Kristin Baker Spohn was recently named the newest health-tech investor at Social Capital, where she’ll work alongside early Facebook investor Chamath Palihapitiya and focus on early-stage start-ups. This marks the latest Silicon Valley venture firm that is making major strides into health-technology. Andreessen Horowitz, Benchmark, GV, CRV and others have all added partners with a health background to their ranks.
Prior to joining the fund as a partner, Baker Spohn worked in the health care group at Goldman Sachs, and as an operator at Castlight Healthand Collective Health.
This is her story about what happened when she noticed a duplicate billing for a procedure she had during her pregnancy…
I’ve spent my entire career in health care.
It’s impossible to work in this industry and not lament how challenging our system can be for patients. But I didn’t truly appreciate its complexity until I was the one navigating it on my own.
Several years ago, I was diagnosed with gestational diabetes and classified as a “high risk” pregnancy. Following my doctor’s orders, I had an additional ultrasound to check on the growth of my baby. A little over a week later, I went into labor and delivered my happy and healthy son.
We settled in with our new life at home and in a few weeks the onslaught of hospital bills and explanations of benefits (EOBs) from my health insurance administrator arrived. As the diligent chief financial officer and resident health care expert of our family, I jumped in, determined to reconcile the insurance reimbursement with the hospital bills.
In the haze of new motherhood, my recollection may be fuzzy, but it went something like this:
In one hospital bill, I noticed that there was a duplicate charge for my additional ultrasound.
Most people would groan — or worse, not even notice the duplicate charge — but for me, it was game time. I felt like an athlete who had trained for this moment for years. My finance background and attention to detail enabled me to reconcile and find errors in complex financial statements and models. My work at Castlight prepared me to understand all of the different healthcare systems, billing and reimbursement codes. And my weird love of negotiation energized me as I approached the starting line.
How it went down
Step 1: Pull all the documentation together. It is immediately clear that the information in the bills and EOBs isn’t sufficient. I need an itemized bill from the hospital and a detailed EOB from my insurance administrator in order to make sense of all of the charges. Because I am on a high-deductible plan like millions of Americans, I also need the benefits coverage detail and my accumulators (how much of my health insurance deductible I had spent at the time of the ultrasound) in order to calculate my co-insurance responsibility.
Step 2: Log into my insurance provider’s web portal to look up ultrasound coverage and attempt to determine my remaining deductible at the time of the ultrasound. I find the coverage information under “imaging benefits” and read that ultrasounds are “covered as a preventive service,” but it’s unclear what constitutes a preventive ultrasound vs. a non-preventive ultrasound, and which category mine falls into. I will need more detail from the hospital to figure this out.
Step 3: Call the hospital to get an itemized billing for the date of service which included the ultrasound. I request the CPT code for the service and am told that it is in a different department and I’ll need to call back after 9am the next day.
[At this moment, my son starts crying. Break to change his diaper.]
Step 3b: Call the other hospital department line and ask for the CPT code (the guy on the line is shocked I know what a CPT code is and is confused why I’m asking for it).
[Next, I break to put my son down for a nap.]
Step 4: Call the insurance administrator for benefits coverage information related to ultrasounds. I’m informed that my benefits detail is specific to my employer’s coverage and I should call my company’s benefits team to ask for it.
Step 5: Call my company’s HR team. They say, actually, since we are a fully-insured employer, the benefits should be available through my insurance administrator. Of course.
[Break again to take a quick work call.]
Step 6: Call the insurance administrator back and ask for the detailed summary of benefits. The support representative says I can go on the web portal, download, print and fill out and a request form and the document will be snail-mailed to me. Snail mail!
Step 7: Put my son in a stroller and walk to Fedex/Kinko’s to print out the form and mail it in.
[Wait several weeks, it doesn’t arrive. Baby gains two pounds!]
Step 8: Call the hospital back to request that they not send my bill to collections as there is an ongoing discussion with the billing department and insurance administrator over benefits coverage. I am assured by the support representative that this is noted in my file.
Everyone having fun yet?
Good, because we’re going to rinse and repeat…for several weeks.
Why I gave up
After bouncing between three web portals and at least five call centers (across hospital departments and insurance administrator customer service lines), and spending more than 18 hours on the phone asking for CPT codes, diagnosis codes, and benefits information, and requesting extensions on my bill so that I could continue to pursue the reconciliation, I received….a collections notice.
I had been confident I could take care of this situation on my own, but after weeks of roadblocks and hold music, I felt defeated. I paid the bill. I couldn’t risk the negative impact an unpaid bill could have on my credit score as my young family considered buying our first home.
Despite the fact that I had a (self-designated) advanced degree in healthcare technology, benefits and billing, I failed to successfully navigate the system.
I was recovering from childbirth, caring for a newborn, working on my company’s upcoming IPO, and struggling to reconcile my hospital bills from a set of common services in a pregnancy.
My experience, while personally disheartening, added new fuel to my my passion for driving innovation and change in healthcare. If can’t figure this out, what hope is there for the rest of us?
How health care could be
Contrary to some of the recent rhetoric from lawmakers, high-deductibles and health savings accounts (HSAs) won’t magically create empowered healthcare consumers or a functional healthcare marketplace.
Stakeholders across the healthcare ecosystem system need to innovate, remove friction points and thoughtfully design products and processes that enable the experiences we would want for our own families. I’ve worked to help build two such innovative companies. And I’m joining Social Capital to broaden that reach.
I’m looking to work with health care entrepreneurs that understand the world as it is today, but also see how it could be. A world where everyone gets the experience they deserve, whether they’re experts in the healthcare system, or the next new parents struggling to understand a bill.