Sam was a happily married marathon runner who worked as a medical social worker in a local hospital. He was 29 years old when he discovered a lump near his shoulder. A biopsy and lab review showed that the mass was a rare type of sarcoma. His oncologist had never treated a patient with such a tumor type, and helped Sam locate a sarcoma specialist in Boston who performed a special surgical technique and had experience with some innovative new therapies.
Sam felt lucky that his insurance would allow him to receive treatment anywhere in the country. A careful reading of his policy confirmed that he would be liable for 20% of the bill if he stayed within network, and 40% if he went out-of-network. The Boston hospital was not within network, but Sam and his wife had some savings and felt the 20% difference would be well worth the investment.
Sam did well with treatment, but he and his wife were shocked when the bills started arriving a month later. What they anticipated would be a few thousand dollars in co-pays and deductibles, was close to $20,000, an exorbitant amount for this young family. They called an advocate to help them figure out if mistakes had been made and if they were really responsible for the bills.
The advocate helped them figure out that they were subject to “usual customary and reasonable (UCR)” charges. This means that their insurance company had only agreed to pay 60% of charges that they thought were acceptable in terms of price. Because the hospital had charged more than what the insurance company considered usual customary and reasonable, Sam was being charged the rest.
The advocate helped Sam and his wife create a financial plan for their family. The advocate also empowered them to call the hospital in Boston and negotiate a lower price along with an affordable payment plan that they could contribute to each month. While they have been forced to keep a very tight budget, they are working to pay off the debt without going broke.
