About Christine M. Cooper, CEO
A patent lawyer recruited to Koehler Fitzgerald LLC in 2016 because of her large law firm experience and IT skills, Christine was quickly elevated to a member of Koehler Fitzgerald LLC and leads the health care practice. Christine is the CEO of aequum and is dedicated to assisting and defending plans and patients.
About aequum LLC
Founded in 2020, aequum LLC serves third-party administrators, medical cost management companies, stop-loss carriers, employer-sponsored health plans and brokers nationwide to protect plan participants, improve employee satisfaction with their health care plans, and generate plan and participant cost savings. aequum LLC helps patients defend medical balance bills and brings savings to employer-sponsored health plans by providing administrative and other services to its partners. In addition, its sister organization, Koehler Fitzgerald LLC, provides legal advocacy to plan participants. Visit aequumhealth.com.
Medical Travel & Digital Health (MTDHN): Can you tell us about yourself and your journey as CEO of aequum?
Christine Cooper (CC): Coming from a commercial legal background before getting involved in the healthcare space, I initially felt challenged by my desire to help people and better society. I had a hard time reconciling that desire with representing large corporations.
Moving into my current role as CEO of aequum, meaning “what is fair and just,” allowed me to advocate for and represent patients who needed help, which was incredibly gratifying. Going to law school instills a hope of making a difference, and this role gave me that opportunity on an individual level.
As I transitioned more to a business role within the company, I found immense satisfaction in growing the business and being able to help more people. We’ve built an amazing team of individuals with the biggest hearts who are dedicated to their jobs and building relationships with the people we work with including patients, employers and employees, plans, and TPAs. It’s a wide variety of individuals that I get to interact with on a day-to-day basis and see how all the key stakeholders come together to make a successful health plan and keep costs affordable.
Our growth has been amazing. There’s clearly a need for patient advocacy and plan protection services in the space because it is so big and complicated. So, we’ve been very fortunate to grow by about 50% each year since we formed.
MTDHN: Can you tell us a bit about the implications of the Medical Debt Cancellation Act?
CC: The Medical Debt Cancellation Act proposes the cancellation of certain medical debts to provide temporary relief to those who are overwhelmed by healthcare costs. It also limits the ways that medical debt can be incurred in the future. It’s a response to the growing crisis of medical debt.
The act is likely going to shift the responsibility for medical debt to future taxpayers, as resolving these debts will require funded grants. Initially, the impact will be positive for low income and vulnerable populations, but since funding is required, we will see this shift.
It may also have a significant impact on individuals’ credit scores. Currently, about 5% of Americans have a medical debt on their credit report. Under this act, the Fair Credit Reporting Act would be amended to exclude medical debt, preventing credit bureaus from reporting it.
This 5% figure is significantly down from 14% after the credit bureaus removed all medical debt under $500 from credit reports in response to the Consumer Financial Protection Bureau (CFPB) call to remove the debt. This change had a huge impact for Americans that have the medical debt because it was preventing them from being able to get beneficial loan rates and being qualified for a mortgage or refinancing. It really hindered their ability to obtain lending.
Therefore, if the act passes, I believe the alteration of the Fair Credit Reporting Act will be a major component.
Overall, I can see both positive and negative impacts – we’ll have to see where it ultimately ends up.
MTDHN: Do you think that a change in government leadership will impact either the support or passage of it?
CC: Even with a change in leadership, we’re likely still going to have a standstill in this space. It will depend on what the shape of Congress looks like versus what the administration looks like. If we end up with two different factions in there, we’re not likely to get a whole lot done, even if there is bipartisan agreement. I don’t think we’re going to see a big shift in healthcare.
Proposed legislation, aside from something like Medicare For All, has a lot of bipartisan support. We see Democrats and Republicans working together on drafting legislation but then it fizzles out and nothing gets done. I believe we will likely see more of the same going forward.
MTDHN: How do medical billing practices contribute to the problem of medical debt?
CC: There are a few ways:
First, providers charge excessive amounts based on their chargemaster rates, which are completely arbitrary amounts set by the board or other executives. These rates are designed to give providers leverage when negotiating with big insurers. However, those chargemaster rates are also used against or used to negotiate with self-funded health plans and individuals who are out-of-network and don’t have the same bargaining power that a larger insurer would have.
Additionally, medical bills often have errors that increase the bill amount, and due to existing contracts, patients have limited rights to challenge those inaccuracies. This can sometimes involve fraud and abuse, resulting in elevated bills that are difficult to dispute. Most individuals are not going to be able to look at their bill and know whether it is proper or not. So, this type of increase is leading to increased medical debt.
Lastly, the lack of price transparency is also prohibiting consumers from making educated decisions about their healthcare. There is a need for a shift in consumer thinking but if consumers knew their costs up front, they might avoid incurring such high medical bills on the back end.
For consumers to have access to pricing, hospitals have to be willing to comply with laws such as the Hospital Price Transparency Rule, mandated by the Centers for Medicare & Medicaid Services (CMS). This rule requires hospitals to disclose prices in a standardized, machine-readable format including listing insurer-negotiated rates and the underlying rationale.
Hospitals are reporting huge amounts of data that no individual could parse through. So, you have to have other companies that are evaluating, running and distilling the data into something usable. But what we’re finding is that the data is either inaccurate or incomplete. That is why it’s important to make hospital pricing more accessible and user-friendly for consumers.
MTDHN: What policy changes do you think are necessary to address the issue of medical debt effectively?
CC: First, I believe there needs to be effective enforcement of existing legislation and increased penalties for failing to comply with the existing price transparency laws. Many of these statues that have been passed lack enforcement mechanisms or have insufficient penalties. There aren’t many incentives for compliance. As we discussed, even though consumers may not be able to directly use the disclosed data, it can be distilled into something they can use.
One underutilized process that could make a significant difference is the advanced explanation of benefits (AEOB), which provides clearer, more comprehensive information upfront, allowing health plans to better inform patients about potential costs and reduce the likelihood of unexpected medical bills.
I believe the AEOB will go a long way in helping consumers, patients, employers and employees to be able to understand the true cost of their health care. While reading an AEOB might require some guidance, it is a simpler format than the large spreadsheets with incomprehensible numbers available on hospital websites. Utilizing and enforcing the AEOB process is crucial, but it’s been and continues to be delayed.
Finally, legislation should avoid shifting the burden of healthcare costs onto future taxpayers or through increased premiums.
For example, the No Surprises Act sounds great on the surface because people are no longer legally liable for their out-of-network costs in certain circumstances. But there’s still money being exchanged and it has to be paid for by someone. We are probably going to see increases in premiums, deductibles and other costs as a result.
MTDHN: How do you think lawmakers and healthcare providers can work together to reduce the burden of medical debt on patients?
CC: This is a tough question because most large healthcare facilities are supposed to be nonprofit entities focused on patient care, but they’ve really turned into for-profit centers. I think the providers need to focus on the patients first and not their bottom line.
The lawmakers need to bring other key stakeholders, such as third-party administrators, insurers, larger employers and even small employers, into the conversation. By doing so, I believe we can have a more meaningful dialogue instead of limiting the conversation to just the large hospitals and legislators.
It’s important for the legislators to listen to all the different key stakeholders and perspectives to create effective solutions. But the reality is, it’s easier said than done.
For me, the No Surprises Act has been eye-opening because the process seemed so out of touch with what actually happens in the payment space that it’s almost as if the legislators didn’t hear anybody or even ask basic questions about how medical payments are processed.
Therefore, I think there needs to be more listening rather than just pushing things out as quickly as possible to make it seem like the lawmakers are doing something.
So much of the lawmaking seems driven by a desire to gain more votes but what’s really needed is for the lawmakers to slow down and put together a quality bipartisan solution.
MTDHN: How can employers help to reduce the burden of medical debt for their employees?
CC: First, employers should educate themselves on the health plan options available to them, ask questions and push back on their brokers so that they are more informed about what their brokers are offering their employees and what the employer can offer.
Employers should educate their employees on healthcare options by encouraging a meaningful review of the medical plan options during the open enrollment period. They should also give the employees time to ask questions and understand what options are available and how the different plans would benefit the employee.
Employers can also offer plans that would give their employees more control, such as utilizing Health Savings Accounts (HSAs), a valuable tool that provides triple tax benefit: contributions that are tax-deductible, earnings that grow tax-free and withdrawals for qualified medical expenses that are also tax-free.
Additionally, adopting a “pure” Reference-Based Pricing (RBP) strategy can help avoid unreasonable or excessive provider charges – potentially lowering both the cost of coverage and employee point of purchase cost-sharing. These are more innovative plans that can provide significant benefits but are underutilized and misunderstood.
There are many different ideas out there that could be very beneficial for employers to evaluate and explore. However, it often seems like they are presented with the same plans each year without taking the time to explore what might be the best for their employees and the business.
I think more effort needs to be put into evaluating and selecting healthcare plans upfront to prevent issues, ensuring a successful healthcare plan for an employer and employee, as opposed to reacting to problems on the back end.
MTDHN: What are some of the biggest benefits of having a medical billing partner like aequum and how can they help with medical debt?
CC: Having an advocate for the patient and health plan is crucial for controlling medical expenses. An advocate can assist with the understanding of the debt collection process, protect the member from aggressive tactics and ensure that patients do not have to pay beyond the reasonable amount for the medical services they receive.
From a business perspective, this support trickles down even further by saving the health plan money, which can keep premiums, deductibles, copays and coinsurance at a reasonable and affordable level for their employees. This, in turn, will help with employee retention.
In addition, having an advocate may encourage employees to seek care they otherwise avoid because they’re afraid of receiving a large medical bill. Access to preventative care is important for employees to prevent catastrophic claims and reduce absenteeism. This aligns the interests of both employers and employees.
Finally, having an advocate for the employee will also reduce the amount of time that the employees are spending with the HR department on healthcare issues because an advocate can step in and fill that role, alleviating that burden on the employer.
For example, at aequum, we are dedicated to advocating for and supporting patients, health plans and their members and dependents, as well as insurers. We offer a unique blend of advanced payment-integrity expertise, patient advocacy and legal services that can benefit companies of all sizes. Our products and services help our clients to secure reasonable rates, reprice egregiously high out-of-network claims and avoid surprise bills or challenge them in court.
We utilize proven strategies like post-pay bill review and strategic implementation of reference-based pricing, recovery overpayments and avoidance of excessive charges. We offer comprehensive patient advocacy services that empower health plan members and their dependents to choose high-quality providers at the lowest cost, improving outcomes and driving satisfaction.
MTDHN: How is having a medical billing partner not only attractive for smaller to mid-size companies but for larger companies as well? How does it differ and how does that work?
CC: Having a medical billing partner is important for companies of all sizes and the benefits can be seen most clearly in employee retention. Whether you’re a large employer or a small employer, losing employees is costly. We also know that health care is one of the biggest expenses for an employer.
Whether you are a large employer with 5,000 employees or a small one with 50, a medical billing partner can clarify the complexities of healthcare and health insurance. It can be beneficial since the partner can take on roles that the employer might either overlook or handle less efficiently. This service is beneficial across the board. Whether you’re a large or small company, your employees are getting balance bills, high medical bills and/or bills with errors. Providing patient advocacy saves money for both the company and the employee.
Even with in-network type claims, which are typically harder to challenge, a medical billing partner can structure a system or process in which that patient can challenge the accuracy of their bills with the potential for huge savings to the employer and employee.
MTDHN: Do you think price transparency can help avoid some of the issues that individuals face when it comes to medical debt?
CC: Absolutely. I think price transparency can be used as both a shield and a sword, and we’re starting to see this happen across the country right now.
As a shield, it can provide the information necessary to make educated decisions and truly turn a patient into a consumer of medical care. But it is going to involve a shift in our thinking. Right now, many people, including myself, don’t invest enough time in researching healthcare options. We tend to just go where we’re told and when we have a problem. So, altering that thought process is key.
As a sword, we’re seeing states tell providers that if they’re not complying with these price transparency laws, then they can’t collect on their medical debt and other innovative legislative type actions. This means if a provider isn’t transparent, the patient would not be held liable for the debt, which offers significant protection. We are seeing this type of legislation because there’s so much pushback from the providers on disclosing information.
It’s also important that price transparency extends beyond providers. Insurance companies and plans also need to be transparent with their members so it’s a comprehensive effort across the entire healthcare ecosystem.
MTDHN: What role does financial literacy play in managing medical debt and how can healthcare providers support patients in this area?
CC: Financial literacy plays an important role in managing medical debt, especially since many Americans are living paycheck to paycheck. Balancing their everyday expenses with medical debt is very challenging.
Healthcare providers must first avoid taking advantage of the vulnerable population, especially those living from one pay period to the next. I think they should discontinue the use of medical lenders who are charging excessive interest rates to finance medical bills. Unfortunately, we’re seeing more providers pushing people to use these companies which results in patients entering a contract that is very hard to get out of and they’re stuck paying and with high interest rates.
I think healthcare providers could also do a better job following their own guidelines when it comes to financial aid, making it easier for patients to access what is actually already available.
These two things wouldn’t be a huge change for the provider either. We’re not asking them to absorb all the medical debt – we’re just asking them to not take advantage of vulnerable people and really implement their own policies.
MTDHN: Can you share any success stories where interventions significantly reduced medical debt for patients? What were the key factors in these successes?
CC: I have two different success stories I’d like to share because success isn’t just about the dollar amount – there are softer successes with our business that I believe are equally important.
First, from a dollar value standpoint, one of our largest wins was in defending over $500,000 in balance bills, which were bills that were incurred over a period of time due to a recurring condition. We managed to get the bill completely written off, leaving the patient with no further liability for that amount.
On a smaller scale, which can still have a big impact, our team recently achieved a full write off of a $4,000 bill by persistently negotiating with the provider, making it clear that the bill was unreasonable. The provider ultimately wrote off the entire balance.
Despite the smaller dollar amount, this success is significant because smaller bills are often the ones that are litigated or aggressively collected and end up on your credit report. Being able to tackle and handle those smaller bills on behalf of the patient is impactful. Our team put in a ton of effort to communicate with the member, made sure they were in the loop on what was going on and constantly pushed on the provider until we got it written off.
The key factors in success start with patient buy-in through regular communication and relationship development. It’s important to have open lines of communication with the member and provide them with someone they can trust to handle their situation. Being able to alleviate their concerns is one of the biggest things we can do to calm and reassure them, which in turn allows us to go through our process.
It’s also important to partner with law firms with significant legal experience defending medical bills. Having a law firm’s letterhead on communications or having a lawyer reach out to a provider has a lot of gravitas and adds seriousness to the situation, leading to quicker resolutions.
Additionally, developing relationships with the providers is also important. We’re not burning bridges but rather learning from the providers, understanding their process and tracking trend lines through our proprietary database. This data allows us to approach providers with concrete information to effectively resolve the medical bills.