Why I Founded CALMBA

My youngest child was born in 2016. Several hours after he was born, he was diagnosed with atrial septal defect (ASD), which basically meant that there was a hole in his heart. He was immediately admitted the Neonatal ICU.  Fortunately, an echocardiogram revealed that the ASD was one that would close on its own. He ended up spending 6 days in the NICU, with numerous consults from pediatric cardiologists, pediatric pomologists, and neonatologists. He grew up to be a healthy child.

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The entire episode cost approximately $150,000, but insurance paid for all of it (or so we thought) after copays and deductibles. Several months after he was discharged, we started receiving separate bills from neonatologists and cardiologists. It turned out that these specialists were out of network and we received a balance bill, where we were billed the difference between what the specialists charged and what insurance paid. The total balance bill was approximately $5,000. My first call to the insurance company wasn’t helpful as I got a customer service rep who told me that out of network was a separate deductible and I would be responsible for the bill. I requested the full insurance plan documents and found out that patients wouldn’t be held responsible for out of network physicians at an in-network facility. Armed with this knowledge, my second call went a lot smoother, as the insurance company agreed to negotiate with the providers on my behalf. In the end I wasn’t responsible for the balance bill.

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I was troubled and outraged by my experience for several reasons. First, the insurance company was initially disinterested in negotiating on my behalf, despite my plan covering the charges. They should have been doing their job!  What if I didn't have the experience and knowledge to read plan documents and insisted on following up?  Second, the physicians balance billed for charges that were out of my control. I went to an in-network hospital and they assigned doctors that were out-of-network.  What was I supposed to do?  Check my newborn out of the NICU to find a in-network doctor?  Third, the absolute amount of the charges was staggering.  The average American family does not have $400 in their savings account to repair their car – imagine what a $5,000 surprise bill will do to their finances and mental state. Furthermore, they will likely not have the knowledge to fight this bill.

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I had been thinking about starting a non-profit since my son was born in 2016.  In March of 2019, around my youngest son's third birthday, I decided to execute on my vision and founded CALMBA.

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Gary K. Ko

Founder and President

California Medical Billing Advocates