How to Protect Yourself from Unexpected Medical Costs
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Adria Goldman Gross has spent over 25 years helping individuals through the complexities of medical billing. As the founder and CEO of MedWise Insurance Advocacy and MedWise Billing, Inc., Adria fights tirelessly to reduce overcharges and secure fair treatment for her clients.
In this interview, she shares her insights on insurance challenges, how she approaches each case and client, and the critical lessons learned throughout her career — along with the personal joys that drive her both in and out of the office.
In this article
Client services
Joy Wallet: What services do you offer to help clients with insurance issues?
Adria: Insurance has gotten better recently, as certain new laws were passed in 2022, but it isn't good enough for people not to still have issues with their medical bills. That's where I can help with my medical insurance advocacy.
Sometimes, people go into emergency rooms and find out that their insurance no longer covers emergency rooms or that those emergency rooms are out of network. People also often get overcharged or get their claims denied. I can help even when you're trying to get pre-authorization but are not receiving it.
Read also: Types of Health Insurance Plans
Common challenges
Joy Wallet: What challenges do you see most of the time regarding insurance?
Adria: The fact is that insurance companies never want to pay out the money.
Here's an interesting situation. Recently, I had a client who works in emergency rooms. He's not a doctor but does radiology as a part of a group that goes into different hospitals to test people in the emergency rooms. He had insurance through the company he worked for. His policy said he's only allowed to go into an emergency room twice a year, and they can only pay $200 each time he goes. He went to two hospitals in Texas under the same name but in two different locations. His insurance didn't even pay the $200. Moreover, they charged him almost $35,000 for two visits (one was $4,000 and change, and the other was $29,000). When I looked at those bills, I realized that the maximum he should pay was less than $1,500. It was a hard job, but I got them to lower it to a reasonable amount.
These are the kinds of issues that are going on all over the place right now. I read an article recently that says that one of the insurance companies doesn't even want you to go to the emergency room and won't pay for it. They just want you to go to urgent care.
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Personalized approach
Joy Wallet: How do you approach each client's problem?
Adria: Every case is different. I even get phone calls where people are getting thrown out of rehabilitation even though they really should still be there (that happens with a Medicare Advantage plan in the United States). In other situations, someone has a long-term care policy and meets all the requirements to get paid, but the insurance company is not paying out. Or, like I said before, you go to an emergency room, and your insurance doesn't want to pay for whatever reason.
People tell me their situation, and I then tell them how I feel about it and if I can handle the case. I also have to know if it will be worth it for them. There are even situations where I don't want to take any money. A guy recently called me, and I gave him free information because the bill was so low. I didn't want him to hire me for him to waste money, and I didn't know what the results were going to be. I gave him good advice, and he overturned the case and got the money (it was $3,100). He got back to me after almost six months and sent me a check in the mail for my hourly rate. It was very kind of him.
Industry trends
Joy Wallet: What trends have you seen in the last couple of years, and do you think things will change for the better or worse?
Adria: Well, things are getting much better because of these new laws, and more money is being paid. It started in 2020 and got even better in 2022. I don't have as many calls as I used to, but I still see today that insurance companies take the money and insure their people but don't want to pay it out.
I worked for two insurance companies 30 years ago, and they taught us how to deny a claim within two weeks of employment. I became a supervisor of claims within a month. Those trends are still going on today despite all these new laws.
Handling denials
Joy Wallet: What advice would you give someone handling an insurance claim denial?
Adria: The first thing you have to do is find out why the insurance company denied your claim. People call me about that, and I ask them why, what the bills were, what services were rendered, etc. There are services that an insurance company is never going to pay for. The provider, the doctor caring for you, should know that and tell you. In some cases, those doctors are out of network, meaning you'll never get paid, but very often, they never tell the patient that.
I wrote a book that came out about nine years ago, and people still buy it. It's called Solved! Curing Your Medical Insurance Problems. It is a guide that tells people the steps to take when you have a denied claim. So, first of all, you have to find out why it's denied and then figure out what you can do to overturn that case to get it paid. You must call the insurance company and the provider (doctor or hospital) to find out why they're denying your claim.
There are different reasons why your claim could be denied. Sometimes, it's due to the incorrect billing. Sometimes, people never get the pre-authorization. In some cases, it's because you went to an out-of-network provider.
I had a case recently where the guy got pre-authorization in November 2023 but went for the surgery in February 2024, and even though he had a pre-authorization, the insurance company wasn't going to pay it. They didn't have a contract with the insurance company that month when he was pre-approved to get paid — and they didn't tell him that. So, he gets the procedure done and gets a bill for $31,000 in the mail. He called me, and we went through the whole thing. The hospital wasn't being too helpful. This past February, I made the front page of a newspaper, so I called the guy who wrote that article and asked him to help me with this. He got in touch with the hospital, and believe it or not, they got scared and finally agreed to help us. My client only had to pay his deductible for the year. Everything else was paid for.
Medical insurance myths
Joy Wallet: What are some of the most misunderstood aspects of medical insurance?
Adria: The first thing you need to do — and people never do — is to read the insurance policy carefully. Look, we're all so busy. We work. We have families to take care of. When you get that insurance policy, how much time do you have to read it? Still, you have to read it to know what is covered and what isn't. When you apply for insurance, the company will often give you a little booklet that might only have 6–12 pages, telling you what you're covered for and not covered for. Still, it doesn't go into much detail about different conditions you might have that you won't be covered for. You must carefully read the big policy, which usually has 200 pages or more.
When I started, I worked in travel insurance. Those insurances have a pre-existing condition exclusion, too. Now, if you have diabetes and your medication has changed over the last 12 months, and you pass out when you're away, you'll be denied. You must pay extra money to have those pre-existing conditions on your travel insurance policy.
Read also: What Does Travel Insurance Cover?
Staying informed
Joy Wallet: How do you stay updated with new healthcare regulations?
Adria: Insurance companies are supposed to notify you when changes are made. As for regulations, the only thing that I can recommend is Google Alerts. When anything in the news pops up about a topic, I go on Google and subscribe to it. That's the only way it works. If you don't work for that insurance company (which most people do not), how do you know about any change? With Google Alerts, you'll get emails with the news and changes.
Cost protection
Joy Wallet: How can people protect themselves from unexpected medical costs?
Adria: I'll tell you what I've done. Let's say you're going into the hospital for surgery. If you're having surgery, you're going to have an anesthesiologist. A lot of times, an anesthesiologist is at a network. So, before a planned procedure, you must ask who the providers are to check if they are on your policy.
Today, I talked with a woman on the phone, and she didn't understand her deductible. She thought she had a deductible of $3,000, but I looked at her explanation of benefits and saw that she has a $6,000 deductible. I read to her exactly how much they will pay out, what the deductibles are, and what her copay is. She didn't know that.
I want people to remember that before the surgery, you should call an insurance company and ask some questions. I told her to get the case number and the name of the person she talks to when she calls the insurance company. You have to get the case number to prove you had a conversation with them on this date. If she were to call them back and she didn't have a case number to go back to, they could turn around and say they don't have any notes on that.
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Client education
Joy Wallet: How do you educate your clients about insurance policies? What should they do?
Adria: I used to help write some policies, so I know how they work. Still, if I ever have any questions or concerns, I will call the insurance company and get the case or a reference number for that conversation. When you call them and say you have surgery and ask if they will cover it now, they could say yes, but the thing is, depending upon what the diagnosis is or how they send the bill in, you might not get covered. I see more claim denials with the wrong diagnosis.
The power of negotiation
Joy Wallet: What role does negotiation play in reducing those medical bills?
Adria: Let's go back to that woman I talked with today. I've been working with her for a few months, and in the beginning, we didn't realize she hadn't met her deductible for the year (she thought it was $3,000 when, in fact, it was $6,000).
Here's the other thing: I always tell people to figure out whether or not they were billed correctly. You have to see what the procedure codes are. You can look up the Medicare rates in the United States, and most insurance companies go according to those rates. You have a CPT code, which is a five-digit number. If you check the Medicare rates for that CPT code, no matter where you are in the United States, the price is within a $10 or $20 difference. Insurance companies normally never pay more than 165% of that Medicare rate.
Now, they're billing this woman almost $1,600. When I looked at those procedure codes, I saw she shouldn't be paying more than $450. We already sent them the procedure codes, and they didn't want to budge, but I told her to fight it if she wanted to because she now knows what the amount should be. Rather than paying almost $1,600, if she wants to fight with them, she could reduce it if they agree to less than $450.
Lessons learned
Joy Wallet: What are the biggest lessons that you learned on this job?
Adria: I've learned that every insurance company always wants to save money, which is understandable. If you own a business, you have bills to pay. Sometimes, however, those companies are very greedy. Many people don't look back to see whether or not they're even responsible for their bills. You may get duplicate bills and keep paying them, not realizing what you're doing. Also, as people get older, they might have dementia or Alzheimer's, and they might not have anybody working with them, so they don't understand things.
What I have gained from being in this industry is the knowledge of how to help people. The major reason for bankruptcy in the United States is medical bills. I never want to see anybody in that arena where they don't have enough money to live. Even when I spoke to this woman today, with that bill for over $1,500, we discussed how much she pays out just for the insurance. She has a deductible of $6,000, and she's paying out about $2,000 a month. That is $30,000 out of pocket.
You need to try to help others in any way possible when they have a condition. I've done a tremendous amount of volunteer work in my life and learned you shouldn't be frightened to go against the insurance companies or even your doctor. People, especially seniors, are scared that doctors will not take care of them, but you must learn not to be frightened and fight for your rights.
Finding joy
Joy Wallet: What brings you joy in life, both professionally and personally?
Adria: I was a very sick child, and I had an insect bite that put me in a coma. I almost didn't survive. I lived with epilepsy. After the brain surgery, I went into the health insurance industry. I have since written a few books. Solved! Curing Your Medical Insurance Problems was the first. The international edition of it is Multi-Payer Medicine Nightmare Made in the USA. My most recent book is called Apparently DIFFERENT.
When I was sick for so many years, people were avoiding me. But I have to tell you, after my first book came out, I realized that I had to get another book out because people with a condition very often do not get respect from others. The book Apparently DIFFERENT is about me and 25 other people who had a difficult life. I've been cured. Thank you, Lord. I'm grateful every day. But some people can't be cured, and that book is all about respect for others with a condition.
My next book, coming out in the next year or so, will be called Apparently DIFFERENT for Kids because kids need to learn at a young age. Autism is very common, and these children do not get the respect that they deserve. I will have stories of children with all these different conditions in it. Nobody has a perfect life, and you can't expect others to be perfect. That book is going to be about how you treat other people. I went through that. I lost my friends. Then, after I had the brain surgery and I didn't have seizures anymore, people wanted to be my friends. It's all about my own experience, respect, and not being rejected.
It's so important to believe in yourself. You have to trust yourself and believe in yourself, and that will help you throughout your life.
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