“I don’t know how we’re going to get through this.”
Hector and his wife, Maria, are in their twenties with small children. The cost of living is high in their city, and the young family lives paycheck to paycheck. Hector works hard at his job, and Maria stays home to look after their family. Hector received a pay increase, and is planning to use the extra money for daycare so Maria can go back to school. And then, a necessary surgery threatened to change everything.
On his way home from work, a severe thunderstorm hit. Hector’s car skidded off the road, out of his control. He slammed into a utility pole and his steering wheel hit him hard. However, luck was on his side that day—Hector was able to walk away from the accident with minimal injuries, though he was told by insurance he would need to total the car. When Hector went to bed that night, he felt shaken up and worried about how they would afford a new car, but glad to be safe. If only this was the last of his worries.
The next day after breakfast, Hector’s chest felt like it was on fire—he had heart burn worse than anything he had ever experienced. Worrying it was due somehow to his accident, he went to the nearest hospital. Hector was diagnosed with a diaphragmatic hernia, a result of his chest trauma during the accident. The hernia had caused his organs to shift upward, resulting in his extreme reflux. The doctor recommended surgery right away to prevent damage to his organs.
Recovery followed by shocking news
Hector’s surgery went well. He still had healing to do, but was released after a few days into the relieved arms of his family.
Unfortunately, trouble wasn’t over for the family quite yet. A month after the accident, Hector received a startling bill from the hospital—the charge for his surgery was $151,000. He was responsible for a portion of this amount based on his healthcare plan, and he started to panic. He wasn’t sure how he and Maria would be able to cover their portion, and keep food on the table.
Support and negotiation
Hector called Meritain Health Customer Service immediately to ask about the bill. A customer service representative, Andrea, had good news: the Meritain Health Cost Management team had already been alerted of this high-cost claim and were working to negotiate a lower rate. Hector and his wife were ecstatic and breathed a huge sigh of relief.
High-dollar claims negotiation
Because of the high-dollar amount of Hector’s claim, it was automatically identified in Meritain Health’s system for review and transferred to a member of our Cost Management team to take action. For comparison, the team researched what similar facilities charge for the same procedure, and discovered it was much less.
Then, through expert negotiation with Hector’s hospital, we were able to reduce the billed charge for his surgery by nearly $125,000. Hector was responsible for his deductible and just 40 percent of the final negotiated charge. This helped both Hector and his employer save on the cost of care.
Advocates for Healthier Living
Meritain Health provides the benefits members like Hector and his family need for good health all the time—from routine preventive services, to surgery in extreme situations. Our high-dollar claims negotiation adds to our members’ peace of mind through cost savings. It’s all part of our mission as Advocates for Healthier Living. Every day, Meritain Health works hard to keep our healthcare accessible and affordable for our members. This way, their main concern isn’t covering the cost of care, but instead getting and staying healthy.
This story is based on an actual member experience. Names and information have been changed to protect the member’s privacy.
This communication is intended for informational, promotional purposes only. The amount of total savings represents the savings off of out-of-network billed charges that are the product of individual negotiations directly with the provider. The reference to previous outcomes made as a part of this communication does not guarantee success or similar outcomes in any new or future negotiation, as the result of each case depends upon many factors, including but not limited to the facts of each case.
Health benefits and health insurance plans contain exclusions and limitations; see your plan documents for complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary and are subject to change.
