Can't Get Cost on Upcoming Surgery

[JOHNNIE36]

No wonder this country is so screwed up on the subject of health care. I'm not saying the doctors. I'm talking about the health insurance companies, the hospitals, surgery centers, etc. DW is going to have rotator cuff surgery (same day surgery as outpatient). We have a Medicare Advantage insurance plan which has been a good way for us to go until this surgery. And, we are new to Blue Cross Blue Shield this year. Same surgeon is in this plan as in our last plan. No problem there.

Question I'm asking is what is our copay or deductible at the facility. Can't find out. Why? According to BCBS, copay at a freestanding sameday surgery center is $265; however, the surgery center this group of surgeons uses is not covered by BCBS. The surgeons in this group are not licensed to use the facility that IS covered by BCBS. So, we opt for a hospital that is in our plan. BCBS says an outpatient surgery is 20% of the allowable cost but they can't tell me what that cost is. Pretty cut and dried on an overnight stay. That price is also $265 but you can't just opt to stay overnight. The guidelines in the coverage manual state that the type surgery dictates whether or not it is considered "same day surgery". Your surgeon could write an order for you to stay overnight but you would still be billed for "same day surgery", the 20% deal.

I went to the hospital to try to find out about the price. They couldn't tell me. BCBS can't tell me. Still got a couple feelers out there but I'm losing faith in the system. No wonder people are pi**ed at our health care in this country. This is just a little problem. Wait till a big one comes along.

 

[FUEGO]

I have the same issue. I have tried to get price quotes from our insurance company on a particular procedure, even giving them the CPT code for the procedure. They could not even give me a cost estimate based on the CPT code because they said it depended on what facility the treatment was at and how the doctor charged it (is it a "hospital" facility or an office/outpatient facility?) and what other codes they charged along with the procedure.

I eventually gave up and just figured it wouldn't cost us more than $100-200 out of pocket after the insurance company pays their 80% and applies a huge negotiated discount to the rack rate charged by the doctor. I believe it came in just over $200 and included a number of additional CPT codes for diagnostics and lab tests etc. Going in to the procedure, we knew there was a very small chance that the diagnostic test would reveal information that would be slightly beneficial to the ultimate outcome, but possibly very small. If we were paying the $3000 or so that the doctor charged we never would have opted for the test, but since we figured our cost would be relatively modest, the peace of mind was worth it since we weren't paying most of the cost.

In general, if I can google for the cost of a medical procedure, I assume my insurance will end up cutting the cost in half due to negotiated discount, then I pay 20% of the remainder. Generally works out to around this amount.

 

[Moemg]

Depending on the surgery the price may vary depending on the supplies used , equipment needed , etc.. An example is a shoulder arthroscopy is one price but if they repair a tear in your rotator the cuff the price goes up and some of these things they do not know until they look inside. You could probably get an estimate from the physician's office or the hospital billing department.

 

[MichaelB]

The last time I called UHC to try and determine the cost of a procedure for DW the rep told me I should be prepared to pay the entire policy deductible amount for the year, it was my policy obligation to have that amount available, and it was not my concern how much any individual service cost. We had a brief discussion and I chose to hang up when it became clear the rep had no intention of leaving that script.

 

[Mulligan]

The last time I called UHC to try and determine the cost of a procedure for DW the rep told me I should be prepared to pay the entire policy deductible amount for the year, it was my policy obligation to have that amount available, and it was not my concern how much any individual service cost. We had a brief discussion and I chose to hang up when it became clear the rep had no intention of leaving that script.

I have never had to use my HD plan, but this is the part I dread when it occurs. I know they cant give you a specific quote like buying a car, but approximate outcomes would be nice. It seems like they treat billing practices like we are still in the 1990's with $100 deductibles. Im also worried I wont know how the game is played. Meaning, I may have the correct in network physician, but the building the operation was performed in wasnt, or the anthesiologist wasnt, etc.

 

[Moemg]

Meaning, I may have the correct in network physician, but the building the operation was performed in wasnt, or the anthesiologist wasnt, etc.

When I had my cataract surgery the surgeon was in network but the outpatient center was not but they agreed to take whatever BC/BS paid.

 

[Mulligan]

When I had my cataract surgery the surgeon was in network but the outpatient center was not but they agreed to take whatever BC/BS paid.

How much legwork did you have to do Moemg before you had all your " ducks in a row"? Did the insurance company assist you in this, or did you have to know what to do on your own to avoid all out of network surprises?

 

[MooreBonds]

It's true that there are many sources of roadblocks in creating a more transparent healthcare system - one such frustration was a few years ago from my primary care physician.

I'm a very calm, laid-back guy - but had my temper pushed beyond my limit once, due to an enraging comment by my father (also my boss at the time) during a very stressful time of my life. I felt a slight 'odd feeling' in the upper part of my brain - I didn't assume that a vein/blood vessel had burst, but that's the closest description I could come up with. Wasn't painful, just a brief (2 second) sensation, then went away.

Rather than worry, I made an appointment with my physician. She said that it was probably nothing, given my age and lack of family history with strokes....but gave me orders for an mRI at a nearby hospital just to be safe. I asked her what it would approximately cost, and she gave me a blank look, as though I was asking her what she thought she wanted to eat for lunch 10 years from now.

When I reminded her that I had a High Deductible Health Plan, and that I might want to shop around since I was footing the entire bill, she still didn't seem concerned at all about whether one facility might charge me twice what another would (nor any idea whatsoever what the charge might be). Luckily, the network price ended up being about $1,000 - less than I was afraid it would come to for everything.

 

[Brat]

In my situation Medicare is primary and my contract says that if the MD or facility does not accept Medicare negotiated rates I must pay the difference between their charge and Medicare.

 

[eridanus]

Price transparency would help a lot with reducing US health prices. It would probably apply downward pressure to salaries, which is against the interests of health care professionals.

 

[Chuckanut]

price transparency would help a lot with reducing us health prices. It would probably apply downward pressure to salaries, which is against the interests of health care professionals.

bingo!!

 

[Moemg]

How much legwork did you have to do Moemg before you had all your " ducks in a row"? Did the insurance company assist you in this, or did you have to know what to do on your own to avoid all out of network surprises?

No legwork the surgeons office set it all up and had the Outpatient Center agree .

 

[73ss454]

I can't tell you how many hours each week I spend jerking around with Dr.s, Hospitals, billing agents and my health ins. company. I pay my co pay each time I visit and then it starts the ball rolling on endless bills from the folks mentioned above for co pays that I already paid.

No doubt that there is an industry in health care devoted to getting patients to pay 2 and 3 times for the same services. I keep track of all my visits and co pays but it drives me crazy.

 

[flyfishnevada]

Price transparency would help a lot with reducing US health prices. It would probably apply downward pressure to salaries, which is against the interests of health care professionals.

+1

 

[Nords]

Depending on the surgery the price may vary depending on the supplies used , equipment needed , etc.. An example is a shoulder arthroscopy is one price but if they repair a tear in your rotator the cuff the price goes up and some of these things they do not know until they look inside. You could probably get an estimate from the physician's office or the hospital billing department.

This sounds a lot like the conversations I have with the repair service at our local Toyota dealer.

I felt a slight 'odd feeling' in the upper part of my brain - I didn't assume that a vein/blood vessel had burst, but that's the closest description I could come up with. Wasn't painful, just a brief (2 second) sensation, then went away.

You left us hanging-- was there a diagnosis?

 

[JOHNNIE36]

Depending on the surgery the price may vary depending on the supplies used , equipment needed , etc.. An example is a shoulder arthroscopy is one price but if they repair a tear in your rotator the cuff the price goes up and some of these things they do not know until they look inside. You could probably get an estimate from the physician's office or the hospital billing department.

I agree with your post as this happened to me when I had rotator cuff and the surgeon told us to be prepared if DW doesn't have the surgery done sooner. Said the arthroscopy surgery planned could esclate to requiring incisions if she does any damage due to the delayed procedure. However, I'm really questioning the cost of the hospital facility, whether it is considered "outpatient" or "inpatient". That is the cost I'm trying to determine.

 

[Brat]

I have a good friend who is a (now retired) General Surgeon. He had a number of acadamic awards and graduated from one of the USA's finest universities so I asked why didn't he specialize. He said that a surgeon must be prepared for the unexpected, you start anticipating one condition and find another. You don't just stich up the patient and say 'not my department'.

Given our pay for service health care I can understand why pricing can be difficult.

 

[Moemg]

However, I'm really questioning the cost of the hospital facility, whether it is considered "outpatient" or "inpatient". That is the cost I'm trying to determine.

I would call the hospital billing information and insist on getting the answer even if you have to get a supervisor involved . By the way a shoulder repair can be very painful so make sure you have the pain medication ready plus ice bags unless they are giving you an ice machine . Most patients after shoulder surgery need to sleep in a recliner for a few days . Also make sure she wears something easy to get on to the hospital . I would suggest she bring a large button front blouse because it needs to go over a sling ,elastic waist pants and slip on shoes .

 

[clifp]

I have a good friend who is a (now retired) General Surgeon. He had a number of acadamic awards and graduated from one of the USA's finest universities so I asked why didn't he specialize. He said that a surgeon must be prepared for the unexpected, you start anticipating one condition and find another. You don't just stich up the patient and say 'not my department'.

Given our pay for service health care I can understand why pricing can be difficult.

I agree.

But the car repair analogy is in many ways a good one. It is pretty common mechanic to say, I think your problem is either X or Y, but I won't know until I look. X will cost you $300, Y will cost $500. Sometimes the start looking at the car and they say say the problem is actually Y+Z and the cost is going to be $1,000. They have a pretty good idea how long the repair will take and the material involved, in fact most of the time the manufacturer has specific hourly estimate. If it takes longer than expected the mechanic typically eats the distance if they finish early they make more profit. Now medical care is different, but there are absolutely situations like pricing out for MRI, or even the potential for a less expensive test that medical community should start looking at automotive industry or even dentistry.

The big problem we face a society is so much medical care is paid by other people money that there is little incentive to be cost conscious.

 

[Nords]

You don't just stich up the patient and say 'not my department'.

But the car repair analogy is in many ways a good one. It is pretty common mechanic to say, I think your problem is either X or Y, but I won't know until I look. X will cost you $300, Y will cost $500. Sometimes the start looking at the car and they say say the problem is actually Y+Z and the cost is going to be $1,000.

Yeah, at least the mechanic calls you and says "It's gonna take more work and cost more than we figured, you still think it's worth the trouble?"

 

[W2R]

Price transparency would help a lot with reducing US health prices. It would probably apply downward pressure to salaries, which is against the interests of health care professionals.

I couldn't agree more! I just had an example of that in my life, today.

My insurance no longer covers as much of prescription drug costs in 2012, as it did in 2011. Today I got my first prescription refills under the 2012 rates, and they had "only" gone up from $48 to $67. My best estimate had been about $90-$110 following what I had been told two weeks ago.

The only information received on paper directly from BCBS was a masterpiece of weasel-wording, self-contradiction, and meaningless fluff verbiage. Why must the patient be left completely in the dark on costs?

 

[NW-Bound]

The medical billing in this country is totally messed up!

I have a friend who had a knee replacement recently. He said that the main surgeon was inside the network of his insurance company, while the assisting surgeon was not.

The result was that the assistant surgeon charged him about twice what the main surgeon did. And so, the insurance company refused to pay!

My friend said, hell no, he wouldn't pay more. So, in the end, the assisting surgeon had to reduce his bill, to the same as that for the main surgeon, if my memory serves.

Why was all the above billing detail not revealed to the patient? Didn't he have a choice in the matter? Who invited that assisting surgeon?

I guess in this country, we are all so used to the total bill being picked up by the insurance policy provided by the megacorp, and then when we are on Medicare, to be covered by Uncle Sam that nobody bothers to let the patients know anything anymore.

"Don't worry about it. You've got it covered." This just got me all worked up...

 

[JOHNNIE36]

I couldn't agree more! I just had an example of that in my life, today.

My insurance no longer covers as much of prescription drug costs in 2012, as it did in 2011. Today I got my first prescription refills under the 2012 rates, and they had "only" gone up from $48 to $67. My best estimate had been about $90-$110 following what I had been told two weeks ago.

The only information received on paper directly from BCBS was a masterpiece of weasel-wording, self-contradiction, and meaningless fluff verbiage. Why must the patient be left completely in the dark on costs?

W2R, not saying my method of holding down drug costs would work for everyone but I reduced ours a lot starting last year. Suggestion: take any generic drug prescription to WalMart and check their prices. If the price is close, use WalMart since your cost will not count towards the donut hole. Remember, it's your cost PLUS the insurance companies cost that go toward the donut hole.

I take Plavix. No generic available for sale in this country, so I got it last year from a Canadian pharmacy. In 2012 I changed our Medicare Advantage plan to BCBS. Through their mail order pharmacy I was able to get a reduction in the cost of the Plavix to $135 for a 90 day supply by getting my doctor to complete a form called "formulary or tier esception". The form verifies that the doctor has tried all other options to Plavix and that nothing else is available. The generic available from the Canadian pharmacy cost me $85 for a 90 day supply. I'll pay the extra $50 to get the brand name. Now I have to be careful since BCBS paid $422 on the Plavix. That's a total of $557 toward the donut hole. That's why buying other drugs outside the insurance plan (see WalMart) is cost effective.

 

[W2R]

W2R, not saying my method of holding down drug costs would work for everyone but I reduced ours a lot starting last year. Suggestion: take any generic drug prescription to WalMart and check their prices. If the price is close, use WalMart since your cost will not count towards the donut hole. Remember, it's your cost PLUS the insurance companies cost that go toward the donut hole.

I take Plavix. No generic available for sale in this country, so I got it last year from a Canadian pharmacy. In 2012 I changed our Medicare Advantage plan to BCBS. Through their mail order pharmacy I was able to get a reduction in the cost of the Plavix to $135 for a 90 day supply by getting my doctor to complete a form called "formulary or tier esception". The form verifies that the doctor has tried all other options to Plavix and that nothing else is available. The generic available from the Canadian pharmacy cost me $85 for a 90 day supply. I'll pay the extra $50 to get the brand name. Now I have to be careful since BCBS paid $422 on the Plavix. That's a total of $557 toward the donut hole. That's why buying other drugs outside the insurance plan (see WalMart) is cost effective.

Johnnie, my problem is not with the generics; it's with the one that isn't generic. My doctor does not want to try me on other options so I doubt that he would sign such a form, if it would even apply in my case (I have no information from BCBS about such a form even existing that would apply in my case). I'll ask him again. At any rate, I'm less worried now than I was since I don't have that $95 co-pay that I was warned was in effect, less than two weeks ago! That was the point of my post. As for the donut hole, I'm not on Medicare yet so I'm not quite sure what you are talking about but I'm sure I will figure it out one of these days.

 

[Bestwifeever]

DH had a prescription change last week that isn't one of the $4/mo Target generics. He called the mail-order prescription insurance people to ask what it would cost just for grins as he has no choice not to have it filled--they told him they wouldn't know what the pills would cost until they actually filled the prescription. That same day.