Two out of three people who fought back, won

Hey friend,

My mail sits on the kitchen counter in a pile for about three days before I deal with it. Always has. But there's one kind of envelope that never makes it into the pile, and you know the one I mean. Window on the front, hospital name in the corner, and suddenly you're standing there opening it before you've even put your keys down.

I read a lot of healthcare news every week. Most of it is about software and mergers and things that will never touch your life. But four or five stories came out this week that land directly on that kitchen counter, so those are the ones I want to talk to you about.

1. When you appeal a denial, you usually win

Insurance companies now have to report how often they say no to care your doctor ordered. In my old world that "no" has a name, prior authorization, but you can think of it as a permission slip your doctor has to get before you can have a test, a scan, or a surgery. The first year of that data just came out, and insurers denied somewhere between 12 and 18 out of every 100 permission slips.

The denials themselves aren't really the story. The story is what happens after your procedure (or your medicine, or your specialist) gets denied. Most people never fight a denial; they read the letter, they feel a little sick, and they file it away. But of the people who did appeal on a Medicare Advantage plan, 67% got the answer reversed. On Medicaid it was 47%, and on a marketplace plan it was 43%. One company, Centene, reversed 93% of the Medicare Advantage denials that people bothered to appeal.

Two out of three.

I want to be careful here, because that number can sound like a promise and it isn't one. Some denials are correct. Some appeals fail. But an awful lot of people are getting told no by a stranger at a desk who never met them (or an AI tool), and the only reason that no sticks is that nobody fights back.

What this means for your wallet: Treat the denial letter as the beginning of the conversation rather than the end of it. That letter is required to tell you how to appeal and how long you have, and the window is usually short, so open it the day it comes. Then call your doctor's office and ask them to send a letter of medical necessity. That letter is what wins most of these, and the staff there write them all the time.

One thing worth knowing: if you get insurance through your job, like roughly 150 million of us do, your company doesn't have to report any of these numbers. You can't look up how often your plan says no. Appeal anyway.

2. There may be $7,000 sitting in your benefits right now

Healthcare is overwhelming.

You just got a scary diagnosis. Nobody has billed you a dime yet, but money is already walking out the door. It's gas to a treatment center forty miles away, a hotel the night before an early surgery, somebody to watch your kids, and a week of drive-through dinners because you did not have it in you to cook.

A new study out this week found that 44% of people spent $1,000 or more in that window, before a single hospital bill showed up. But fewer than one in three people knew there's a benefit that covers exactly that kind of thing. It usually goes by hospital indemnity, critical illness, or accident coverage, and it pays you cash when something big happens, which you can spend on groceries or gas or childcare or whatever the emergency actually requires. One large insurer just rolled out a version that pays up to $7,000.

And when employers offer this stuff, only 20 to 25 out of every 100 people sign up for it.

I get why. That open enrollment packet is designed by lawyers and yeah... it FEELS like it's supposed to be hard to understand. But this is the rare case where a few dollars a paycheck buys you the thing you'll actually need, which is cash in hand during the worst month of your life.

What this means for your wallet: When your open enrollment packet shows up this fall, go looking specifically for those three phrases. If you already have that coverage and something happened to you this year, call the number on your card and ask what you can still file for. A lot of plans let you go back.

3. Get ready for your open enrollment packet

Employers are expecting their health costs to jump about 9% next year, and they've guessed low three years running, so it may land higher than that. It sounds like a company problem, but that cost rolls downhill into your premium, your deductible, and whatever quietly disappears from your plan.

Two things to watch for. Prescription costs are climbing faster than everything else, projected up around 12% two years in a row. And if you take a GLP-1 for weight loss, look closely, because the share of employers covering those drugs for weight loss dropped from 72% to 60% this year, and not one company in the survey said they plan to add that coverage.

What this means for your wallet: Don't auto-renew. I know it's the easiest button on the screen, and I know you're tired. But pull up the drug list, find your own prescriptions, and check them one at a time before you click anything. If your medication got dropped, you want to find that out in November while you still have options, not at the pharmacy counter in January.

4. There's a robot making your bill bigger

Hospitals are using artificial intelligence to comb through your chart and pull more money out of the visit. The industry calls it revenue optimization. What it does in practice is bump your visit up to a higher billing code, so a routine appointment gets billed like a complicated one. It's working well enough that 64% of employers say it's driving their costs up.

What this means for your wallet: Ask for an itemized bill every time, not the summary with three lines and a total. Then go looking for the ordinary stuff: a room charged for a night you were already home, two of something you only got one of, a level of visit that doesn't match the eleven minutes you actually spent with the doctor. You are allowed to call and ask what a charge is for, and you are allowed to keep asking until somebody explains it in plain English.

5. Same doctor, same room, brand new fee

Hospital systems keep buying up independent doctors' offices, and from where you're sitting nothing changes at all. Same building, same doctor, iffy parking. What changes is that the office can now bill you like a hospital department, which means a facility fee shows up on your bill. That's a charge for using the building. You get nothing extra for it.

You'll usually know it happened because the sign out front changed or your paperwork suddenly has a health system logo on it.

What this means for your wallet: Call before your next appointment and ask one question: "Will I be charged a facility fee for this visit?" Then ask if there's a location in the system that doesn't charge one. Sometimes there's an independent office down the road and sometimes you're stuck, but you should find out before you go rather than three weeks later in an envelope.

Quick hits

Surprise bills are still illegal. There's a fight going on in Washington about how much the No Surprises Act costs to run, and you'll see headlines about it. The part that protects you hasn't changed. If you went to an in-network hospital and got a bill from an out-of-network doctor you never picked, that bill isn't yours. The No Surprises Help Desk is 1-800-985-3059.

Medicare folks, there's a deadline. A proposed rule could shut down home monitoring programs for around a million people managing things like heart failure and diabetes from their living rooms. More than 200 healthcare organizations asked the government to slow down. Public comments close September 14.

Don't trust the chatbot's price. Hospitals are rolling out AI tools that estimate what your care will cost, and about half of us are willing to use them. Only about 4 in 10 people believe those tools are working in their interest, which strikes me as a healthy instinct. An estimate from a chatbot is not a price. Ask for a written good faith estimate, which you have a right to.

The point is - you don't ever have to take anything you get about your medical bill - or a denial - at face value. The system assumes you won't fight back.

Fight back. Read everything.

I hope this was helpful to you.

Talk soon,

April

P.S. If you're staring at a denial and you don't know where to start, hit reply and tell me what it says. I read every one.