California Medical Billing Advocates Inc

To Reduce or Eliminate Unjust Medical Bills Before They Become Crippling Debt

aka CALMBA   |   San Francisco, CA   |  https://www.calmba.org

Mission

We act as patient advocates to reduce or eliminate unjust medical bills before they become crippling debt. Given the complexity of the U.S. healthcare system, patients often receive large surprise medical bills despite having health insurance. Additionally, many patients who are underinsured or uninsured receive medical bills directly from hospitals and doctors. The dollar amount of the bill sent to the patient is often grossly inflated and has little correlation with how much the providers expect to get paid. Many patients cannot afford to pay these bills, let them turn into medical debt, and potentially bankruptcy. We believe many of these bills are excessive and unjust to the patient. Our mission is to reduce or eliminate these bills using financial, legal, and medical tactics.

Ruling year info

2019

President

Gary Ko

Main address

1390 Market St STE 200

San Francisco, CA 94102 USA

Show more contact info

EIN

83-4336436

NTEE code info

Patient Services - Entertainment, Recreation (E86)

Health (General and Financing) (E80)

Alliance/Advocacy Organizations (T01)

IRS filing requirement

This organization is required to file an IRS Form 990-N.

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Communication

Programs and results

What we aim to solve

SOURCE: Self-reported by organization

Our mission is to reduce or eliminate unjust medical bills before they become crippling debt. Given the complexity of the U.S. healthcare system, patients often receive large surprise medical bills despite having health insurance. Furthermore, many patients who are underinsured or uninsured receive medical bills directly from hospitals and doctors. The dollar amount of the bill sent to the patient is often grossly inflated and has little correlation with how much the provider expects to receive as fair payment. Many patients cannot afford to pay these bills and let them turn into medical debt and potentially bankruptcy. We believe many of these bills are excessive and unjust to the patient. Our mission is to reduce or eliminate these bills using financial, legal, and medical tactics.

Our programs

SOURCE: Self-reported by organization

What are the organization's current programs, how do they measure success, and who do the programs serve?

Medical Bills Negotiation - Negotiating Billed Charges to More Reasonable Rates

Reimbursement for U.S. healthcare services is based on a patchwork of contracts between payors and providers. Providers start with a list price of charges for services, commonly known as chargemaster. Payors negotiate discounts from the chargemaster price through in network contracts. The chargemaster is often vastly inflated and is commonly used as a tactic by providers to apply negotiation leverage against payors, since payors and patients risk incurring inflated charges by being out of network. CALMBA will try to negotiate these inflated bills to more reasonable rates based on usual and customary charges (UCC), average contracted rates (ACR), and Medicare / Medicaid reimbursement rates.

Population(s) Served

Most balance bills occur when patients receive care from facilities-based physicians who are out-of-network, where the patient has little to no choice in verifying network status nor the alternative in choosing an in-network provider. Balance bills are an artifact of the dysfunctional reimbursement dynamic between insurance companies and facilities-based specialties, but patients end up being the unfortunate casualty by receiving these surprise bills. To make matters worse, health plans have little incentive to assist patients in balance billing matters, since most of the time these are out-of-network providers where no contract exists. As a result, patients are often left on their own to address these surprise bills. CALMBA will deploy financial, legal, and medical tactics to assist patients in negotiating balance bills.

Population(s) Served

Given the complexity in translating healthcare interactions into a system of codes and bills, there are numerous chances for billing errors to occur during the process. This does not necessarily imply ill will by the participants, as it is normal for errors to occur within complex interactions. However, most of the time the patients do not know how to identify and correct these errors. CALMBA will try to identify and eliminate billing errors on the patient’s behalf, by recruiting medical coders / billers to review medical bills, and outsource complex cases as needed to experts.

Population(s) Served

As part of the medical bill negotiation process, CALMBA will develop a deep understanding of the patients' financial profile, which includes income, expenses, and assets. In addition to negotiating a reduction in medical bills, we will also provide financial advice with the goal of putting the patient in a more stable financial footing going forward. These advices include but are not limited to financial literacy, budgeting, and debt management.

Population(s) Served

Where we work

Our results

SOURCE: Self-reported by organization

How does this organization measure their results? It's a hard question but an important one.

Number of Cases Received

This metric is no longer tracked.
Totals By Year
Related Program

Medical Bills Negotiation - Negotiating Billed Charges to More Reasonable Rates

Type of Metric

Output - describing our activities and reach

Direction of Success

Increasing

Context Notes

The number of cases that were submitted to us for review.

Number of Cases Accepted

This metric is no longer tracked.
Totals By Year
Related Program

Medical Bills Negotiation - Negotiating Billed Charges to More Reasonable Rates

Type of Metric

Output - describing our activities and reach

Direction of Success

Increasing

Context Notes

The number of cases that we had accepted after evaluation. Due to limited resources, we were not able to accept every case.

Dollar Amount of Medical Bills Under Negotiation

This metric is no longer tracked.
Totals By Year
Related Program

Medical Bills Negotiation - Negotiating Billed Charges to More Reasonable Rates

Type of Metric

Output - describing our activities and reach

Direction of Success

Increasing

Context Notes

Cumulative dollar amount of medical bills that we are actively negotiating a reduction for patients.

Average Cost to Negotiate Each Case

This metric is no longer tracked.
Totals By Year
Related Program

Medical Bills Negotiation - Negotiating Billed Charges to More Reasonable Rates

Type of Metric

Output - describing our activities and reach

Direction of Success

Holding steady

Context Notes

Our estimated cost to negotiate each case.

Average Dollar Amount of Medical Bill Reduction

This metric is no longer tracked.
Totals By Year
Related Program

Medical Bills Negotiation - Negotiating Billed Charges to More Reasonable Rates

Type of Metric

Outcome - describing the effects on people or issues

Direction of Success

Increasing

Context Notes

Average dollar amount reduction in medical bills that we negotiated.

Social ROI (Economic Impact per Dollar Spent)

This metric is no longer tracked.
Totals By Year
Related Program

Medical Bills Negotiation - Negotiating Billed Charges to More Reasonable Rates

Type of Metric

Outcome - describing the effects on people or issues

Direction of Success

Increasing

Context Notes

We measure ourselves by the economic impact we make on patient's financial health. In 2019, we achieved an 18x return: every $1 in operating cost resulted in $18 reduction in patient bills.

Goals & Strategy

SOURCE: Self-reported by organization

Learn about the organization's key goals, strategies, capabilities, and progress.

Charting impact

Four powerful questions that require reflection about what really matters - results.

While Obamacare had led to historic gains in insurance coverage, it is estimated that 56 million Americans are uninsured or underinsured in 2018. 41% of underinsured adults reported deferring medical care due to cost, while 47% had difficulty paying their medical bills and debt.[1]

These figures are highly troubling in the context of the average American family's financial profile. According to the Federal Reserve, 40% of adults would not be able to pay for a $400 unexpected expense at all, and 60% would not be able to pay without borrowing or selling assets.[2] In 2017, "over one-fifth of adults had major, unexpected medical bills to pay, with a median expense of $1200. Among those with medical expenses, 37% have unpaid debt from those bills... Over one-quarter of adults went without some form of medical care due to an inability to pay".[3]

Think about what these numbers mean. 40% of ADULTS would not be able to pay for a $400 unexpected expense. 20% of ADULTS each year had received an unexpected medical bill with a median expense of $1200. That implies that 8% of US adults in any given year would receive an unexpected medical bill and would not be able to pay for it!!!

Unpaid medical bills will eventually be sold to a collection agency, at which point they become medical debt and impact credit scores. Once on the credit report, medical debt can remain for up to 7 years. A low credit score affects multiple aspects of a person's private and public life, including many that don't involve borrowing. Many rental leases and job applications require credit checks. Insurance companies often include credit scores in determining premium prices. The patient will be subject to debt collection and possibly abusive practices.

Due to the dysfunctional U.S. healthcare payment system, the dollar amount of the medical bill sent to the patient is often grossly inflated, and has little correlation with how much the provider expects to receive as fair payment for that service.

WE BELIEVE MANY SURPRISE MEDICAL BILLS ARE EXCESSIVE AND UNJUST. The damage to the consumer has already begun by the time that medical bills are reported to collection agencies as medical debt. Therefore, we try to negotiate a lower reasonable bill before they become medical debt.

The organization will start with three major services in negotiating medical bills: 1). Negotiating charity care or discounted rates in medical service for uninsured / underinsured patients; 2). Assisting patients with balance billing by out-of-network providers; 3). Identifying errors in medical billing due to the complex nature of the US healthcare reimbursement system. We will seek to create systems and procedures to assist at these intervention points on the patient's behalf. Longer term, we plan to provide financial education to enable people to rebuild their financial profile after addressing the surprise medical bill, and possibly acquire medical debt with the intent of forgiving them.

Program 1: Negotiating Billed Charges to More Reasonable Rates

Reimbursement for U.S. healthcare services is based on a patchwork of contracts between payors and providers. Providers start with a list price of charges for services, commonly known as chargemaster. Payors negotiate discounts from the chargemaster price through in network contracts. The chargemaster is often vastly inflated and is commonly used as a tactic by providers to apply negotiation leverage against payors, since payors and patients risk incurring inflated charges by being out of network. CALMBA will try to negotiate these inflated bills to more reasonable rates based on usual and customary charges (UCC), average contracted rates (ACR), and Medicare / Medicaid reimbursement rates.

Program 2: Negotiating Balance Bills

Most balance bills occur when patients receive care from facilities-based physicians who are out-of-network, where the patient has little to no choice in verifying network status nor the alternative in choosing an in-network provider. Balance bills are an artifact of the dysfunctional reimbursement dynamic between insurance companies and facilities-based specialties, but patients end up being the unfortunate casualty by receiving these surprise bills. To make matters worse, health plans have little incentive to assist patients in balance billing matters, since most of the time these are out-of-network providers where no contract exists. As a result, patients are often left on their own to address these surprise bills. CALMBA will deploy financial, legal, and medical tactics to assist patients in negotiating balance bills.

Program 3: Billing Errors

Given the complexity in translating healthcare interactions into a system of codes and bills, there are numerous chances for billing errors to occur during the process. This does not necessarily imply ill will by the participants, as it is normal for errors to occur within complex interactions. However, most of the time the patients do not know how to identify and correct these errors. CALMBA will try to identify and eliminate billing errors on the patient’s behalf, by recruiting medical coders / billers to review medical bills, and outsource complex cases as needed to experts.

Surprise and excessive medical bill is a deeply complex structural issue within the U.S. healthcare reimbursement system that intersects multiple disciplines in finance, law, and medicine. Our board of advisors consists of an ex-healthcare finance executive with 20 years of experience, a professor from UCSF medical school, and a professor from UC Hastings law school. Our officers consists of finance executives who had experience in building successful companies from scratch and carrying out their vision. Together, we hope to combine our deep individual expertise in finance / law / medicine, and execute on a vision in creating a nonprofit infrastructure that negotiates surprise and excessive medical bills on behalf of patients.

The origin of CALMBA came from Gary’s personal experience with balance billing in 2016. As a highly experienced healthcare finance executive, he successfully fought the bill by examining the benefit design and the circumstances in which he was billed. However, he felt that the situation was deeply unjust, as the average American stood little chance in navigating such a complex system. In 2019, Gary decided to execute on his vision to launch CALMBA, with support from faculty and resources at UCSF and UC Hastings.

Medical bill negotiation strategies: We continue to work with financial, legal, and medical professionals to refine our negotiation strategies to improve our chance of success.

Corporate: We have developed a scalable infrastructure primarily using in-kind donations from Google, Microsoft, and salesforce.com. The organization is built to scale up with contractors / employees / volunteers as donation and budget allows more resources for medical bills negotiation.

Media: We are reaching out to local patient advocacy groups, as well as national media to get our message out. According to data from the federal reserve, 8% of adults in the U.S. are expected to receive a surprise medical bill in any given year. The challenge is to get the word out to patients who need help.

Fund Raising: We plan to generate quantifiable results, and then reach out to large donors and grant making organizations.

Financials

California Medical Billing Advocates Inc
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Operations

The people, governance practices, and partners that make the organization tick.

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Connect with nonprofit leaders

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Build relationships with key people who manage and lead nonprofit organizations with GuideStar Pro. Try a low commitment monthly plan today.

  • Analyze a variety of pre-calculated financial metrics
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  • Compare nonprofit financials to similar organizations

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California Medical Billing Advocates Inc

Board of directors
as of 2/25/2020
SOURCE: Self-reported by organization
Board chair

Gary Ko

California Medical Billing Advocates

Term: 2019 - 2020

Daniel Dohan

University of California, San Francisco

Jaime King

University of California, Hastings

Board leadership practices

SOURCE: Self-reported by organization

GuideStar worked with BoardSource, the national leader in nonprofit board leadership and governance, to create this section.

  • Board orientation and education
    Does the board conduct a formal orientation for new board members and require all board members to sign a written agreement regarding their roles, responsibilities, and expectations? Not applicable
  • CEO oversight
    Has the board conducted a formal, written assessment of the chief executive within the past year ? Not applicable
  • Ethics and transparency
    Have the board and senior staff reviewed the conflict-of-interest policy and completed and signed disclosure statements in the past year? Yes
  • Board composition
    Does the board ensure an inclusive board member recruitment process that results in diversity of thought and leadership? Yes
  • Board performance
    Has the board conducted a formal, written self-assessment of its performance within the past three years? Not applicable

Organizational demographics

SOURCE: Self-reported; last updated 08/21/2019

Who works and leads organizations that serve our diverse communities? GuideStar partnered on this section with CHANGE Philanthropy and Equity in the Center.

Leadership

The organization's leader identifies as:

Race & ethnicity
Asian American/Pacific Islanders/Asian
Gender identity
Male, Not transgender (cisgender)
Sexual orientation
Heterosexual or Straight
Disability status
Person without a disability

Race & ethnicity

Gender identity

 

Sexual orientation

No data

Disability

No data