A Tale of Persistence

Introduction

This is a story of persistence.  Or tenacity.  Or ornery stubbornness.  I’ll let you be the judge. It’s also a story about how I used the Livro de Reclamações, a Portuguese online complaint book, to get a resolution to a long-running dispute.

Part One:  The back story 

For the last 30 years or so, I have had recurring episodes of skin cancer.  They are not serious or life-threatening.  Mostly they are an annoyance.  Every year I have one or two appointments with a dermatologist who cuts off or freezes some small growth on my upper body.

[Tip for younger readers:  Wear sunscreen.  Now!  You can thank me 30 years from now.]

While we lived in Parede, I started seeing a dermatologist at one of the major private hospitals in Cascais.  For this story, I’ll refer to him as “Dr. X”.  I liked the guy.  He was outgoing and very personable.  The kind of guy you’d want to go have a beer with after work.    

In January, 2023, Dr. X removed a small cancer from my upper chest.  It took less than 30 minutes for him to cut it out and stitch me up.  No big deal.  

A couple weeks later, I got a bill from the hospital for € 522.  When I looked at the bill, I realized they had not coded in my insurance policy,  So I called the billing department and asked them to look into it.   A friendly agent named Nuno said he would take care of it.   

About 6 weeks and a couple of phone calls later, I received an updated bill that was about € 231 – the negotiated rate that my insurance company and the hospital had agreed on.   There was another bill for the pathology department – € 63.  So my total outlay was just under € 300. 

Now, fast forward to January, 2024.  I had another minor procedure performed at the same hospital, by the same doctor.  This time, though, it was a much quicker procedure.  The doctor removed a small growth – about 2mm x 5 mm – from my scalp.  It did not require any stitches and I was out the door in about 15 minutes.  Again, no big deal. 

Several weeks later, I received the invoice from the hospital, and my jaw dropped when I saw the amount.  € 1910!  I was stunned. The bill was six and a half times more than the procedure a year before the one that took longer and was more invasive.  

It was € 400 more than we paid for Mary to have surgery on her arm last year – at a different hospital – when she had a fully staffed operating room and a 5 hour recovery period.

So I called the billing department at the hospital, and by random chance ended up speaking to Nuno again.  He remembered me.  After I explained my problem, he did some research and told me the hospital had not applied the authorized amount from the insurance company.  He told me he had sent a request to have the invoice reviewed and that I should not pay it.  

I was hopeful that this problem would be resolved quickly, but two days later I received a call from the hospital.  A different agent told me that the invoice was correct and that if I had a problem, I should take it up with the insurance company.  

So I called the insurance company and was told they had authorized a charge of € 1080, but that they had not seen an invoice from the hospital. 

I had also noticed that the procedure code on the invoice didn’t seem to match what was actually done.  It was coded as Excisão de tumor profundo – deep tumor excision.  But the doctor had barely scraped the surface of my head! It didn’t seem profundo at all.

I looked back at the invoice from the year before, and saw that it had originally been coded the same way, but it had been changed for the revised invoice.  So I figured that they had made a mistake this year.  

Part Two:  Who’s on first?

I’ll spare you the details, but the short version is that over the next six months I had multiple phone calls with multiple people from the hospital. I had multiple emails with a person in our insurance agent’s office.  A couple times I actually spoke to someone from the insurance company.  

Bottom line:  The insurance company had authorized the hospital to charge me € 1080, but the hospital would never acknowledge that.  

After two months of back-and-forth, our insurance agent suggested that I go to the hospital.  She said sometimes in Portugal you can get things done in person that you can’t accomplish with phone calls or emails.  So what the heck.  It was a four hour round trip to and from Lisbon – metro to train to bus, then repeat in reverse.   

At the customer service counter, an agent looked up my account, printed out the invoice, scowled at it, then took it to review with a colleague. She came back a few minutes later and said, “There’s been a mistake on your invoice. Don’t pay it.”  She told me that they would look into it and get back to me. 

So I went home, again hopeful that the situation would be handled.  

A couple days later I got a call from a person at the hospital who told me they were working with the insurance company to resolve the problem.  

Then six days later, another person from the hospital called.  She wanted to discuss the outstanding invoice and asked when they could expect payment.  She was surprised when I told her about my visit to the hospital and the subsequent call.  

I sent an email to our agent and told that where I came from, we’d say that “the left hand didn’t know what the right hand was doing”.  

These maddening twists continued.  It was like no one in the hospital communicated with anyone else.  And no one would take responsibility to try to resolve the problem.  

Sometimes I was baffled by this.  But more often I just pissed off.  Which is why I kept digging in my heels, even as Mary often suggested that I just pay the bill and move on.  

It went on like this for another two months.  I had been assured by some people at the hospital and our insurance agent that both parties were talking and working out the details.  But I also continued to receive periodic messages from both – the hospital maintaining that I owed them € 1910 and the insurance company saying they had agreed that the correct amount was € 1080.

Sometime in May, five months in, I heard that someone from the hospital and someone from the insurance company finally had a direct conversation about the bill.  My understanding, from the insurance agent, was that the hospital had finally agreed to the € 1080 amount and they would fix the invoice.

I waited, but no revised invoice came.

So at the end of June – six months after the procedure- I called the hospital billing department one more time and said, “Hey, you know, I understand the insurance company and the hospital have talked, and this thing ought to be settled. Tell me how much I owe.”   

The billing agent responded, “You owe us 1910 euros.”

I think I laughed, but I said, “Look, I’m not going to argue with you, because I know you don’t have any authority to fix this.  So tell me, who’s in charge of this department, and can I talk to him or her?” 

Maybe that was a bit condescending, but I was pretty fed up and ready to unload on someone.  The agent replied, in a cold voice, “No, you can’t do that. You’ll just have to file a complaint.” 

“Okay”, I said, “I’ve held off doing that several times during this whole process, but now that’s exactly what I’m going to do.” 

Part Three: The Livro de Reclamações

A common fixture in every business here in Portugal is a little red and white sign about the size of a sheet of printer paper that’s usually hung in a prominent place along with business licenses and other official notices.  

The sign announces that the business has a Livro de Reclamações – a complaints book.  It’s mandatory that every business make it available.  There’s a physical book, but there’s also an online version.  If you have a complaint about a business, you can ask to enter it in the book and the business has to permit you to do so. 

[A quick side note:  Our friend Carol at Our Portugal Journey, just published a detailed post about the Livro.  If you want to understand more about how it works, check out her excellent post.]

During our three years here, we had never used it, and didn’t know anyone who had.  But during this six month ordeal I had done some research and learned that if you file a complaint against the business through the Livro, several things happen.  The company gets a copy (if you file online) and your complaint is also sent to whatever government agency regulates that type of business. 

I considered lodging a complaint at several times while dealing with the hospital, but always felt like it was the “nuclear option”, so I held off.  

But once that agent said, “You’ll just have to file a complaint”, I knew it was time. 

l studied the online form to understand what information was required and found that in addition to stating your complaint, you could also attach additional documents to support your case. 

I had been keeping a Google Doc with notes about every interaction I’d had with anyone about this problem.  It took several hours to make sure it was up-to-date, accurate, and included copies of every invoice and email message.  When I was done, it was 53 pages long and I had to split it into three documents to fit within the maximum size limits.  

In the basic complaint, I gave a summary of my experience and said there were three things I wanted from the hospital:  

• I wanted answers to four questions that I had asked repeatedly and that were never answered:  Why was the 2024 procedure 6 ½ times more expensive than the earlier one.  What are the detailed charges that are included in the invoice amount?  What does “EXCISAO DE TUMOR PROFUNDO” mean?  Is there a procedure code that is more appropriate for a minor excision on the scalp?
  
• I wanted a revised invoice that reflected the amount approved by the insurance company – € 1080.
  
• I wanted an apology for all the time and energy I’d had to spend trying to get the problem resolved.  In lieu of an apology, I would accept a further discount on the invoice.   

Once I got everything uploaded, I pushed the “submit” button, and hoped for the best. 

When a complaint is filed in the Livro, the business has 15 business days to respond to you.  So I quit thinking about it for 3 weeks.  

Then, on a Friday, at five o’clock in the afternoon, I got an email from the hospital.  The subject line indicated they were sending me an invoice.  

I started not to look at it, thinking “this is just going to ruin my weekend”, but curiosity got the better of me. I opened up the email, opened the attached invoice, and for the second time in the whole process, was completely shocked.

The invoice showed a different procedure code and the total amount due was € 270 !

I laughed out loud. I called Mary, “Hurry up and come look at this!” 

She took a look at it and said, “Go pay it.  Right now!”  

Coda: What happened next

The following Monday, I received another email, this time from an attorney who said she represented the hospital.  She demanded payment of the € 1910, plus € 93 in interest. And she warned me that if I didn’t pay nos próximos 5 (cinco) dias (within the next 5 days), they would immediately initiate legal action against me. 

(This was the second time I’d had a lawyer threaten me over this bill.  The first one started with me after about a month, but eventually stopped after the hospital got serious about talking with the insurance company.) 

I replied to the new attorney, with a copy of the new invoice, and said, “Sorry, this has already been taken care of.  I guess your client didn’t bother to notify you.  Have a nice day.” 

But the most surprising thing of all happened a few days later.  I got another email from the hospital, acknowledging my complaint, and apologizing for the whole thing.  

So the moral of the story, or the lesson learned, is this:  Persistence sometimes pays off. 

Mary has called me stubborn. I prefer to think I’m tenacious.  And there were times throughout the whole thing where she said, just pay the damn thing. Get them off our backs. 

But I wasn’t having it. I was not going to pay what I thought was an outrageous fee for something. I wanted a fair price.

And I got one!

The end

So that’s my story. I hope this narrative helps somebody else who’s caught up in a dispute with a business or organization here in Portugal. Maybe it will give you some insight into how the Livro de Reclamações works and the benefit it can provide you. 

Until next time / Até a próxima vez

Mike

The Writer

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A footnote

It was impossible to get any details from the hospital or the insurance company.  As noted earlier, the invoice from the hospital was simply one line, with a charge.  

The insurance company wasn’t much better.  Things work differently here than in the US. In the US, when you file an insurance claim, you generally get back an “Explanation of Benefits” document, where they give you the details of what procedures were done, what that hospital or doctor’s charges were, how much your insurance will cover, and the amount you owe.  So you have a pretty clear breakdown of the costs and coverages.  

We didn’t get that here.  In fact, we never got any details from the insurance company.   But apparently, the insurance companies have negotiated rates for procedures with the hospitals and doctors and they basically dictate to the provider what they can charge. 

At least that’s the way I understand it. But in our case, they dictated a particular amount, and the hospital never acknowledged, at least to me, that they heard it or understood it. 

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