Never Pay The First Bill - Fight the Healthcare System and Win

Welcome to the Self Funded with Spencer podcast. Healthcare is broken and we aim to fix it one conversation at a time. Hey. Hey. Welcome. Welcome to Self Funded with Spencer. I'm your host, Spencer. That's why it's not Self Funded with Tom, because I'm not Tom. I really appreciate you guys checking out the show. If you're new. Awesome. Glad to have you. If you're a returning listener, thank you as always. Literally could not do this show without you. Today's episode is a fun one, a really, really fun one because I have Marshall Allen on the show. Marshall has a really, really big public Persona within our industry. He's a really high profile individual. That's because he's written a book that's causing some stir and stir in a good way. It's called Never Pay the First Bill. What his book does is based on his 15 years of investigative journalism within the healthcare space, working for an organization called ProPublica. And he discovered throughout that decade and a half that, my goodness, there is a lot of fraud, waste, abuse, overcharging up, coding, unnecessary charging, et cetera, et cetera in our medical establishment where people are often left with enormous medical bills that are inappropriate and they're left going, well, I don't know what to do. And not having a lot of recourse. Well, they don't have a lot of recourse until they read Marshall's book or put into motion his practices. He teaches the common man and commonwealth in the United States how to fight back against these charges, how to collect information that will be useful, how to actually file suit in small claims court against some very, very big organizations and win. It's a David versus Goliath story. But the reason David can win is because there are tens of millions of Davids and, and ultimately often more often than not, the truth is on David's side. So if you don't leave this episode with a little bit of self righteous anger, then I'm not sure you paid attention. And if you don't leave this episode smarter and with an action plan, the next time you get a bill that you're looking at and going, what in the world is this? I can't pay this. This didn't happen. If you don't know what to do after this episode, at least go get his book. Because then if you get his book, then you'll definitely know what to do. Okay. And he's got a series of videos coming out that's going to teach people.

What to do as well.

This man is doing great things for our industry, and I'm so excited to share his episode. Without further ado, Mr. Marshall, the idea.

Marshall, do you want to start. You want to do a podcast? You feel like doing a podcast tonight?

Do I feel like doing.

Doing a podcast? Yeah. Should we actually do it?

Yeah.

I was gonna say, you've been here, like, an hour. We've having a great conversation. Was like, let's actually capture. All right. So, Marshall Allen, welcome to the podcast. How you doing, sir?

I'm doing great. Thanks for having me here.

Well, it is my pleasure. I appreciate you letting us try out the new setup. It's cool. That's why I have the Ascend podcast team. The folks that are listening won't be able to see it, but I encourage you to look at the video as well. This is a pretty cool setup and a cool space. Awesome.

Yeah, thanks.

Well, my pleasure, man. So, Texas transplant. I want to start there. We were talking about you. Love the hospitality. Was Texas everything you envisioned and. Or more. Or were some of the stereotypes true? Tell me about your, you know, transition to the Lone Star State.

So one thing that I've always said, my wife and I've always said about Texas is we've never known anybody who's moved to Texas and didn't like it, and so we knew very little about Texas. I mean, I had been to Dallas and Houston and Austin. I mean, I'd been to the cities in Texas. But until you're here and the people are so friendly, I mean, I think that's been the most refreshing thing, is just the genuine friendliness of the people everywhere you go. So even the checkout line at the grocery store, you know, the person, the woman's making conversation with you. I had a woman invite me to her church, you know, checking me out.

Very normal here in Texas. Yeah.

In New Jersey, I mean, I think people are so stressed out there, you know, they don't even, like, acknowledge your humanity. Like, I'd be walking my dog through the neighborhood. I would pass another neighbor walking on the street, her dog. And, you know, I'm a person. Like, I talk to people in elevators. I'm very extroverted, you know, so. So I'd say, hi. You know, I always think you should greet somebody, pass them on the street, especially in your neighborhood, they would ignore you. They wouldn't say anything. And that wasn't uncommon. And I'm not quite sure what it was. I mean, I love New Jersey, so I loved living there, and we had great friends there, but sometimes it was. I don't know if they were stressed out or what. I mean, the cost of living is high.

Maybe that was it.

I love hearing that about Texas because I've been here out of my 39 years in existence. I've been here 34 years.

Right.

So you grow up here, you don't think anything different. It's almost ingrained in who you are. Nobody. Your parents don't say, hey, make sure you smile and wave at everybody when you're walking your dogs. It just is a thing that you see your entire life. So it's interesting, somebody from a perspective outside coming here and thinking like, oh, this is refreshing, or this is new. I'm just going, well, that's, that's normal life here.

Yeah, I mean, I'm sure it would make some people uncomfortable. You know, maybe as extroverted. You know, some people are like, well, I don't really want to talk to everybody.

Please don't talk to me.

Yeah. Whereas I'm extroverted. So for me, I think it's fun and interesting and, you know, it's just, it's nice to acknowledge the humanity of the person.

I agree with you. It's almost, I was telling you, it's almost neurotic in nature for me. Like if I am see somebody, I have to acknowledge their existence or I feel like, oh man, did I make them angry or are they going to be upset now that I didn't do so. So, man, anyway, so I'm glad you like Texas. You moved down from New Jersey. Was that transition for your new role or what brought you down?

So I took it.

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Job with the Office of the Inspector General for the Department of Health and Human Services. So basically now I do my day job is I left ProPublica where I was there for 10 years and now my day job is doing evaluations and inspections, we call it, of federal government spending on health care. So all of the taxpayer dollars that are being spent on Medicare, Medicaid, the cdc, the nih, any of these Department of Health and Human Services programs are kind of like fair game. So we develop evaluations and inspections. I'm new to the job, and anytime I am on in a venue like this, I have to make the disclaimer. I'm obviously not here speaking on behalf of the federal government. I'm here talking about my book. I'm an author and educator, but I always make sure and make that clear because I'm not a spokesperson for them.

Totally fair.

Like I get that right. And I don't think we want to represent that. That's the case. But so six months in, it's almost funny to ask this with a government job. Is the honeymoon phase over? I mean, or is are you kind of getting the reality of what the role is, what influence you might be able to have? Is it still too new?

Oh, it is. Like, it's a big agency and journalism is so freewheeling and independent and this is so collaborative and structured. I mean, I have got a lot to learn to learn how to navigate the system. But in terms of the work that's being done and the amount of influence that can be had, it's very exciting. That's why I went there because. Or one of the reasons I went there is that I have now documented for 17 years, 16 or 17 years, all of these problems with our healthcare system and all the ways that it's not set up in a way that is really designed for the benefit of the public and to have the opportunity now to bring about some type of change, whether it's with a federal government program or a Medicaid or Medicare type of program, to be able to identify issues that need to be changed and bring about improvement is huge. And then that's also what I'm trying to do now with my book and with Allen Health Academy and the things I'm doing in the employer sponsored health space and just the consumer, you know, for working Americans. That's, that's really exciting for me too. So in a way, I feel like I have the best of both worlds. I get to do a meaningful job for the OIG and then I get to do meaningful work independently for working Americans.

Well, it's just a nice balance too. And obviously that's kind of where you are today. But I am very curious to hear the origin story of how you you obviously are the author of Never Pay the First Bill. You mentioned you were a ProPublica investigative journalist for 15 years. But I'm curious, how did you even find the space? Like the healthcare space or this, you know, fraud, waste and abuse or corruption or whatever you want to call it, like what drew you to this? And I know there's a ministry background as well that I want to hear.

Yeah, so I, I never had any clue what I would want to do with my career. And I mean I'm a, I mean people know I'm pretty just open about my faith. You know, I'm a Christian and so my wife and I would pray that God would direct us and what we would do. And so I spent five years in full time ministry. Then I started freelance writing for these small Christian magazines and really got the bug. I mean I really, I thought I would stay in full time ministry and that once I started freelance writing, especially doing stories that were more investigative, you know, I've always loved investigating things. I'm very curious, I'm very morally minded. So when I see things that are wrong, it really irks me and I want to do something about it. And I saw the power like when you would write stories, you can bring about change just with one story and exposing a problem usually like shames whoever the person is or the institution is that's causing the problem and then at least motivates them to change that one thing that you write about. And so I saw right away that you can have a lot of influence. And also I'm a very curious person and I like to learn. So a journalist only talks to interesting people. Like by definition you're talking to people at the most extreme interesting moments of their lives and you're documenting that. It's a very kind of privileged position to be in where like you're sitting down for an interview with someone and you can ask them anything. I mean it's like this, the role you're in right now, you can ask me any question and I'll probably answer it, right. And that's really fun actually. And I'm a people person so I would always get to know people and meet people. But in terms of healthcare journalism, again, complete accident. I covered like for my first five years in journalism. You know, you cover like city council meetings and school board meetings and they open a Starbucks in town and you write about it and like they have a different reporter assigned to the holiday, every holiday. So like if it's Christmas day, you know, you're going to some like Food pantry where they're feeding homeless people Christmas dinner and stuff, and you're writing stories about that. So when I got to the Las Vegas sun, the editors there said, hey, Marshall, we want you to cover healthcare. And the first words out of my mouth, no joke, were, I can't imagine anything more boring than writing about healthcare. I thought it sounded like. I mean, my eyes were glazing over as we were having the conversation.

And what was the motivation for them to be drawn to that Was the thing that you should cover, right? Was there a story that they thought was. Might be breaking?

I don't know. I think. I think they just needed someone to cover that beat, and they knew it's an important beat, and so I needed a beat. So maybe, I don't know, I should ask him, because I don't really know what it was, but it was the perfect beat for me. Like, I realized right away that this is the most interesting thing to cover because it addresses two things that are extremely important to any person, their health and their money. And so I found as long as I could write about stories from the point of view of the patient who has to navigate this giant, complicated system, very disjointed, siloed, not set up for their benefit, ripping them off, often harming them. I've done tons of stories about quality of care and patient safety problems.

So when I wrote about from the point of view of the patient, all these stories were investigative. And I realized if I could use the patient as kind of my vector into the story, you know, I could get the patient to gather all their medical records, and I could get the patient to waive their HIPAA rights so that I could talk to their doctors, their insurance companies, and really get all. All sides of the story. I just developed a really good understanding of the healthcare system. And this was after doing thousands of stories. Like, I figured it out one time. I think I've interviewed more than 10,000 people. I mean, I've done, you know, two or three stories a day for five years. I mean, all those stories, you're talking to two to five people in Las Vegas for five years. I did two or three stories a week. Those ones were more in depth. You're doing five to 10 interviews per story there at ProPublica. I mean, you're doing fewer stories, but you'd be talking to scores of people per story. And so I have talked to insurance people, doctors, brokers, patients, and I've had people tell me what's going on from the point of view of what's in the best interest for the public. And so I've learned a ton about the healthcare system and that's really what ended up leading me to write the book. But to give you an example of how quickly I saw the potential. So when I first started covering healthcare, I just started booking coffee appointments with doctors, nurses, hospital executives, anybody who would talk to me. And I'd just say, hey, look, I'm a journalist at the Las Vegas Sun. I'm covering healthcare. I know nothing about health care, but can you tell me what I should write about, what's interesting or what's in the public interest around here? Now, I remember this meeting that I had with this one doctor, and he was an older doctor, and he said, well, has anybody ever told you about how foreign doctors are being exploited in Las Vegas? And I was like, no, no one's ever told me about that. So he told me about this.

Scam, really, that was being set up by these employers who would sponsor the visas of foreign medical graduates. About 30% of the doctors in the United States are foreign medical graduates. So we bring in the best and the brightest doctors to the United States and then they end up immigrating here. But they immigrate through a program called the J1 Visa Waiver Program, where they have a waiver on their visa. The employer sponsors their visa so that they can work in like an underserved area, you know, like a rural area or like a blighted urban area. But the catch here is that you get some unscrupulous employers who have that doctor under their thumb because they sponsor their visa. They started cheating these doctors out of their wages. They would work them 120 hours a week. They would redirect them from the underserved areas into the big fancy Las Vegas hospitals where they could rake in more money for the boss. There were these employers, one of the employers had like 16 of their doc of these doctors on his staff. He had built a whole empire on the labor of these foreign born medical graduates. And so we called the investigative series Indentured Doctors because that's what they were. They had to serve for three to five years under the thumb of these unscrupulous employers. And it was amazing. I couldn't believe it. I was like, in the United States of America, we have doctors, the best and brightest, smartest people being exploited by these bosses who can control them because they, they sponsor their visas. And I documented this all over the country. It wasn't just happening in Las Vegas. It blew my mind.

They use the term bosses and under the thumb, it almost feels like a Mafia esque style.

Right. A lot of it is. I mean, people will use the word cartel sometimes to describe like the health insurance industry or the. And I mean, that is a term that actually is a fair term. I mean, it's a conglomeration of large institutions that are working together to drive up the cost of healthcare. That is the definition of a cartel. And so part of what I do, the book gave me a lot of freedom to reframe things a little bit, to be less detached. When you're a reporter for a place like ProPublica or the Las Vegas sun, you're being very objective, you're being very measured in the way you report things. And the book is actually quite objective too. But. And I don't actually use the word cartel in the book, but what I will say is, I'll say we have a system that is a lot of things you see are legal, but they're immoral and they're unethical. Well, you know, I wouldn't put that in a story for ProPublica. But when I'm writing my book and I'm giving an assessment of what's happening in our healthcare system, a lot of what we see, frankly, is immoral and unethical. And we've just come to accept it. But my position is I don't accept it.

You know, so, so I appreciate that you don't accept that.

Yeah.

Because you've been beating this drum for a while now. But I think, you know, we're talking prior to the podcast, it's like for me, being relatively new to this, the exposes that you're doing, some of the examples that you showed at some of the conferences we attended recently, they're so egregious that I'm going, if, if, if the public knew the extent at which this fraud is happening, or I don't know if you just want to call it abuse or gouging, whatever the exploitation, whatever the, the terminology is, somebody is the, the balance of power is obviously tilted away from the individual. So if you are out here beating this drum loud enough, I'm going, like, if enough people just were, knew this, we, everybody would be angry about how bad it actually is. And I know that was probably the part of the motivation for the book. But when you were you leaving ProPublica as you were writing this book, or were you doing both simultaneously?

Not at all. No, I did both simultaneously. And the government job just sort of came out of nowhere, like very unexpected. I never thought I'D be working, I mean, for the federal government. Never imagined I would be, but.

No, it was something I did. A lot of it came out of my ProPublica work. So if you look at my ProPublica stories in 2017, 18 and 19, I did a series in 2017 called Wasted Medicine, which is all about squandered healthcare spending. Experts estimate we are squandering $800 billion a year on wasted healthcare spending. And that's, you know, high prices, administrative bloat, like over treatment, just treatment that's not necessary. The complicated way we pay claims, you know, we have hundreds of insurance companies, all of them with hundreds of different plans. This complicated way claims are going. Millions of claims a year being processed through this system. There's tons of mistakes, tons of overcharges. They estimate that alone could save a couple hundred billion dollars.

Well, so the last guest on My podcast was Dr. Sanjay Prasad, and he's. I misspoke. He's not an ear, nose, and throat surgeon. It's some autology. I forgot exactly the term. But he talked about his. The reason why he started surgicality is because, one, they were looking at the quality metrics around the physicians. But two, he said, do you realize how many unnecessary surgeries are performed in the United States? He said, rough estimate is somewhere between 15 to 30% of all surgeries are unnecessary. He spoke to an orthopedic surgeon in Texas, and he said that doctor estimates the number of spine surgeries that are unnecessary near as 80% in Texas. That's an astonishing percentage. Right. And so you're talking about the unnecessary spending or the bloat. Right. How much of that would be reduced just by diverting somebody away from a surgery that they don't actually need?

Right. And how much harm is that cause exactly those patients?

Permanent harm.

Permanent harm. And the complications are also really high with spinal surgery especially. And so I, you know, I have a chapter in the book about that, how to avoid over treatment. You know, and so the fun thing about the book is that I could take the things I've learned by talking to thousands of people doing all these interviews again, independently. Nobody's paid me to do anything. Nobody's told me what to say. And then I get to say, okay, here's what a patient can do. The consumer has more power than they think. It's just we've been conditioned to be passive. And I think that's frankly, because it would be easier for everybody in the system if we just passively let them, you know, use us as billing Units.

To take advantage, whatever the term. Yeah, no, I think you're right.

Right.

I think the opaqueness of this. Right. The complexity that you just described, you know, it's all, whether intentionally or unintentionally designed, again, to make the member or the person that actually is receiving the care, choosing the care completely in the dark about the cost, what's appropriate, second opinion, anything that you name, we are at a complete disadvantage against the system. So was there an extreme egregious example? I mean, we don't even need to sensationalize this because I think reality is actually stronger than fiction in this regard. But was there a story that you heard that was like, oh my God, obviously you talked about the doctors, but was there a particular situation with a patient that was being taken advantage of or this extraordinary bill that was in their lap where you just go, now this is the thing I need to sink my teeth into and really go after.

Well, it's always been the two things. Cost and quality are the two things I've dug into because that's where the patient is being taken advantage of the most. But I remember sitting in the kitchen of a woman named Carol LaRocca. She was, I don't know how old she was at the time, maybe 75 years old, older woman on a fixed income, not a wealthy woman at all. And she's sitting there crying because she's in debt because of a medical bill that was caused by an infection she picked up while she was undergoing a very common elective operation. So here you have a hospital acquired infection where they send the bill to the patient, the insurance company doesn't cover the antibiotic that she needs, so she's thousands of dollars in debt. And she has bill collectors hassling her and harassing her to pay the debt for an infection that was caused by the medical care she received. And I think that's always been the thing that's maybe gotten me the most outraged, is not only do we send unfair bills to every patient, but when a patient gets harmed, injured while undergoing medical care, they still get stuck with the bill. That to me is the worst part. Just another example. A woman at my church in New Jersey, you know, when people know you cover healthcare, you know, these conversations end up coming up. So she tells me about she had a hernia surgery about nine months to a year after the operation. The incision started to open up again. It got red, it started to open up, it got infected. Well, she had to go back to her surgeon and found that they had left some gauze Inside the incision that is an obvious retained foreign object is the term that they use in healthcare for that. Obviously, that's a mistake, right? But the problem is for anybody to admit the mistake, then they're afraid of liability, right? So when a patient gets injured, they do everything they can to avoid it. They gaslight them, really, they shun them so that they don't have to put.

That gauze in your body. That wasn't us, right?

So in this case, she was getting bills because of the gauze that was left in her side. And I was like, look, here's at least what you need to do. You need to tell the surgeon, try, you know, try and be friendly with him, let him know you're not going after him to sue him. But at least you don't want to be billed for the corrective action it's going to take. Because she needed more procedures, she needed antibiotics, and they were able to take care of that. But it took a lot of negotiating with her to make sure that she didn't get billed by the surgeon and the hospital for this mistake that was made, that was harm caused to her. So that's how twisted this is. I sometimes say all the things that you teach your kids to do when you've made a mistake or done something wrong, you should admit what you did, you should apologize for it, and you should make it right. I mean, you have kids, I have kids. That's kind of what I'd say decent people do to train their children, right? The healthcare system doesn't do any of that. When harm is caused, there's denial, there's ignoring, there's obfuscation, and then the patient is expected to, you know, defend themselves or take care of themselves. And that's really what my book is. It's almost like a. It's a guerrilla guide to self defense against the healthcare system.

Well, let's. So let's talk about that. Let's talk about practical steps, right? You know, these situations that you describe. I know part of the book is the action plan of what to do if you find yourself with a bill that you think is, you know, overcharging you, maybe, there's obviously some charges on there that were inappropriate. Or you maybe you just find out, hey, I've got this really big bill and I don't know what to do. Maybe I need to look a little bit further into it. So let's talk about some practical steps that your typical patient or your typical person could actually deploy today to start fighting something like this. What would You. Where would you start?

Number one thing, get an itemized medical bill, right? So often you get a bill, it's just like a lump sum or an aggregate of medical services or, you know, emergency room services or something like that. It has to be itemized and you need the billing codes. And by the way, if they ever hassle you or won't deliver a billing code or a itemized bill, I just wrote this in my. I have a newsletter. So if everybody would sign up for my newsletter. It's free. I'm going to plug it right now. Marshallallen.substack.com okay, that's my newsletter.

Put that in the show notes, too.

Yeah, so I just wrote this about it because I was a friend of mine back in New Jersey needed an itemized bill and she wasn't able to get it. And I didn't realize I had never really read the whole HIPAA privacy law. And usually you think of the HIPAA law and it's just focused on privacy because that's really what's been emphasized by the medical community. You know, protecting the private health information of patients, which is great. But HIPAA also has a whole arm of it that's about access to information. So under hipaa, you have a right to your medical records, and under hipaa, you have a right to all your billing records. So once I realized that, I told my friend, I was like, oh, well, here you got to cite HIPAA because they're so paranoid about violating hipaa. And through the Office of Civil Rights, a federal government agency, you can complain about HIPAA violations and they enforce them. So I put a template in my substack newsletter that people can use to make a written request for your itemized medical bill. And you can use it for your medical records or anything else like that, too. But any HIPAA covered entity, your insurance company or your doctor or your hospital is required to.

Not violate your HIPAA rights. So now you send a written request and say, under the HIPAA law, I'm making a request for my itemized medical bill, including the billing codes. They are required to give you that under the federal law. And then I put in the letter, too. And if you refuse to give this to me, you'll leave me no option but to file a complaint with the Office of Civil Rights. Well, I had a patient read that newsletter and she emailed me the next day. She said, I have been trying to get an itemized bill forever. I use this template, and I immediately got my itemized medical bill. And again, it's Sad that it has to come to this.

Yeah, it's pretty astonishing.

Like, like it's ridiculous. Right? I just had a person email me who said that they, they weren't given access to their medical records. Like, are you kidding me? This is like the ABCs of healthcare that we have a right to our medical records. But she was told, she asked for her medical records and was told, well, we don't typically give those to patients. You know, we'll give them to your primary care doctor. Okay, I'm sorry, no, I asked you for my medical records. This is my personal medical information. I want to know what's in my medical records. So again, I told her same thing, side hipaa. And I don't know what's happened with that one yet, but what I'm doing is I'm equipping and empowering patients so that they can help themselves. You know, like, I'm not going to be able to step in and do it for them, but there is a ton of stuff that people can do on their own. So anyway, when you said that. But first thing, get an itemized bill.

And you said there tends to be this paternalistic nature. Yeah, Definitely around the member. Right. Or the patient, or what do you consider. What is the terminology you like to use?

I mean, patients, consumers. Yeah. Employees. I mean, I'm thinking, I'm also thinking more working Americans as opposed to Medicare patients. And that's only because Medicare patients actually are not getting ripped off nearly as much as working Americans are. Usually working Americans, you know, when they hit that 50, 55, 60 age, they're just.

Biding their time until they can get on Medicare.

Well, so I like that. Working Americans. Right. The number sounds like such an unemotional, detached term. So working Americans. Right. But as you're helping a working American navigate through this system. Right. We talked about some of the steps. But why do you think there is this paternalistic treatment of a working American that they. Oh, they can't figure this out on their own or it's too sophisticated for them to navigate? Like, why do we.

First of all, I don't think most people, I would say 99% of people who work in healthcare don't even understand the healthcare system themselves. Okay. And I'm talking doctors, hospital executives, insurance executives, brokers. They know their siloed piece of it. They're experts in their siloed piece of it. So I'm not underestimating their expertise, but they don't understand all how all these forces work and how all these forces are interconnected and working against the patient. And so I think a lot of times they are. I've heard people say a lot. Well, people aren't going to do that. Like, it's just too much work, it's too much hassle. And I'm like, look, I have documented the stories of hundreds of patients who have been harmed or ripped off by the medical system. They are very motivated. The people I talk to are extremely motivated and they've been ignored by the doctors, the hospitals, the employers. Everybody else has blown them off. And so as a journalist, and journalists do these stories all the time. I mean, I'm not the only journalist doing these stories. I mean, Kaiser Health News, New York Times, ProPublica. There's amazing healthcare journalism being done every day. There are a lot of patients out there who are getting really ripped off, who are very smart people, people just like you or me or the people watching our conversation here. Very smart, very motivated people who are getting stonewalled by the system.

If we can tap into that group, let's say it's, I don't know, I'm saying there's 185 million people who are in this category of working Americans or their families on these employer sponsored plans or getting their own Independent Insurance. 185 million. So let's say, yeah, not everyone's going to do it. Let's say 10% do. Would 18 million empowered Americans make a difference in our healthcare system? They Would, absolutely. Would 18 million informed people who push back when they are getting an overpriced medical bill make a difference? I know they would. So sometimes I use the comparison of David and Goliath a lot. I mean, partly it's my faith background, so I love the Bible story, but everybody knows that story, right? The weak individual up against the giant. Well, so David can beat Goliath in a one on one battle. But what I'm talking about now, or what if there are 18 million of these Davids, right, who are empowered, informed, equipped, motivated. That's the group I'm trying to harness and equip and then inspire, right? So again in my newsletter I'm sharing stories every week of people who have David's who have beaten Goliath. It's fun.

And so I think what I liked about you, obviously talking about folks that can defend themselves in small claims courts and the entities that don't necessarily want to fight that because of a number of different reasons, cost, time, things like that. But when you have the truth, if you will, on your side, when you can point out what has happened to you and it's objectively laid out. Well, that's how David defeats Goliath, right? Is because you have the power of the truth behind you.

Yeah, exactly. And I think in the book, so you get an itemized bill. So that's your first step. You get the billing codes that come with the itemized bill. Well, there are websites now where you can look up the average price that insurance companies pay for those services in your area. So fairhealthconsumer.org, healthcare blue book, there are others. Hospitals are now required to post prices on their websites. So you can see, oh well, this is what they charged my health plan, the discounted price. You can see if that's a fair price or not. You can also check and see if those services were actually accurately to the ones that were provided to you. Nobody can tell that as well as the patient can. So when we're talking about defending our employer sponsored health plans against fraud, well, who better to empower than the people getting the care? Because no one else can tell whether that care, whether those codes actually reflect the care provided. Like I talk a lot about upcoding, you know, explain upcoding. Yeah, well, upcoding to me is the most common type of fraud that we see in healthcare today. I mean, I don't know, do I know that? No, but it's very common. And what happens is you go for a doctor office visit or you go to an emergency room visit. They can code that anywhere from a level one, which is the simplest type of case, to a level 5, the most complex. A level 5 code is only supposed to be used if you've like been in a traffic accident and you're brought in unconscious with multiple injuries. It's like a life threatening type of care. Again, level four a degree down from that level three, medium.

The number of level four and five codes that you see on quite simple visits to the emergency room. It's incredibly common. Well, once patients know that. So again, another example, a woman named Jennifer Sisson, who lives in Texas, here in a rural part of Texas, her daughter ended up going to the emergency room with appendicitis. The appendix had not ruptured and she ended up getting transferred to a different hospital where she had her operation done there. Anyway, at the first hospital, they billed it as a level five emergency room visit. Of course, again, that's not a life threatening situation. It's not an uncommon situation, doesn't require a high degree of medical decision making. It's not especially complicated. So she read My book, she saw that it was upcoded. She pushed back against the upcoding. And I think she saved $595 just on that portion of her bill. That's a big savings. Then she went to this other hospital where her daughter had surgery. And again, I write in the book about financial assistance plans. Nonprofit hospitals are required to provide a certain amount of charity care. And so she applied for financial assistance and she saved thousands of dollars. Then on the bill for the financial assistance, I think it was about 4,000 more dollars that she saved. So right there, on one episode of Care, that family saved about $4,500. So if you can help people understand, like, okay, you're going to have to learn some new skills here. Okay, it's going to be a little different than what you're used to, but if you can learn these skills, you could save hundreds or thousands of dollars per healthcare encounter. Yeah, like, people don't realize just how much overpriced and price variation there is in the system. They don't understand how much fraud and upcoding there is. And again, they don't know how to push back. So if you can show them these things and show them what to do about it, there's a lot of.

I like the empowerment aspect. Right. Because that's really what you're talking about, is empowering the little guy, little gal in this equation. Now, it's difficult to necessarily ascribe intent to somebody else, but with this amount of upcoding that's happening, you have to believe that's either they're being trained to do this. It's not a mistake if it happens at all.

Software programs are designed for it.

Some.

So in terms of intent, I mean, you can never get inside anybody's mind. But they would say their intent is to capture as much revenue as they should from each case. Now, they would say it's an appropriate amount of revenue they're capturing. That would be their argument. But, I mean, I know doctors who work for major medical centers who get emails from the billing department that say, hey, are you sure you can't add this diagnosis code to that case? Or are you sure you didn't do this procedure on that patient? Because if they do, if they can, they can upcode it, they can increase the level of complexity. So the billing department, in some cases, going back to the doctors and saying, hey, are you sure you can't just tweak that a little bit? Just juice it just a little bit? And now, is it intent to commit fraud?

I mean, that sounds intentional.

I mean, you know, they would say no. I would say it's questionable. And when patients push back, it creates a burden for the hospital to defend what they're doing. And often it's just easier for them to roll over and waive that portion of the bill or correct it.

Well, and that's the crazy part about this, right? So let's say you go shopping and you buy shirt and pants. Well, when you get your receipt, they charge you for 17 shirts that you didn't buy. You're gonna go, well, I didn't get these 17 shirts. But it sounds like within the medical process, Right. This claims process, there is the ability to insert additional things in there, and the member is either unaware or doesn't have that itemized bill. So they don't necessarily know that was included in that package of claims.

Right.

But it's just a. It seems like such a weird thing to me that if you did shopped in any other equation where there was a transaction, you have a receipt for said transaction, you can go through that and go. Even if you go to a restaurant and they throw something on your bill you didn't buy, you go, well, I didn't have that. But it's so difficult within this equation to empower the member to do so. One thing I think I like that you tell the story about is. And I even saw you doing it when you checked in here, he's going through the terms and conditions. It's like he's been trained to do this. He's obviously living the walking the walk.

I don't sign anything without reading.

I think that's a great practice. Yeah. No, but you actually talk to members about. Or let's call them working Americans. I want to use that term. You talk to them about when they go into, let's see, maybe an er, Right. And you look through the terms and conditions, and you're having them either mark things out or actually write in their own terminology. So talk to me about that practice. I think it's fascinating.

So this is. This is something that Al Lewis from Quizify, he and some of the folks there came up with. I don't know if they call it this. I think they call it this. The battlefield consent. Right.

Okay.

This language that you insert into your ER Financial Responsibility agreement, where it basically says, I agree, they want you to sign something that says, I agree to assume all charges. And so, again, to tell you another story, my son was just in the emergency room last week, just a few days ago. Thankfully, he's okay. It was no problem. But they actually thought he might have a blood clot in his lung. Okay, so very serious, right? Yeah, he had some weird pain in his back. He went to his university doctor. The university doctor said, I don't know, I think it might be a blood clot. So they refer him to the er. Well, as a parent, I'm like, oh man, what are you supposed to do? I mean, you have to check that out. Right? Well, so I'm on the phone with him and they're doing all the appropriate tests. They actually, it seems like they did a really good job in the ER and they were able to rule out a blood clot. He didn't have a blood clot. He was fine. But they did all these tests, man, I'm telling you, I'm worried when I get this bill. And so you have to, in some cases anticipate the problem that could happen. Right. And so the informed, the consent language that we inserted into it, and this is something that I got from Quizify and they've done webinars on it, look it up, because they have some great examples of defending it. But when they give you that financial agreement, it really just says, I agree to take responsibility for all costs related to my care, all charges. And my son is 18 years old. So now he's an adult. Right. And we know how much of an adult an 18 year old is. I mean, he obviously doesn't have a clue about assuming responsibility for his emergency room bills. I mean, thankfully he has me to help him with it. But it was two in the morning and they're asking him to sign this agreement. They actually had him sign it on the way out after they did all the tests, which they should have done it before, but. And he's tired, he's exhausted. He's been there for nine hours. He's like, dad, come on, do I have to? I'm like, trust me, write this in. And it was an electronic form, so he had to get him to print the form. And then he wrote it in. And basically the language said, I agree to pay for all appropriate treatment up to two times the Medicare rate, including what my insurance company pays. So basically what you're agreeing to is, I will pay you up to twice the Medicare rate. You're putting a ceiling on the amount that you're willing to pay for this.

It's a whole premise of reference based pricing.

Exactly. It's reference based pricing. And you're also saying, I agree to appropriate pay for the appropriate treatment. Right. So if they would have like they didn't do a CT scan on them, they didn't do an MRI on them. But if they would have run him through the mill of all their imaging tests, some of that might not have been appropriate. In this case, it was appropriate. So we will pay for that. We will pay what's fair for that. But if it's unfair, you know, a lot of times employer sponsored health plans might get charged anywhere from two times Medicare, five times Medicare. I've seen 10 times Medicare in emergency rooms. So what if that ultrasound he received should have been priced at $200 and they priced it at 2,000? Well, there's no law against them doing that. They could send me to collections, I could have a big fight with them. But by writing that language in, it really is preparing me and my son. But we'll do this together for a potential court battle.

Yeah.

If I do need to sue them in small claims court, my son would do it. We would have that language where we would say, you know what, when we signed in, we agreed to pay you two times the Medicare rate. We wrote it right here in the agreement. It's a contract. Like, why would you ever enter into a contract where you don't read it and agree to the terms that are fair for you? Right. You don't go to a car dealership and buy a car and they say, okay, sign this financial agreement for your car. And then you drive off in a Toyota and they charge you like it's a Lamborghini. We don't do that.

Yeah.

So I think.

Well, so talk to me about the provider perspective from that. So if you're writing in this, and they probably don't see this very often, let's be honest. So what do they do when they see you've handwritten some additional language in the contract?

Well, this woman the other day at the er, it was again two in the morning, and she's dealing with all these patients. She was so harried that she didn't even push back at all. And I just had my son take a photo of it. So we have a record of it and have them make a copy of it and put it in his file. But I'll give you another example. I went for a. Again, we just moved to Texas, so I went to this primary care doctor and I'm reading the, you know, the agreement and it says, I agree to pay for all charges. Well, I just wrote the word appropriate and I inserted it before charges. I agree to pay for all appropriate charges. And then I went up to the desk, you know, to the woman, I said, hey, I altered your financial services agreement. I hope that's okay. I just want to make sure that you see that I. That I. That I altered this. And she looked like she had seen a ghost. You know, I completely freaked the poor woman out, of course, because this is an unusual thing, and I'm kind of coming off, like, confrontational and awkward. I was trying to be friendly about it. And she goes, oh, well, you'll have to talk to the doctor about that. And by the way, in this. In this agreement, it said all this stuff like, if you don't pay your bills, we'll send you to collections. I mean, it was kind of aggressive. So I go back to talk to the doctor. He was a great guy, very impressed by this doctor. He did an excellent job examining me. No complaints. But I had this document with me, you know, And I was like, hey, doctor, I do need to talk to you about this financial services agreement. And he goes, oh, that thing? He's like, I got that from some other doctor. I haven't. I don't think I've read that thing for years. And I was like, well, there's some language in here that's actually not really very fair to patients.

He didn't care at all.

Yeah.

And I said. I said. I said, well, did you know it says in here that you'll send people to collections? He's like, it says that in there?

Yeah.

I'm like, dude, come on. I'm like, you got to read your own contract, because it makes. He said, I've never sent anyone to collections, and I never. And I never would. And I said, well, then you need to correct this.

Yeah, it should be in the language of your contract.

You look like a jerk with this form. And it turns out that he was actually a very nice guy. And I actually ended up walking out of there without even signing anything.

Well, I don't think that's that uncommon, though. Right. Because a lot of the physicians, they're in this business to practice medicine, and the business aspect of it is almost secondary, and it's not necessarily even one they're even something interested in or if they're even necessarily proficient at it.

Right.

It doesn't necessarily enter the equation until it has to. And so I don't think they have that. That side of them necessarily inherent into their nature. So I'm not surprised that that might have been missing from the equation. The last thing I would hope you might be able to highlight. And I. It was in the conference we were at recently where you're. In your keynote speech, you had some examples of this, and I think you alluded to it earlier, where you looked into certain procedures at certain locations and the variability between if you had different insurances versus, you know, a direct pay or a cash pay model. You don't necessarily have to say exactly who or what. However you want to highlight this, but I think that variance that you said, it could be anywhere from 200.

It's insane.

A thousand times Medicare or whatever. A thousand percent of Medicare. Like, people need to be aware that whatever name is on your ID card can change the cost of your care as well.

Yeah. We have a health care system that, again, I'm reframing the way we think about this, but it's discriminating against people based on their insurance coverage. And an example that I talk about a lot that I documented is a woman named Gabby who was a bridge engineer in New Jersey. And she emailed me because she was upset about her hospital bill. She had gone to the emergency room. All she had done is cut her finger. She had three stitches in her finger, but it was after hours, so she ended up having to go to the emergency room that was right near her house. She had a United Healthcare coverage. Well, I had her get the itemized bill. You know, this was actually before my book published, so I was just kind of walking her through the steps. And this is something I enjoy, by the way. So if any of your listeners have a question, you can message me@marshallallen.com that's my website. I am responding to all those messages and I'm helping patients every day. So this is something I really do for fun. I mean, this is my hobby. And also it's proving the concept. Right. So I then share these stories in my newsletter. So, you know, I get something out of it, too. But I'm learning a ton by really digging in. And there's a little different strategy with each one, which I like. So with Gabby, she got that itemized bill and saw that the main, the biggest charge was for her level three emergency room visit. And it probably shouldn't have been a level three to begin with, because a level three requires three things. A thorough examination. She had had no examination. I mean, she just went in for a cut in her finger. They didn't examine her. A thorough history, like medical history. They did not do a medical history of this woman. She just had a little cut on her finger. And a level three also requires medical making of moderate complexity. Okay, okay. So again, did it Take medical decision making of moderate complexity to stitch her finger with three stitches. No, you or I could have figured out what needed to be done here, and we don't. I don't have any formal medical training. I mean, I don't know if you do either. So I would call that a level one. But anyway, that was upcoded. But that charge UnitedHealthcare's discounted rate. So this, by the way, is the power of transparency. So the federal government passed a rule called the Hospital Price Transparency Rule. So now hospitals are required to post their prices, and they're required to post their cash prices, Medicare prices, and the discounted prices they've given to every insurance plan they take. This is incredible. These spreadsheets on hospital websites, and a lot of hospitals are not complying with it. So unfortunately, many have chosen to just sort of ignore the federal law. But many are. And thankfully, in this case, Gabby's hospital was. So she got the spreadsheet, she looked at the prices, and United Healthcare had agreed to a discounted price of $5,805 for that Level 3 ER visit. The Blue Cross negotiated rate was about $800, the Medicare rate was $230, and the cash price was $256. So she was being charged 22 times the cash price just because she had United Health Care. And again, in this case, I had Gabby. She agreed to waive her HIPAA privacy rights so I could call UnitedHealthcare. And UnitedHealthcare talked to me, and they told me why, actually, which was very interesting, right? I mean, it's like a big mystery. They said, well, we agreed to a higher price for our first year in the contract to bring them in network, and then in future years, we're gonna try and reduce that. Well, okay, at least they had a reason. But it's not a good reason if you're Gabby and you're getting overcharged. Right?

Yeah.

So anyway, Gabby was able to get that negotiated. She actually ended up suing them in small claims court, and they came to a settlement. All she's allowed to say is that they came to a settlement that both parties would agree with because she had to sign something. But I know, because I helped her through each stage of the process, that she was able to get this taken care of and didn't have to pay for it. At least that was what I saw up before it was actually closed. So that was the deal because she actually had these conversations. Again, patients get ignored by hospitals all the time, but when you sue them in small claims Court, they have to respond. So she had been blown off by this billing department, completely ignored. After she sued them in small claims court, she ended up having the CFO of the entire hospital chain on the phone urging her to take this deal. And I know about it by the way, because she got their consent to record these calls. So all these calls, I have recordings of all these calls. But basically they were like, you know, just take the deal. And she ended up taking the deal.

Jeez, talk about a power imbalance. Right?

Total power imbalance. But again the power small claims court because.

Well, the weird thing though is that you have this third party that's negotiating on behalf of a person. The person is unaware of these negotiations to really kind of arbitrary nature of the pricing point that they agreed to in order to get people in network.

Yes.

And you as the person, as the, you know, working American just is, is subject to it.

Yeah. And this is where, you know, we have always assumed that our big insurance companies are getting the best deals for us. And that's how they get employers to sign.

That's what they market to us. That's what they tell me.

That's right.

And I believe them.

I know, but now look at now the prices that are on all the websites and you'll see that they are not living up to that side of the bargain. And when you think about it, the insurance companies, why would they care that much about what people spend on health care? I mean, it's not their money and they end up making more money as the costs go up because they're just a middleman who's taking a cut out of the middle. And if it's, if it's a self funded employer, which you work with a lot, well then it's the employer's money. I mean, it's the employee's compensation, but it's funded by the employers. So then the insurance company is just a third party administrator that's administering the plan. But it's not their money.

It's not their money.

So why would they protect it that aggressively?

Well, I remember I went to a seminar and you don't necessarily want to say who or where or whatever, but the gentleman that was talking was an underwriter, ex underwriter for a very big bucha organization. And he talked about, and he was actually explaining to these employers at the seminars like they want you as sick as possible. You don't understand. They don't want you healthy, they want you sick.

Right.

They want you to come in the door as often as possible because as soon as you come in the door, like you said, we can upcode, we can charge for all sorts of things. And so their goal is for actually the cost of healthcare to go up. Those insurance carriers make more money as the cost of care goes up. It's a really perverse inverse incentive. And I think even just casting a light from a global perspective at that equation is helpful for people to understand that, you know, shiny car that you have with some pretty logo on it is actually not acting in your best interest most of the time. Right. And so that, that'll be my one single diatribe for this particular.

We need the employers to wake up. Right. And so I'm glad that that guy was giving that talk to employers because employers need to wake up and recognize that it's a facade. You know, what they have been told is a facade. It's actually not real. It's not. There's a lot of myths that the industry has perpetuated on the employers to make them think that they're getting a great deal. You know, this myth of like rich benefits or this myth that oh, well, we're protecting your money, we're watching out for your money, or oh, we use our market share to get you a better deal. No, no, they're actually operating in the interest of themselves and their shareholders. And that's not a big surprise if you actually think about it. But we need some employers to have some courage to stand up against what's, stand up for what's right. So they need to get with some advisors that know what they're doing. There are so many amazing Vendors now and TPAs.

Data analytics vendors, transparency vendors who are bringing solutions. They have these solutions that pass through PBMs. They have so many solutions for all these employers. The employers just need to have the courage to embrace these things. And so that's why I look at it. I'm trying to educate the employees and the employers. But if the employees understood what's going on, then they would actually, from the ground up, tell their employer, hey, what are you doing to protect my compensation that's being used for my health benefits? And I hope that will give the employers more courage once everybody understands a little more that the employer and the employee need to work together to have a smartly designed health plan so that you can protect the money. And again, it's not all bad. Like I'm focusing on the negative here, but there's a lot of TPAs and PBMs that are being very fair with employer sponsored plans and they're lowering Their costs while providing better benefits. And there are hospitals and doctors. Like, we talk about price variation. Well, that means there's lower priced medical clinicians, too. So identify the lower priced ones that are still high quality. Go to them. Yeah, exactly. Shun the price gouge.

Use the power of the market.

Use the power of the market. And I do. I'm a big believer in that. And so I think that that's possible. And again, it's never really been tried, but you're seeing it happen more and more. Like you're seeing a growing move.

A groundswell, man.

Oh, there's a groundswell. There definitely is. Where people are getting more courageous and more emboldened. And that's also why I'm trying to share more of these stories so that people see how it works when I.

Appreciate you sharing the story. How are we doing on time, Nathan? Are we are coming up on eight? Okay, 55. All right. Yeah. So I definitely want to get. We'll get out of here. We got things to do.

I know.

It's in the evening as well. One thing I do want to talk to you about before we leave is your interest in moving some of these stories to the medium of video. So could you talk to me about what you're doing there?

So I ran a crowdfunding campaign. I got this idea, actually, from Taylor Lindsay. Okay. I got to give a shout out to Taylor Lindsay. He's a health Rosetta advisor in Virginia. I was talking to him about my book about one year ago now. Okay. So last spring. And Taylor was like, look, the book is great, but most employees are not going to read a book. What I really need are videos. Do short videos that explain all these concepts and tactics and principles so that employees can watch the videos. And then I'll give them like a certificate to complete it. I'll give them an incentive to do the videos. And then they'll be equipped and they'll be able to navigate the system better. They'll save themselves money and they'll save the health plan money. And I was like, that is a great idea. So we ended up running a crowdfunding campaign this last fall. Raised about $55,000.

Oh, my goodness.

On Indiegogo. By again, generous contributions probably from a lot of the people watching this video. Many, many brokers, advisors, TPAs funding this, this project because they know, okay, if we can educate the employees, this can make a real difference. So we have 16 videos. They're three to five minutes each. They contain all of the practical principles and tips that are in My book, how to get an itemized bill. How to price your bill. How to check to make sure it's accurate. How to contest it. How to win an appeal if your insurance company denies you care you need. How to avoid over treatment. How to get your medical records. How paying the cash price is often less expensive than going through your insurance plan. How to use a hospital financial assistance policy. All these very practical things. And they're animated, they're illustrated, they're very interesting. So it's taking me longer than I would like, but that's because of the production quality is going to be very high. They're going to be very interesting videos and fun and engaging.

They need to be engaging.

They have got to be engaging. You can't just do a boring, snoozy healthcare video and expect employees to really engage with it. So my goal is to roll that out. I call it the never pay pathway. And the goal is to roll that out to employer sponsored health plans across the country. And there's also a component of this. So the videos are one piece. Then I'm going to have a smartphone app that we're developing now too. So all of this information can be right in someone's pocket. And then also there's going to be a coaching component where people can join an online community that I will moderate and if they have a billing question, they can submit it to the online group and we'll talk about it in the group and I'll run regular webinars and we will build up a community of equipped and empowered employees.

That's what it said. I'm glad you use that term community, because that's what it really sounds like. You're using the videos to build a community. Is that going to be like a Discord server or what? What is the Facebook group?

Kajabi is actually the platform that we're using. I think Kajabi seems to be able to do everything that we want to do. So it'll be hosted in Kajabi.

So I know you said it's taking a little longer than expected. Do you have a rough estimate of ETA when you think spring of this year?

We're months away. Okay, cool. I mean, ideally we're. I would say we're within two months, but it's hard to commit to a time because we have to make sure that we do it right and we have to just make sure that everything is like up to snuff. But it's. I'm excited because we have. The majority of them are done now, so I'VE seen them. I've watched them in succession. It's really, really fun to see all this put together. So I'm totally pumped to launch it.

Well, I'm excited too, because when we talked about this a couple months ago, I'm thinking, yeah, that is like the medium in which to capture a broader audience, maybe a younger audience as well. Right now everybody wants bite sized, digestible content, but if you can have substance to that bite sized digestible content, I think this would work very well in that medium.

I think so. And if people want more info about that, you can go to marshallallen.com I am taking pre orders. If people, I've had a number of pre orders come in, but at the same time, people can wait and see. And all the people who contributed to the crowdfunding have access. They're going to have early access. They'll be the first people to get access to it.

Well, cool. I know we got to get on the road. Help me land this plane last. Last bite sized nugget, if you will. What is things that you want to leave the audience with that have listened this far? I know we have great conversation and I want to, I can't wait to actually go back and listen to it myself. But you know, what do we want to leave the folks with today? Maybe one or two things, just things to think about or things they could put in motion today based around this conversation.

Well, I think the thing I would say is never underestimate the power of an informed and motivated patient. Okay. So again, in my substack newsletter that published today, I love this story because this woman, Leslie Donovan, took my book on her own. She was in a billing dispute with Sutter Health. This is a giant healthcare system in Northern California. In fact, one that has been accused by the Attorney General of California and the Department of Justice of some quite unethical billing practices. Anyway, she ended up having this billing dispute getting ignored. She followed all the steps in my book to price the bill, to send a warning letter, and then to sue them in small claims court. Ten days after she filed her case, she got a call from Sutter Health. They didn't acknowledge the lawsuit, but what they did is they said, we realized that we made a mistake when we did this with you and we're refunding the money that you've paid and we are waiving the rest of your bills. So it works. People can do this. She saved about sixteen hundred and fifty dollars right there. Now, was it a lot of work for her? Of course. Did she have to be engaged. Yes. But she knew that she was being wronged. She's a mom of five kids. She manages her family's money. She protects it. She didn't want to be ripped off. And she also morally knew this wasn't right. So she was very motivated, did all this on her own. And so patients have a lot of power. They just have never really learned or been taught how to use it. And so don't underestimate the power of equipping patients.

Well, I was gonna say, you know, you're helping unleash the lion, if you will, a little bit. And I hope this movement continues to gain critical mass. I think it will. I appreciate everything that you've done. I appreciate you coming on this thanks show today. And thank you, obviously, for continuing to take this as far as you possibly can as well. So I'm excited to see what the future holds. I can't wait to see those videos. And thank you again for joining me on the podcast.

Thank you, Spencer.

My pleasure.

Thank you to our podcast sponsor, True Captive Insurance, a premier medical stop loss captive for groups of 25 to 1000. True Captive believes in healthcare that is personal and insurance that isn't complicated. Check them out at trucaptive.

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