While chasing a girl back and fourth through a doorway, this modern-day Pavlov’s dog jumps whenever he gets to the spot that’s normally blocked by a child proof gate.
The universe doesn’t have to be expanding into anything in order to expand. I know that sounds ridiculous, so let me give you a different example that is easier to understand.
Imagine that you have a line that goes on forever. On that line, you have a mark every inch. There are an infinite number of inches. Now move each marker so they are separated by two inches. The whole pattern has expanded. It still goes to infinity, but the markers are further apart. The pattern has expanded, but the length is still infinite.
Now a new example. Suppose you have a long piece of rubber, going all the way to infinity. (That piece of rubber represents the universe.) The rubber has marks on it every inch. Now stretch the rubber, until the markers are two inches apart. It still goes to infinity — but it has expanded.
Physicists think of “space” not as emptiness, but similar to a piece of rubber. (But they don’t call it rubber; they call it the “vacuum”. “Particles”, in physics, are just vibrations of the vacuum.) The vacuum can expand, just like the piece of rubber. But because it goes all the way to infinity, it doesn’t need more space. A clever way to say it is that “there’s lots of room at infinity”. (That’s clever, but it doesn’t really explain anything.)
Now here is something new that might confuse you, or might help. In the standard physics theory, the galaxies are all getting farther apart; that is the expansion of the Universe. Yet in the way the theory describes it (I mean in General Relativity Theory) none of the galaxies are actually moving. All that is happening is that the amount of space (vacuum) in between them is increasing.
No, you will not learn this in school, or even in college (unless you have an extraordinary professor). It is usually taught in graduate school, when you are earning a Ph.D. degree. At that point the language you will encounter is this: “In the Big Bang Theory, all galaxies have fixed coordinates. (That means they are not moving.) The ‘expansion’ is described by the ‘metric tensor’, which describes the distances between those fixed coordinates. In the Big Bang Theory, it is the metric tensor which is changing; that represents the expansion of the Universe, even though the galaxies aren’t moving. The recent discovery of accelerated expansion means that the rate of expansion is increasing.”
Maybe you’ve read about the curvature of space. Put a black hole between two unmoving objects, and the distance between them will suddenly increase — even though they haven’t moved. So “distance” is not as simple as people thought. It was Einstein who came up with the remarkable idea that “space” (that is, vacuum) is flexible; it can curve and stretch.
I expect you will find this to be very confusing. That’s not a bad sign; it is a good one. When you learn new things that are completely different than you ever imagined, then “confusion” is the first step.
Five patients tell us how they pushed back — and won.
I’ve come across some astounding charges investigating how emergency rooms bill patients. A woman in California fell off her bike and now faces a $20,243 bill. A patient in New Jersey never got past the ER waiting room and ended up with a $5,751 bill. A dad in Connecticut got a bill for $629 for the Band-Aid put on his 1-year-old daughter’s finger.
Most patients can’t afford these kinds of bills. But they often don’t know that it’s possible to negotiate them down.
I recently interviewed a dozen patients who successfully got their bills reduced, some who were unsuccessful, and even one whose bill went up after he attempted to get it lowered (more on that later).
I learned that people can indeed shrink their bills, but only if they’re willing to put in significant time and, in some cases, money. Here’s what patients say worked — and didn’t.
1) Challenge what’s in your bill and how it was coded
Sue Null is a professional patient advocate at a firm called Systemedic who has helped me decode numerous medical bills for my stories.
She says that when you challenge a medical bill, you need to find two things: the right information and the right person.
Find any documentation about how your medical visit was coded and what services were provided. The first bill a hospital sends will often just have one big number. Null recommends tracking down an itemized bill. (Beware, sometimes hospitals do not make it easy to get these records — and you might be transferred through a few departments as you go.)
Once you get an itemized bill, you can analyze it for mistakes. You might see a charge for something that never happened, duplicate fees, or things being billed at exceptionally high prices.
One way to check if the fees are especially high is to look at a database like Fair Health or Healthcare Bluebook to see what nearby doctors and hospitals typically get paid for the type of care you received.
In the emergency bills I’ve read, I’ve seen a decent number of success stories from patients who challenge the coding of their facility fee — the charge for walking into an emergency room and seeking care. Emergency rooms typically charge higher facility fees to cases they deem especially complex, using a 1 to 5 scale.
Those fees can be really different: At Zuckerberg San Francisco General Hospital, for example, a level 1 facility fee is $561 while a level 5 is $11,958.
Sam Metcalf, 34, was coded as a level 5 visit when he went to a Milwaukee emergency room for what he suspected was bronchitis. That coding surprised him.
“Somebody came in, did a short exam, and then prescribed me some pills and sent me on my way,” Metcalf says. When he got the bill for around $300, he reached out to a patient advocacy firm that his employer contracts with.
The firm negotiated with the hospital, arguing that the visit ought to be coded as level 1 rather than 5 — and the hospital agreed, wiping out Metcalf’s outstanding bill.
2) Ask for a prompt-pay discount
Let’s say everything on your bill looks right — you aren’t being charged for something that didn’t happen, and the fees look pretty similar to what other hospitals charge in your area.
At this point, your best bet is probably to ask for a prompt-pay discount. Patients I’ve spoken with said they often found hospitals pretty willing to offer a discount to those who are ready to pay their bill right then and there.
From the hospital’s vantage point, this often makes sense: It can be easier to take a smaller payment rather than chasing down a bill you might never pay.
But there is a lot of variation in the discounts if any, that hospitals are willing to offer. In the interviews I did, some patients told me their hospital was willing to negotiate right off the bat. Others quickly said no. And sometimes different consumer representatives would offer different discounts. It all depended on who picked up the phone.
Patricia Rowan emailed me about negotiating multiple health care bills of her own. She says she’s received discounts ranging from 20 to 40 percent.
“I figure it’s always worth asking for a discount,” she says. “Worst they can say is no, and many have — especially the ‘nonprofit’ hospital in town where I just had my baby!”
3) Call. Then call again. And again. And again.
This is something I heard from nearly every patient I interviewed: Negotiating a medical bill almost always involves time on the phone. That’s a better place to start than a hospital’s website, which often doesn’t advertise the discounts that a consumer representative will know about.
This is all about getting to the person who has the power to change your bill — the “right person” that Null, the patient advocate, thinks of as the second key thing you need to be successful in your negotiations.
“You can ask a question, but if you’re getting nowhere, then you are persistent and ask for a supervisor,” Null says. “And if that person isn’t helping, you ask for the director of the department. Sometimes you have to push your way all the way up to the CFO’s office.”
Martha Shea told me about negotiating down her husband’s $12,000 bill for emergency surgery in Jacksonville, Florida. The first time she called, the surgeon’s office agreed to knock 15 percent off the bill. Then she kept calling, each time asking if they would consider offering a discount. Each time, a few hundred dollars disappeared.
“I could have afforded to pay the whole thing, but I knew I had time,” Shea said. “So I wanted to wait, and each time, the physician group would knock it down a little bit.”
After about six months, Shea had reduced her bill to $7,800. That’s when the doctor’s office informed her they’d be sending the bill to collections unless she paid. Shea did not want that to happen — she worried that it could negatively affect her credit.
“I went in and wrote them a check,” Shea said. “Maybe I could have gotten it lowered more; it’s hard to know. But I didn’t want it in collections.”
Melissa Jackson spent more than a year negotiating a medical bill for an emergency surgery resulting from a complication of childbirth. The bill started at $12,966 and was ultimately wiped out completely — but getting there wasn’t easy. (Jackson requested I use a pseudonym to share her story. While she is done negotiating her bill, she worries about possible retaliation from the doctor for speaking publicly about the experience.)
“I learned the tricks, like you have to call when they open or, even better, start dialing a few minutes before they open,” she says. Calling earlier lowered the time she’d spend on hold.
Jackson ended up creating a workstation at her coffee table, and kept all her medical records and insurance forms in a nearby basket.
“It was a full-time job that I didn’t get paid for but felt obligated to do,” she says. She recounts sometimes spending upward of six hours on the phone in a single day. “At one point, I broke out in a rash. I was really stressed out, because this was basically all our savings on the line.”
4) Consider hiring a professional
Sometimes it will be obvious when there’s something wrong with a bill. But often, medical bills can be difficult to navigate, a jumble of billing codes that seem like a foreign language.
Null, the patient advocate, specializes in fighting those more complicated bills — and recommends that patients facing especially big bills (think: tens of thousands of dollars) consider working with a professional patient advocate who knows the ins and outs of medical coding.
Some employers now offer patient advocacy services as a staff benefit. If you’re among the 150 million Americans who get health insurance at work, it’s worth checking if you have access to that type of service too.
Other patients have gone a slightly different route: lawyers. This includes Jason Zanders, who was hit by a public bus in San Francisco and received a $27,660 bill for his treatment.
Zanders retained a lawyer to fight the charges but still had to put significant work into the case. The lawsuit ultimately went to a jury trial, and Zanders had to delay his wedding in order to make his court date.
“It was a lot of weight on my shoulders, having the bill out there,” Zanders told me for a recent story I wrote about his case. “I wasn’t really enjoying my job because I was just thinking, I need to go to pay off my bills. I can’t take any vacations because I have this bill. I was preparing for this mindset of, whatever happens will happen, and I’ll have to deal with it, even if it means getting two or three jobs to do that.”
But at the end of the day, Zanders won: The court ordered the city of San Francisco to cover his entire hospital visit.
5) Go public
When all else fails, shining a spotlight on your bill can often do wonders.
This is something I’ve seen in my own work: About half of the emergency room bills I’ve covered as a journalist were cleared after I began inquiring about the charges. In total, I’ve had nearly $100,000 in bills reversed in the course of this emergency rooms reporting project, in states from California to Texas to New Jersey.
This is, of course, a bad way to run a health care system. About one in five emergency room visits result in a surprise bill. So it seems reasonable to assume that there are a whole lot more patients struggling with medical bills than there are health care reporters writing on the topic.
Nonetheless, this tactic seems to work. Find out who covers the health care industry for your local paper and send an email. It’s important that you have your billing documents and are willing to share those with the reporter. (Relatedly: If you’re a health care reporter looking to connect with patients who want to talk about their bills, fill out this form to use Vox’s database of more than 2,000 emergency room bills.)
If you’re not having luck with a reporter, social media can be helpful. Tweeting or posting on Facebook (and tagging the involved parties) is a pretty low-effort way to get some attention to your case.
6) Be aware that sometimes negotiating won’t work — and can even backfire
At the end of the day, it’s really up to the hospital whether to say yes or no. And in some cases, attempts to lower a medical bill can backfire.
Timothy Boudreaux from St. Paul, Minnesota, went to the emergency room last year after cutting open his finger with an apple peeler.
The hospital initially billed him $152. But when that bill came, Boudreaux noticed that he’d been classified as uninsured even though he had coverage. He thinks he might have given the emergency room staff an expired version of his insurance card.
So Boudreaux called the hospital and gave them his insurance information. A few weeks later, a new bill arrived for $200 — turns out he’d lost a big discount the hospital offered to uninsured patients.
“I called the hospital, asked to talk to billing, and said I’d like to withdraw my insurance coverage from the claim,” he remembers. “They refused.”
Boudreaux was understandably frustrated. He buys his own health coverage on the Affordable Care Act marketplaces and expected that his insurer would be negotiating lower hospital prices on his behalf — not leaving him with bigger bills.
“The negotiating they’re doing is pretty poor if the only thing you have to do to get a better price is not get insurance,” he says.
Via Pleated Jeans
There are two types of people in this world: those who confront the people they have a problem with, and those who leave passive aggressive notes. Personally, I love leaving an angry note. It’s quick, easy, and no one gets hurt (especially me).
These fine folks share my proclivity for ducking confrontation and did so with such flair I had to share. The passive aggressive note is an art form, and these masterpieces should be in a museum.