t have to pay anymore than the insurance company’s maximum out of pocket. The insurance company denied coverage.
CC lead me to believe they filed an urgent appeal, which it turned out they didn’t do.

Today Dr. Vargo’s office sent me an email saying they just received an email from my insurance co. and a appeal has been approved.
I called the insurance co. and there is no appeal that been approved!

I can’t do this with these verbal statements of “just trust me” and “never mind what the contract says” when were talking about hundreds of thousands in medical bills!

Did anyone sign such as blanket financial statement? If so, how did it turn out?

 

[Chuck C]

Did anyone sign such as blanket financial statement? If so, how did it turn out?

Yes. Not at Cleveland Clinic, but I had to sign the standard form at UCLA, on the morning of my surgery, which stated that I was responsible for any part of my bill that the insurance did not pay. They did not come after me for any of the bill and insurance paid what had been agreed. Although even a year later they were still billing me for items. It took some time to work it all out, but ultimately I paid no more than I had been promised.

I had to sign the same type of statement when I got eye surgery at UC Riverside. That ended up being a $50,000+ bill that was done out of network because the "in network" hospital that I was supposed to get my surgery done at was full. My insurance fought with them for 6 months, because their contract rate at Loma Linda would have been far less. They tried to get them to at least reduce it. UC Riverside did not budge, and ultimately insurance paid the full 50k plus and they never once threatened to come after me personally, despite the forms that I had signed.

9 days ago I had to take my 80 year old mother to the ER room because she had a bad fall. They are in her insurace network, but she had to sign forms indicating that she was responsible for any part of the bill that her insurance will not cover. I fully expect that she will not have to pay any more than her co-pay of $100 or so.

I think I've been to the ER maybe 6 or 7 times in my life for me and a few times for my kids. I'm pretty sure I signed the "Agreement to Pay" forms every time. Most people don't read what they are signing and just sign on the dotted line. I'm pretty certain those forms are standard. Personally, I can't recall ever having to pay more than what was promised. In fact, its gone very much the other way. My deductible is high and I've had good success negotiating for reductions of my portion on a few occasions. Yes, some will do that- some won't, but it's always worth asking.

Reading the contracts, line by line, that they make you sign upon hospital admittance is a bit like paying close attention to what goes into the sausage and then watching how it is made. Most people just gobble it down, content in their ignorance of the details. Those forms are written by attorneys and they are very one sided. A good friend of mine is an attorney. One time when he was admitted to to the hospital, he took the contract and lined out about half of it and then signed. Well, you can imagine how that worked out for him, lol. I'm not saying that you should close your eyes and sign, but in my experience, it sounds like those forms are fairly standard.

 

[KarenK]

Hi Chuck, You are so very helpful, it is greatly appreciated! It certainly is a stress inducing and confusing time.
You are giving me more confidence in signing that document. But what complicates the situation for me is the CC misleading me on the urgent ins. appeal that they never did. Then emailing me yesterday that they just received ins. approval on an appeal. False. All the willfully inaccurate and conflicting statements do no inspire confidence.

But the real issues are:
1. I have NO ins. coverage at this point.
2. Afterwards it could be a long battle stuck between the Humana Medicare and CC.
3. Easily $450K+, seems so excessive and Medicare doesn't pay much so it makes me think the verbal statements won't be honored. Can I ask what the estimated amount or charges were at UCLA?

Once I fly up there I wonder what additional documents they will want me to sign and/or financial commitments they'll want me to make. It's written in a number of places that they want 50% of the estimates. My experience at the Mayo Clinic was nothing like this. It makes me think I might be better of cancelling, changing insurance, and going elsewhere.

 

[AZ Don]

FWIW, My insurance company has been a pain about pre-authorizations, and the customer support team that I talk to is separate from the team that actually does the pre-authorizations. They didn't have the latest information about my pre-approval and actually said that I should talk to my Dr's office for the latest status of the pre-auth. As I recall they do get the information within a couple days. No idea why it would be like this, but that is my experience - with HealthNet.

 

[Chuck C]

But what complicates the situation for me is the CC misleading me on the urgent ins. appeal that they never did. Then emailing me yesterday that they just received ins. approval on an appeal

It is possible that they are not intentially misleading you. Sometimes the left hand of an insurance company might not be aware what is going on with the right hand. Do you think that they could be talking to different departments at the insurance company? Also, the fact that Cleveland Clinic sent you an email confirming that they have received insurance approval on an appeal is significant. Emails are admissable in court and if they truly are lying to you, that email would go a long way to things going your way, in the event you end up battling them in the end.

Easily $450K+, seems so excessive and Medicare doesn't pay much so it makes me think the verbal statements won't be honored. Can I ask what the estimated amount or charges were at UCLA?

$450k is very high. There is another member who received his quote of a little over 200k, which he shared this week. Mine was about 220k at UCLA. However, that was a negotiated cash pay rate worked out by my carrier. I am part of a cost sharing group, which operates a little different than standard insurance. They received a substantial discount by pre-paying the cost of the surgery. I suspect that the 450k estimate is before insurance adjustment. Have you ever read your EOB forms from your insurance carrier? Many don't ever see those, but my plan forwards copies to me. It shows the initial charges for a doctor visit or procedure, then has the "Adjustment", which is based on the contract which the carrier has with the hospital. It is not uncommon for the adjustment to be 50% to 80% of the bill. For example, my wife had a mammogram recently. Invoice from the clinic was $550. After the insurance adjustment, the bill was $190. It is nuts how this is common practice, but that is a subject for another day.

It's written in a number of places that they want 50% of the estimates.

That is not something which I have noticed before and seems odd, if I am understanding you. Are you saying that they want 50% upfront from you? They want 225k upfront?

I am not saying that you should sign and move forward. You are in a difficult spot if your carrier is telling you that they don't approve and CC is telling you that your carrier has approved it. And, being in a state which ranks 49 out of 50 for healthcare, I don't blame you at all for wanting to get your procedure done at an experienced center of excellence, something which you have indicated does not exist in your state.

No one can tell you what to do. If it were me, I guess it would depend on how far I had let my severity and symptoms progress in determining how urgently I had to move forward before I had all the answers. If I was severe with symptoms and had been in that situation for awhile, I would probably be inclined to move forward with CC and hope that the email they sent you about your insurance approval is accurate. If they are requiring a 50% deposit from you before moving forward, that would be a deal killer for me.

Only you can decide if you feel comfortable moving forward, with the limited assurance that they have given you. I've not heard any stories of CC going after patients for the cost of their procedure in these situations. Be aware also that medical billing is super complicated in the US and the three major US credit agencies have recently enacted a policy of waiting for one year before putting an unpaid medical collections debt onto credit reports. I put a link below, if you want to read about it. If you are worried about unpaid bills appearing on your credit report, this gives you some breathing room to work things out. Even though my carrier had negotiated a 100% prepay before my procedure, I would get medical bills from UCLA, as late as 10 months after my procedure. Reading the fine print on the bills, they indicated that I was responsible. I would forward them to my carrier and they handled it, but I believe there were conversations between them that went on.

Credit report policy on medical debt:

https://www.experian.com/blogs/ask-... medical debt,appears in your credit history.
I would say that I would be inclined to put my health first over financial concerns and Cleveland Clinic has a very good track record with valve procedures. At the same time, no one wants to face financial hardship due to a procedure, so I do not envy the choice before you.

Hopefully you receive some more clear communication from your carrier.

 

[KarenK]

W

It is possible that they are not intentially misleading you. Sometimes the left hand of an insurance company might not be aware what is going on with the right hand. Do you think that they could be talking to different departments at the insurance company? Also, the fact that Cleveland Clinic sent you an email confirming that they have received insurance approval on an appeal is significant. Emails are admissable in court and if they truly are lying to you, that email would go a long way to things going your way, in the event you end up battling them in the end.


$450k is very high. There is another member who received his quote of a little over 200k, which he shared this week. Mine was about 220k at UCLA. However, that was a negotiated cash pay rate worked out by my carrier. I am part of a cost sharing group, which operates a little different than standard insurance. They received a substantial discount by pre-paying the cost of the surgery. I suspect that the 450k estimate is before insurance adjustment. Have you ever read your EOB forms from your insurance carrier? Many don't ever see those, but my plan forwards copies to me. It shows the initial charges for a doctor visit or procedure, then has the "Adjustment", which is based on the contract which the carrier has with the hospital. It is not uncommon for the adjustment to be 50% to 80% of the bill. For example, my wife had a mammogram recently. Invoice from the clinic was $550. After the insurance adjustment, the bill was $190. It is nuts how this is common practice, but that is a subject for another day.


That is not something which I have noticed before and seems odd, if I am understanding you. Are you saying that they want 50% upfront from you? They want 225k upfront?

I am not saying that you should sign and move forward. You are in a difficult spot if your carrier is telling you that they don't approve and CC is telling you that your carrier has approved it. And, being in a state which ranks 49 out of 50 for healthcare, I don't blame you at all for wanting to get your procedure done at an experienced center of excellence, something which you have indicated does not exist in your state.

No one can tell you what to do. If it were me, I guess it would depend on how far I had let my severity and symptoms progress in determining how urgently I had to move forward before I had all the answers. If I was severe with symptoms and had been in that situation for awhile, I would probably be inclined to move forward with CC and hope that the email they sent you about your insurance approval is accurate. If they are requiring a 50% deposit from you before moving forward, that would be a deal killer for me.

Only you can decide if you feel comfortable moving forward, with the limited assurance that they have given you. I've not heard any stories of CC going after patients for the cost of their procedure in these situations. Be aware also that medical billing is super complicated in the US and the three major US credit agencies have recently enacted a policy of waiting for one year before putting an unpaid medical collections debt onto credit reports. I put a link below, if you want to read about it. If you are worried about unpaid bills appearing on your credit report, this gives you some breathing room to work things out. Even though my carrier had negotiated a 100% prepay before my procedure, I would get medical bills from UCLA, as late as 10 months after my procedure. Reading the fine print on the bills, they indicated that I was responsible. I would forward them to my carrier and they handled it, but I believe there were conversations between them that went on.

Credit report policy on medical debt:

https://www.experian.com/blogs/ask-... medical debt,appears in your credit history.
I would say that I would be inclined to put my health first over financial concerns and Cleveland Clinic has a very good track record with valve procedures. At the same time, no one wants to face financial hardship due to a procedure, so I do not envy the choice before you.

Hopefully you receive some more clear communication from your carrier.

CC admitted they did NOT have approval.
Humana’s ins. may be lacking but they have excellent customer service with whom I spent over an hour on the phone as they did everything they could to find out the why it still says denied. I then emailed the CC and requested that they forward the email to me knowing full well that would be impossible because it doesn’t exist. The CC admitted in a return email that they had NOT received approval!

All these constant inconsistencies are a concern. I feel like I’m really being sold, they’ll say whatever to get me to commit.

In thinking about it… they have had multiple opportunities to file an appeal, in an urgent appeal the ins. co. has just 72 hrs. to respond, they could have done this multiple times! Yet they have not, why?

I have no insurance coverage… but I’m only pay the maximum out of pocket? Sure sounds sketchy to me. I did just see on CC’s website that if you don’t have insurance they will discount their fees by 35%. That would only leave me owing only $293K.

I’ve found a lot of what is published in CC’s promotional material and online has not been what I’ve experienced and is very misleading. Their promotional material is in line with a class action lawsuit filed in 2020 regarding unlawful and deceptive business practices which they lost. However, it doesn’t appear that they have changed their business practices, just their promotional materials.

There’s a 5-step appeal process prior to treatment which can easily take a year, possibly two.
There isn’t an appeal process after treatment. Does that mean attorneys and legal battles afterwards? Can I even legally pursue this afterwards? I’ve read a lot of statements about people not surviving the lengthy appeal process, but have found nothing about post treatment options with insurance cos.

On the 50% upfront, I did read that but many statements about upfront payments don’t indicate an amount. Most likely the 50% is on lesser dollar issues. I have no idea of what they may expect me to sign on arrival.

From what I’ve read, larger debts do not go to collections. They end up in court with liens on property, wages garnished, etc. I’m not the least bit concerned about my credit rating. Since my 30’s I’ve always paid cash for everything, homes, cars, etc. I only use credit cards for convenience and they’re paid off monthly. Your money goes a lot further when you are not paying all that interest.

 

[Chuck C]

CC admitted they did NOT have approval

Seems really strange, given that in a previous email they told you that they had received approval.

Humana’s ins. may be lacking but they have excellent customer service with whom I spent over an hour on the phone as they did everything they could to find out the why it still says denied.

Hard to understand that they have denied coverage, but can't explain to you why.

It is my understanding that in accordance with the Affordable Care Act, by law they have to tell you why they deny a coverage. See link below.

• Right to information about why a claim or coverage has been denied. Health plans and insurance companies have to tell you why they’ve decided to deny a claim or chosen to end your coverage. They have to let you know how you can dispute decisions.

https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/appeals06152012a

Since my 30’s I’ve always paid cash for everything, homes, cars, etc. I only use credit cards for convenience and they’re paid off monthly. Your money goes a lot further when you are not paying all that interest.

I think that is a good policy. I always encourage my kids and other young people to not take on debt. Homes, hard to buy a home without debt, great if you are in a position to do so. Cars on the other hand, I always tell them if they need to finance it, then they can't afford it. Few listen.

I hope that you get the answers that your looking for and get this resolved. Can you run a list of other top rated clinics by them to see if they would be more receptive to approving at a different medical center?

 

[KarenK]

Seems really strange, given that in a previous email they told you that they had received approval.


Hard to understand that they have denied coverage, but can't explain to you why.

It is my understanding that in accordance with the Affordable Care Act, by law they have to tell you why they deny a coverage. See link below.

• Right to information about why a claim or coverage has been denied. Health plans and insurance companies have to tell you why they’ve decided to deny a claim or chosen to end your coverage. They have to let you know how you can dispute decisions.

https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/appeals06152012a

I think that is a good policy. I always encourage my kids and other young people to not take on debt. Homes, hard to buy a home without debt, great if you are in a position to do so. Cars on the other hand, I always tell them if they need to finance it, then they can't afford it. Few listen.

I hope that you get the answers that your looking for and get this resolved. Can you run a list of other top rated clinics by them to see if they would be more receptive to approving at a different medical center?

I misspoke when I wrote about the ins. denial. The ins. co. said there has been no activity since the original denial. They did mail a document stating the reason for the denial... I was not "very severe" (critical?) and I was "not in congestive heart failure".

It is so much harder for kids to buy a home anymore or even a car. A lot of things are in such a sorry state due to our political system and corporate greed. I don't know what, if anything, can turn this around.

I just cancelled the airplane tickets and hotel rooms. I need to cancel CC so they stop blowing up my phone and email and on to changing insurance and medical centers.

 

[erricojj]

Something doesn't add up. Why would CC want to perform $450k in services for you knowing that you do not have the means to pay?

 

[dick0236]

But the real issues are:
1. I have NO ins. coverage at this point.
2. Afterwards it could be a long battle stuck between the Humana Medicare and CC.
3. Easily $450K+, seems so excessive and Medicare doesn't pay much so it makes me think the verbal statements won't be honored. Can I ask what the estimated amount or charges were at UCLA?

You state above "I have no insurance coverage" and then refer to having Humana Medicare.

Are you 65 or older? It sounds as tho you may have a Medicare Replacement(?) plan with Humana so I guess you are over 65. Many insurers, along with Humana offer these plans called Medicare "C" (Medicare Advantage). They are structured around "network providers" and "pre-authorization for non-routine services".

"Advantage Plans" plans are now in the re-enrollment period ('til Dec. 7, 2023) and I suggest you talk with an agent about returning to "original Medicare" that has more liberal provider lists. If you go that route, you can then purchase a medicare SUPPLEMENT from a health insurance company to pick up most of the cost "original medicare" does not pay. Be sure to confirm with the insurance company that you will soon need heart surgery and want to have it done at CC. That way you will know what to expect. BTW, all plans (as far as I know....but I am retired) have "lid" on your annual out-of-pocket" costs.

PS. Don't believe the "gross charges" on hospital or physician bills if there is insurance involved. You will never know what they get paid by the insurer. $450,000 for a routine one-week stay and a simple heart OHS (??)......that might happen if it was a double-lung + heart transplant surgery but not a routine OHS without complications.

 

[KarenK]

Something doesn't add up. Why would CC want to perform $450k in services for you knowing that you do not have the means to pay?

i never said I didn’t have the means to pay. And they have ways of collecting. Payment plans, liens, etc. They might be thinking I have deeper pockets then a Medicare plan and that’s why I was mislead and they didn’t follow through with appealing my insurance denial.

 

[KarenK]

You state above "I have no insurance coverage" and then refer to having Humana Medicare.

Are you 65 or older? It sounds as tho you may have a Medicare Replacement(?) plan with Humana so I guess you are over 65. Many insurers, along with Humana offer these plans called Medicare "C" (Medicare Advantage). They are structured around "network providers" and "pre-authorization for non-routine services".

"Advantage Plans" plans are now in the re-enrollment period ('til Dec. 7, 2023) and I suggest you talk with an agent about returning to "original Medicare" that has more liberal provider lists. If you go that route, you can then purchase a medicare SUPPLEMENT from a health insurance company to pick up most of the cost "original medicare" does not pay. Be sure to confirm with the insurance company that you will soon need heart surgery and want to have it done at CC. That way you will know what to expect. BTW, all plans (as far as I know....but I am retired) have "lid" on your annual out-of-pocket" costs.

PS. Don't believe the "gross charges" on hospital or physician bills if there is insurance involved. You will never know what they get paid by the insurer. $450,000 for a routine one-week stay and a simple heart OHS (??)......that might happen if it was a double-lung + heart transplant surgery but not a routine OHS without complications.

 

[KarenK]

My Medicare denied my surgery stating the I'm "not very severe" (I guess that means critical) and I do not have congestive heart failure (so I have to incur more heart damage first). Yes I can go back to original Medicare, however you normally can not get a supplement plan unless you signed up for one in the first 6 months of starting Medicare. I don't know if there are exceptions to this, I need to research that.

As far as going back to the CC... NO! The CC may have great surgeons but their business practices are unlawful and unethical from what I experienced, and their $450k - $500K fees are outrageous. There was a class action lawsuit filled against the CC in 2020/2021 regarding their business practices and the court ruled against them on every point. The CC's website and promo materials are in line with the court but they have not upheld those standards in practice was my experience.

When they couldn't keep their stories straight on the financial issues, speaking out of both side of their mouth, it became clear I'd be dealing with them for many years ahead if I proceeded. They wouldn't file a simple appeal on the front end but they're going to go battle on the insurance denial after the surgery?
I was supposed to fly out today. When the surgeon's nurse practitioner called yesterday to confirm that I was not coming, I was surprised she made a point to tell me things were not her fault.

 

[MIB]

This makes no sense. I'm guessing you have a Medicare Advantage plan.
CC must not be in network for your insurance. If that's the case, you'd be self pay. That would be ridiculous charges.
It's open enrollment now. I suggest you find a different Advantage plan. Make sure your providers are in the plan you choose. Also realize, during open enrollment you don't need to pass underwriting. If you choose a Medigap policy, you will need to get through underwriting unless you are in a state that doesn't allow for them.
Good luck.

 

[KarenK]

This makes no sense. I'm guessing you have a Medicare Advantage plan.
CC must not be in network for your insurance. If that's the case, you'd be self pay. That would be ridiculous charges.
It's open enrollment now. I suggest you find a different Advantage plan. Make sure your providers are in the plan you choose. Also realize, during open enrollment you don't need to pass underwriting. If you choose a Medigap policy, you will need to get through underwriting unless you are in a state that doesn't allow for them.
Good luck.

The CC is in network. The problem is Medicare Advance is not Medicare. They are greedy corporations all about the $$$ so they wrongfully deny coverage.

There are changes in the works on how these companies promote themselves but nothing is being done that I’m aware of about their improperly denying coverage. people died before they get through the lengthy appeals process but I guess that’s ok as long as the powers that be collect the bribes from the insurance lobbyists.

 

[MIB]

A great reason to ditch the advantage plan and get a Medigap plan. The tough part is passing underwriting unless you live in one of the few states not allowing underwriting.

 

[dick0236]

A great reason to ditch the advantage plan and get a Medigap plan. The tough part is passing underwriting unless you live in one of the few states not allowing underwriting.

A question for MIB: You seem to have a good knowledge of the Medicare Advantage plans. Since she had to have both Part A and Part B in order to get a Medicare Advantage Plan (Part C) would she have to go thru underwriting if she opts out of MC Advabtage in favor of Original MC and a private MC Supplement during the "open enrollment" period thru Dec 7, 2023?

I am a retired agent and have had a Medicare Advantage plan since they were introduced years ago. Personally, I have been very satisfied with the concept and have used it fairly often due to my age and cardiovascular issues.

 

[KarenK]

A question for MIB: You seem to have a good knowledge of the Medicare Advantage plans. Since she had to have both Part A and Part B in order to get a Medicare Advantage Plan (Part C) would she have to go thru underwriting if she opts out of MC Advabtage in favor of Original MC and a private MC Supplement during the "open enrollment" period thru Dec 7, 2023?

I am a retired agent and have had a Medicare Advantage plan since they were introduced years ago. Personally, I have been very satisfied with the concept and have used it fairly often due to my age and cardiovascular issues.

May I ask what company your MC Advantage plan is with?

 

[MdaPA]

They did mail a document stating the reason for the denial... I was not "very severe" (critical?) and I was "not in congestive heart failure".

This is not making sense to me. If CC reviewed your test results (e.g. echo, tee, etc.) and gave you a surgery date then you needed the surgery now. I'm finding it hard to believe that some insurance company overrode CC's decision unless some piece of information was missing. I also am surprised CC supposedly dropped the ball with the appeal on this. CC is a world class heart facility which normally runs as a well oiled machine.

 

[MIB]

A question for MIB: You seem to have a good knowledge of the Medicare Advantage plans. Since she had to have both Part A and Part B in order to get a Medicare Advantage Plan (Part C) would she have to go thru underwriting if she opts out of MC Advabtage in favor of Original MC and a private MC Supplement during the "open enrollment" period thru Dec 7, 2023?

I am a retired agent and have had a Medicare Advantage plan since they were introduced years ago. Personally, I have been very satisfied with the concept and have used it fairly often due to my age and cardiovascular issues.

The answer is, it depends. In a few states, they're not permitted to do underwriting. In the majority of states, one will have to go through underwriting. Everyone must have Medicare parts A & B. that's true for both Advantage and Medigap plans.
The difference is advantage plans are guaranteed issue. They have to take you no questions asked, no restrictions about preexisting conditions.
Medigap plans are allowed to choose whether or not to accept a person.
I don't recall what states do not allow underwriting. IL and CA are two. There are a few others.
This change is allowed during open enrollment. Several states also have a "birthday month rule. Changes are allowed during the person's birthday month.
Underwriting is a prickly issue. They can deny not only with preexisting conditions, but also if you've been prescribed certain medications. Each company has their own parameters.