The WealthAbility Show #88 - Health & Wealth w/ Marshall Allen

This is the Wealth Ability show with Tom Wheelwright. Way more money, way less taxes.

Welcome to the Wealthability show where we're always discovering how to make way more money and pay way less taxes. Hi, this is Tom Weira, your host, founder and CEO of Wealthability. So healthcare is, and we've learned this over the last year especially, is really one of the leading causes of financial crisis. It is not just health crisis, it is financial crisis. And so today what we're going to discover together is how to proactively form a plan to successfully navigate the healthcare system. And I am so pleased to have an expert in this area, Marshall Allen, who wrote this new book, Never Pay the First Bill, which I love the title to begin with. As a writer, I always love great titles and that's a great title, Marshall. And Marshall is an in this area and we're just going to have a conversation. So Marshall, welcome to the show and if you can just give us a little bit about your background and why you wrote this book.

Thanks, Tom. I really appreciate the opportunity to be here and talk to you all about this. I think when we think about personal finances and watching our pocketbooks, people often don't. Well, maybe they do think a lot about healthcare, but like you said, when you go to undergo healthcare, you're thinking about your physical issues, but we also have to think about our financial challenges this can create. So again, my name is Marshall Allen. I'm a journalist and investigative reporter. I've been an investigative reporter for 20 years and 15 of those years have been specialized on investigating the healthcare industry. And the last 10 years I've been with ProPublica. ProPublica is a large nonprofit investigative news organization based in New York City. And I felt led to write this book because I get calls and emails all the time.

From individual people who are having problems with their medical bills. They're having things denied, payment denied by their insurance companies. They're burdened by the rising cost of health care. As you said, health care costs can burden people. One in six Americans right now has medical debt in collections. And I would guess that a lot of that medical debt is coming from bills that have been overpriced. They may have errors in them. And so in my book, I show people, step by step, chapter by chapter, how to analyze a medical bill to make sure that you aren't overcharged or billed for something that you shouldn't have been billed for, how to look up prices both before and after you get health care. And why that's so important, because price variation is extreme in healthcare. People don't know you can go one place. Let's say you need a colonoscopy. You could go one place and it might be $1,000. You could go another place and it might be $6,000. I mean, the price variation is so extreme. Sometimes it's better to pay cash than it is to run things through your insurance.

I'll give you an example of that.

Yeah, give me one.

So my, my doctor who's more of a health, actually healthcare as opposed to medical care.

She'S much more on the positive side. She wanted me to get an MRI because she wants a baseline of my liver because I have a hemochromatosis disposition towards too much iron in my blood. She just wants an MRI to get a baseline. And so she actually did the work for me, which I'm forever grateful because I think you do need to have somebody in your corner. And she found out that it was cheaper for me to pay cash than for me to use my insurance.

Crazy. So I have a whole chapter on that and I think that's a great example. Another tip on the imaging studies have shown over and over again that if you go to your hospital based imaging center for your MRI or your CT or other scan, the prices are much, much higher than if you go to an independent imaging center, one that's not affiliated with the big medical system in town. And so people should always check the.

Independent imaging centers, not just the hospital emergency centers. And of course we're talking about things that are elective or scheduled, not things that are emergencies. Right.

So one of the big problems, Marshall, that I see is, you know, we actually, in sales training, we actually learned that, look, if there's enough pain, people don't care what the cost is.

Right?

So if your arm, you just got in an accident and your arm is hanging by a thread, you don't go to the emergency room, say, by the way, how much is this going to cost? I may want a second opinion. You're going to get what you're going to get. You're going to get it right then and there. So I presume that there are things that can be done after the fact, because there's. Yes, I get there are some things. And I'd like to talk about what can you do on the forefront so that you can be prepared for medical emergencies. But let's say that it's too late for that. You've got a medical emergency, you go, I presume there are things you can do on the back end.

So there are a few things. Let's say you have to go to the emergency room. One thing I talk about in my book, the subtitle, the book is called Never Pay the First Bill and Other Ways to Fight the Healthcare System and Win. So the subtitle, I'm trying to emphasize the winning part. Right? And by win, my central argument of the book is that we have been year after year paying more than we should for our healthcare. And if you knew how the system worked and you knew how much waste and excess there is in the system, you could actually pay a lot less and get a lot more. So, for example, let's say you go to the emergency room. I recommend that people write in on the consent form where you sign over and say, I agree to pay whatever charges are billed to me. I recommend writing in that I agree to pay up to two times the Medicare rate for the services I receive. There's no reason why you can't add that to it. And what you do when you do that is you put a limit on how much they're going to bill you. Because hospitals are notorious for over billing patients. And so the Medicare rate is the rate negotiated by the government. That's the price set by the government for Medicare patients. And to say you'll pay twice Medicare is a very generous payment for the hospital, but it also restricts in writing when you agree to pay, that you won't pay whatever they charge. Because they can, Tom, as you know, they can charge anything. And then you're stuck with it.

And you found the hospitals will accept that.

Well, so here's the deal, Tom. Everything is negotiable. Okay, So I like your entrepreneurial sales mindset. Right. So you know this right. Negotiation is the name of the game. And that is very true in healthcare. And so patients need to understand things are very negotiable. The prices are not the prices. In fact, the prices in healthcare are honestly kind of made up. They're made up between the hospital or the doctor and the insurance company. I'm talking in the commercial space for working Americans, not Medicare or Medicaid. But for the 160 million or so who are covered on those commercial plans, the working Americans, those prices are kind of flexible, negotiable. They're discounted. And so we need to be more assertive in negotiating the prices. So let's say you go to the hospital, you get that bill from the emergency room. The first thing people need to do is get an itemized medical bill. Hospitals are accustomed to giving us this lump sum payment like, okay, you went in. Let's say you had a broken arm. You went in, you got it X rayed, you got it reset. You had an examination by a doctor. You have these multiple three different services say, provided. What they like to do is give you this lump sum total. That'll be $15,000. What? Well, you're like, for what? 15,000. What's included in that? That'd be like going to the grocery store, loading up your cart with different items, and then they just give you a lump sum. Pay $120 at the grocery store. And you're like, well, how much were my eggs, how much was my cheese, how much was my bread? We can't compare prices if they don't give us the individual prices of the services. So an itemized bill lists each of the individual prices and make sure you get it with the billing codes. The hospital may not give you the billing codes right away. You might have to call the billing department and say, hi, may I please get an itemized bill with the billing codes. It might be easy and take five minutes. You might need to make another call to them or even call your insurance plan. Your insurance plan. It's easy to get this information from them because the hospital takes that itemized bill and submits it to the insurance plan for payment. So if you have insurance, those insurance customer service people are great for this kind of basic information. So you can get those billing codes. Once you have those billing codes, and it's usually like a five digit number, it's easy to look up online. And I know this sounds complicated and it is a little complicated, but if you understand, you can look up those billing codes online and then you can start checking to see if you got a fair price or not for those individual services that you received.

And for those of you who are entrepreneurs and follow my rule about having an assistant, your assistant can do all this. So seriously, I mean, I find that, you know, do I want to go into all those details? And the answer is no, but my assistant's really good at those detail type things. And if you don't have an assistant, get a virtual assistant. Get somebody, give them the authority to do that. I find, because they'll get into a lot of details because that's their job as opposed to you who might go, ah, it's not worth my time, it's not worth this and it's not worth this. This is where to me, I think another argument for a good personal assistant, frankly.

So that would be amazing to have an assistant. And by the way my book goes.

Through, step by step, how to do each of these things.

So I know it sounds.

It sounds hard because it's stuff that we haven't really done before, and it's learning a new skill. But this can save people hundreds or even thousands of dollars with every healthcare interaction.

I could see that. So let's talk about having an advocate. So what kind of an advocate? Who is your advocate? Who's on your side, who's not on your side? Who should you be? You know, who's. I mean, do you need a lawyer? I mean, I'm sure you do in some cases, but really, before you ever get to that, how do you get somebody that's actually fighting for you?

Well, here's the sad thing about our healthcare system. I mean, if we had a functional.

Fair health care system, I would not have needed to write this book.

But the sad situation that we're all in is that we don't really have a real advocate other than ourselves, our family members, our loved ones, maybe our close friends who are willing to help us at these times when we're incapacitated or in a really vulnerable position. This is the sad thing about this, Tom. No one's coming to our rescue. I would like to think that a health insurer would be our advocate, but the problem with the health insurers is they're more loyal to the doctors and the hospitals that are in their network. I'd like to think that the employers would be our advocates, but the employers are trying to run a business. I mean, they've just made a habit of passing the cost on to the employees. And frankly, again, this isn't to insult anyone, but the employers in our HR departments or our CFOs or CEOs of these companies or people in the benefits department, they often don't have a lot of knowledge about how this system actually works. And they also don't like taking an assertive position for us in terms of advocates. If somebody has the resources, they can hire a professional patient advocate. I actually do recommend people do that. If you're in a position where, let's say it's a lengthy hospital stay or more complicated case and you have the resources. I am telling you, these patient advocates are amazing. They deal with this stuff every day.

So in my business, which is the tax business, if I want to dispute a property tax bill, I hire a property tax professional and I pay them a portion of what they saved. Do the patient advocates work that way? Do they take a portion of the savings or do they Take a flat fee or hourly or how do they work?

It's different for different ones. But I would recommend trying to find someone who takes a flat fee because the portion saved, remember, is coming off of a fiction, inflated price. And so if they said, oh, I take 25% of the savings, but your bill was over inflated by $50,000, well, then you've just really overpaid your patient advocate. And I mean, these numbers are totally bonkers. I've seen knee replacements that should be around $20,000. I've seen them reimbursed at over $100,000. I mean, there is such a massive extreme. So I think you can go to advoconnection. I'm not sure if it's.com or.org, but just Google. These patient advocate organizations have some even information. And in my book, I have the references of how to interview a patient advocate. But if you have the resources, these people are amazing, and they're excellent, excellent to help.

Now, one of the things that I found, of course, I love the whole concierge idea with a physician where you pay. You pay a fixed amount and you get concierge services. Because what I find is, is that if you have that kind of relationship, then your doctor will be an advocate for you, and they'll be an even an advocate with the insurance company or with the hospital. My doctor actually checked around, you know, which one had the best price, which. I didn't ask her to do that, you know. But.

I will tell you again that when I was in the hospital a year and a half ago with pneumonia, and they didn't want to take me in to the hospital, they actually refused. They were gonna send me home. And it was my doctor that forced them to say to keep me in. The next day, the doctor told me, had I gone home, I would have died.

Wow.

Not having an advocate is, I think, a serious issue. I mean, it's the same thing. You know, I deal with the IRS all the time. Not having an advocate with the irs, you wouldn't even, hopefully even begin to think that you could get away with dealing with the IRS on your own. Right. You'd want an advocate to do that. You'd hire me to do that. At the same time, we're talking about bills that can be much higher than our tax bills, and yet we're not bringing in an advocate. So let me ask you a couple of practical questions that I could mark while we've got a little bit of time here. When should we pay a bill?

Well, I think as soon as you.

Verify that the bill is fair and accurate, that's when I would pay it.

And also not overpriced.

And that's why it's important to analyze it. And, you know, but there's a lot of bills. I look at it, I analyze it, I look up to see if it's a fair price, and then I pay it.

But I'm telling you, many, many medical.

Bills, the people who look at them would say most medical bills are inaccurate or overpriced.

So one of the issues that people are, One of the big fears that people have is they're going to ding my credit report, okay? They're going to show me as uncollectible. They're going to send me to a. Anytime they send you to a debt collector, you go, oh, I'm afraid that they're going to ding my. My credit report. So how long, reasonably do you have from the time you get that bill to do that analysis?

Well, so they'll never do that after the first bill. You know, hospitals will send you multiple bills for months.

And so I would say you have some time, right? It's not. And also with that first bill, it's pretty easy to get the medical codes and get an itemized bill and look up the prices. I mean, this process total will take you 15 or 20 minutes. It just might take you multiple phone calls to remind them or multiple emails to remind them. But it's easy to get the basic information you need. And I'm talking about a pretty simple case, right? I mean, say it's a broken arm in the emergency room, or I need to get a CT scan or an mri. Those are things that we can do within a few minutes if we know how to do it. It's the knowing how part. Because until we know how, we feel totally paralyzed by this. This system is like a black box, and it's very intimidating. So that's why what I'm trying to do with the book is equip and empower people so they understand just some basics that you need to know, some principles and some tactics that they can apply. And then it doesn't actually take that much time.

I like it. So let's shift to the front end. Okay, so we talked about the back end here. Let's shift to the front end. What can you do now? Let's say actually to create a plan of action, a strategy to protect yourself going forward. What are two or three things that you can do right now to get ready for so that you don't have These big bills.

I think the first thing to do is take this stuff as seriously as you would take your taxes or your budgeting or your mortgage payment or your cell phone bill or your cable bill. Let's put the same amount of effort and scrutiny into our healthcare costs as we do to everything else. Because what we've done up till now is we have sort of trusted the system to take care of it. We've trusted our employer or our insurance plan to take care of it. And so we've been too passive. And I think when we're too passive, we don't push back and then people take advantage of us. And so frankly, the working Americans have been being exploited by our healthcare system and we haven't yet pushed back. So I think the mindset has to be the first piece.

Does it even make sense? For example, let's say you've got, I mean, I'm in a big metropolitan area, I'm in Phoenix, so, you know, we've got tons of hospitals. You literally have a lot of options. Does it make sense to do some research or have your assistant do some research to find out, okay, which hospital would be better from a standpoint of, you know, what my likelihood of success is going to be? I know, for example, for me, my doctor is associated with a particular hospital, which I find I have more clout with that hospital system than I would with the one that's actually down the street from me. So what kinds of things can we do from that standpoint?

So I would say, let's just say.

It'S an episodic type of care where you know you're going to need a knee replacement, right? And so your doctors told you you.

Feel the pain, you know, in the.

Coming years, you're going to need this. Hospitals now are required by the federal government to post their prices for common procedures on their websites. And they also are required to post their cash prices, their Medicare prices, and their negotiated prices with each insurance plan.

People don't realize it, but this is how crazy the health care system is. You could go to one hospital and your knee replacement price with your insurance company might be $25,000. You could go to a hospital in the same town, very close, and the price is $50,000 or $75,000. These prices are not set based on the quality of care. They're based on market share, reputation, a series of behind the scenes deals and horse trading that goes on between the healthcare institution and the insurance company. And you don't know. And not only that, your insurance company might have a great price on knee replacements and a terrible price on emergency room visits. So you don't quite know. It's not consistent. So where you can look, I encourage people look and see if your hospital is complying with that federal law to post prices. And by the way, many hospitals are not. It is a federal rule that they post their prices. So if your hospital is not posting its prices, let them hear it, Especially some people in your audience. You might know the board member, you might bump into the CEO at a fundraiser, tell them, hey, why are you guys not posting your prices? The federal government requires it. And so far, a lot of hospitals have not complied. And that's information that we need to demand as consumers. I even know some people are uncomfortable calling us healthcare consumers, but unfortunately, that's what we are. We're put in this position where we have to pay a large portion of the bill or maybe even all of it, and we have to check this stuff. And we've been passive. So they've gotten accustomed to just making us pay whatever they tell us to pay. And that's what we need to put an end to. Because when we push back, we can get a better deal. When we look for the best prices, we can reward the people who are treating us fairly and we can penalize the people who are trying to rip us off by avoiding them entirely.

I like that. Now, one of the things, of course, I like is that we can actually get the federal government to contribute in a couple of ways. Right now, normally you're subject to this floor on how much you can deduct, because the deduction obviously is a discount by the federal government. They're contributing a share. If you're in a 30% tax bracket and you get a deduction, they're contributing, the government's contributing 30%, which I think is a great deal. And so there are a couple of things that I always recommend. First of all, if you have the opposite opportunity for an hsa, that's an easy one because that's a deduction before you need it and that money is set aside and available for you. Another one is if you're a business owner, set up, work with your advisor to set up a medical expense reimbursement plan. So there are, in a medical expense reimbursement plan, you get a full deduction instead of this floor where you're itemizing your deduction. So there are some ways to actually get the federal government to contribute, which, you know, I would encourage people to talk to their tax advisor. Now, one more thing. Before we finish up, if we could insurance. How do you decide on deductible, you know, level of insurance? How do you decide on that? Because to me, that's for a lot of people, that's a big mystery.

Well, it depends on the. Everything is so different depending on your family circumstances, depending on the health of your family or the people are going to be on the plan. It depends on what your employer might offer. Or even if you're out on the market looking for an individual plan, it's too hard to say prescriptively what any individual should do because everybody's financial and health circumstances are so varied.

Let me give you a simple example, okay? Do I take the $1,000 deductible plan or the $2,000 deductible plan or the $5,000 deductible plan?

Well, so for that, I just do the calculation based on how much more it's going to cost me in monthly premium for that lower deductible. Right? Because they're going to balance it out. You know, you have to look, how much am I paying up front on each of these plans versus the risk of what I'm going to pay on the deductible?

And then there's also the question of what's the, I mean, what's the likelihood of you even using up your deductible? Right. I mean.

Correct.

A lot of people, they're healthy. They're young like you. Young and healthy, you may not use your deductible. Whereas, you know, somebody in my age bracket might probably will use it every year. Right. I can't imagine not using my deductible, even if it's a $5,000 deductible. So to me, that's part of the question as well.

Are there.

Better insurance companies than others? I mean, should you shop that?

So I do think you should shop it. The hard part is, again, it depends a lot on the geography of where you are, depending on the leverage your insurance company has in a different community to get better prices from hospitals. It's really tough just to say universally, but I do think the mainstream insurance companies are very tightly regulated by the Department of Insurance in every state. And so if it's a mainstream insurance company that's regulated by the Department of Insurance, you can look up what type of complaints they've had, you can look up their history of denying types of care. And so if somebody needs something specific, let's say a specialized type of care or specialized medication, you do want to know before you sign up with an Insurance plan, whether it will cover the particular type of care or medication that you need. So I definitely recommend doing that. But I would say for any insurance company that's regulated by the state, these are mainstream companies, they are very concerned about compliance with the law. And so you have to maybe negotiate with them in a certain way to make sure they cover what you need. If they say deny you care, but they are going to be in compliance with the law, more or less. These are not ramshackle, fly by night fraudulent companies. And so you can get public information where you can about them. You can see denial rates for types of services you might need. But that's a lot of work. I mean, I'm not going to lie. I mean to do that kind of research is tough for any individual.

But it seems to me like we have a lot of listeners who are entrepreneurs. They've got small businesses and they might have an employee that is a key employee, for example, that has asthma or a particular chronic illness or something. And they're like, my wife has some medication that it's very expensive for her. Fortunately she runs a very profitable business. She can afford it, but it's very, very expensive. And so she has to look at, when she looks at insurance for her employees, does it cover what she needs to have covered?

Let me give you the number one, I think most important thing for employers to know and I actually have a section in the book for employers. I have eight chapters. I have eight chapters for individuals and I have three chapters for employers. Because I think employers are the greatest hope that we have of turning around our healthcare system. I think if they took the business knowledge that they're taking to run their businesses and applied it to our healthcare system, I think there's a great opportunity for them to help turn this around. So here's the number one thing I'd say to your employers. Get an advisor, like a broker, an advisor, a consultant who is independent of the insurance companies. Most of the advisors are funded by the bonuses and commissions from the insurance companies, the pharmacy benefit manufacturers, all these vendors that are feeding at the trough of your employee benefit plan. You need to find an advisor who you pay directly. They're still going to make their money. They're just going to be paid by you directly. And their incentive then is to do what's best for you. And that means getting you lower priced health benefits at a lower or lower priced better benefits. That's what they're going to do for you. And where you see people switching to these independent advisors and brokers you're seeing employers drop their overall healthcare spend by 30, 40% a year and improving the benefits, lowering the co pays, bringing in direct primary care. It's really exciting what's happening. And so that's why I wanted to have the book also be focused for employers because I want them to see we don't have to keep doing things the same way. We can apply the same entrepreneurial and business mindset to our healthcare benefits and the savings can be dramatic.

I love that. So Marshall Allen, marshallallen.com, right, marshallallen.com sign up. Never pay the first bill. Highly recommend it. Great having you, Marshall. Thanks for taking the time and thanks for taking time to write the book. I written a few books and I know that it takes a substantial amount of research and time to do so. And particularly I want to thank you for adding in a couple of chapters for the employers because that's, you know, I do think that the employers have a real opportunity not just to help their employees, but remember that when you help your employees, you also help your business. It's a better offering. You can actually promote that when you're recruiting and you can literally take that worry. The more we take worries off of our employees minds, the more they can concentrate on what they're doing for us. Right. Doing for our customers. And so you really want to. When people have serious medical issues or seriously financial issues, it actually is such a distraction from what they're doing in their job that it's just critical that we get this solved. So I very much appreciate that, Marshall, appreciate what you're doing. And remember everyone, we learn these things and don't forget personal assistant. But we learn these things always so that we can make more money. And of course reducing expenses is the easiest way to make more money and lower our biggest expense taxes, which we can also do as we've learned in this arena and we always want to make more money and pay less tax. We'll see you next time. Thanks everyone.

You've been listening to the Wealth Ability show with Tom Wheelwright. Way more money, way less taxes. To learn more, go to wealthability.com.