Cost transparency issue: how to attack?

[athena53]

I had an annual mammogram last month. It was coded as preventative.

The facility offered a 3-D mammo for another $35, payable up front. I accepted that; my mother is a BC survivor so a higher-quality test is better.

Last week I got a bill from the provider (very large hospital) for $200. I checked the Explanation of Benefits from my insurer's Web site, looked up the procedure codes, and found that, while the two procedures for a routine screening mammo (GO202 and 77063) were 100% covered, the $200 they charged for "computer-aided detection" (77052) was not. So, I lose 3 ways here. Since the insurer doesn't cover it, there's no negotiated rate. I pay it 100% out-of-pocket. And it doesn't even go towards meeting my deductible. Last year's mammogram was at the same facility, same insurer (although we moved across a state line so may have slightly different policy provisions), and there was only the up-front surcharge, no surprise bills for procedures not covered by the insurance.

I know I have to pay this if I don't want my credit messed up and, thank God, it won't break the budget- but I'm angry. I feel like either the hospital is padding its bills with separately-coded procedures (sort of like the airlines) or the insurer isn't covering something that should be a part of a normal mammogram. I'm retired and have plenty of time to rattle cages. Where do I start? The hospital billing department (will they give a fig)? The insurer? The state Insurance Department?

 

[Meadbh]

Did you ask beforehand whether the 3-D was covered by your insurance? This article clearly states that most insurers do not cover it, and provides some reasons why.

3D Mammograms May Improve Breast Cancer Screening – WebMD

 

[W2R]

I'd call first, tell them that this isn't covered by your insurance, and at least TRY to negotiate to get the rate down if you pay it immediately. Couldn't do any harm.

 

[athena53]

I knew that the 3-D aspect was not. That's why they collected the $35 up front. The procedure not covered was "computer-aided detection"- maybe using software to digitally scan the results in addition to a human? Why wasn't that part of the up-front payment if it was a necessary part of the 3-D? I'm a bit overdue for a colonoscopy and this has me feeling even less in-control of my medical costs. It will be coded diagnostic due to previous blips (which is why skipping it is NOT an option) and I have had zero success in finding out what the 2 facilities I'm considering will charge, all-in. The facilities tell me to ask my insurance company. The insurance company tells me to ask the facility. I have a $6K deductible so it's completely out-of-pocket and I'm finding it maddening that no one will give me an answer.

 

[pb4uski]

I would call them and tell them that was not part of the deal that they offered you and that you accepted. They offered you an upgrade to a 3D mammogram for $35 and that is what you accepted and paid for.

It sounds like they neglected (intentionally or not) to disclose to you that there would be an additional charge for reading the 3D mammogram. If they had disclosed that to you at the time you decided on the 3D mammogram then you would not have done it and they never got an authorization from you for the 3D reading charge so the fact that they went and did it is on them, not on you.

If you can't avoid the charge, then see if they will settle for $100 paid right now.... if not then file the appropriate complaints and objections and let the process play out.

 

[travelover]

I don't have a solid suggestion, but I totally agree with your outrage. It is like getting off a flight and being charged an additional $50 for the peanuts you ate and $100 for using the bathroom.

 

[athena53]

I don't have a solid suggestion, but I totally agree with your outrage. It is like getting off a flight and being charged an additional $50 for the peanuts you ate and $100 for using the bathroom.

Sssshhhh. You're gonna give the airlines ideas!

 

[Meadbh]

Sssshhhh. You're gonna give the airlines ideas!

They already thought of that!

Paying to Pee: Ryanair's New Flight Bathroom Fee. Have Airlines Gone Too Far? - ABC News

 

[MichaelB]

Where do I start? The hospital billing department (will they give a fig)? The insurer? The state Insurance Department?

I think you have to start by disputing the charge with the hospital, to take the complaint elsewhere you should be able to show you made a good faith effort to resolve. Your state insurance regulator is next, along with your health care insurance provider. I would also complain to your state Attorney General.

 

[TrvlBug]

I had something similar happen last month. The heart monitor my dr. ordered was not covered by my insurance. The clinic said I could pay directly at around $200-300. No problem.

Apparently, the $200-300 is the negotiated rate; my rate was $900. Told them I was not paying it and would only pay the $200-300 I was told it would cost. No problem they said, we'll send you the bill. I dealt directly with the company, not the clinic or my insurance co.

 

[Texas Proud]

First, have you received a bill from the hospital asking for the extra money If not, then do nothing....

When I went in for my colonoscopy they 'required' me to wear these boots that pushed blood from my legs up to my body... they said 'you will be able to keep them'... Why would I need them? I don't...

But, they billed the insurance company $1600 for these things... and then kept disputing the rejection (I know since I kept getting letters saying that MY dispute of the rejected charges did not change their mind)....

I have never heard from the hospital for payment... which if they tried to get the money I would refuse...

 

[athena53]

First, have you received a bill from the hospital asking for the extra money If not, then do nothing....

When I went in for my colonoscopy they 'required' me to wear these boots that pushed blood from my legs up to my body... they said 'you will be able to keep them'... Why would I need them? I don't...

But, they billed the insurance company $1600 for these things... and then kept disputing the rejection (I know since I kept getting letters saying that MY dispute of the rejected charges did not change their mind)....

I have never heard from the hospital for payment... which if they tried to get the money I would refuse...

Wow- were they ostrich boots?

Yes, I do have the bill from the hospital. I'm non-confrontational and I hate Voice Menu Hell, but I'm going to call them tomorrow. I'll keep you posted.

 

[Alan]

I'm a bit overdue for a colonoscopy and this has me feeling even less in-control of my medical costs. It will be coded diagnostic due to previous blips (which is why skipping it is NOT an option) and I have had zero success in finding out what the 2 facilities I'm considering will charge, all-in. The facilities tell me to ask my insurance company. The insurance company tells me to ask the facility. I have a $6K deductible so it's completely out-of-pocket and I'm finding it maddening that no one will give me an answer.

When DW and I had colonoscopies 2 or 3 years ago I made sure that the doctor and facility were both in network and when all the bills started flowing in everything was in-network and covered except 1 of the 2 labs that were used. HI refused to pay, and it took phone calls to the lab plus 2 formal complaints to the HI they finally paid ~$200 of the $1,500 bills (both I and DW) and I paid ~$60. The whole process took about a year to get resolved.

Good luck.

 

[mpeirce]

I find it interesting that my supposedly "crummy" pre-ACA HDHP/HSA health insurance that costs about half what I'd pay on the exchange, totally covered my recent colonoscopy. No co-pay, nothing. It was just included.

 

[bingybear]

I find it interesting that my supposedly "crummy" pre-ACA HDHP/HSA health insurance that costs about half what I'd pay on the exchange, totally covered my recent colonoscopy. No co-pay, nothing. It was just included.

Was this a diagnostic or preventative colonoscopy? Typically preventative are completely covered. However, if you go in for a preventative one and they find something... it converts to a diagnostic colonoscopy and you get more work done. Also, more procedures and labs get added. If you had a diagnostic colonoscopy completely paid for without reaching deductible or MOOP would be interesting.

I knew that the 3-D aspect was not. That's why they collected the $35 up front. The procedure not covered was "computer-aided detection"- maybe using software to digitally scan the results in addition to a human? Why wasn't that part of the up-front payment if it was a necessary part of the 3-D? I'm a bit overdue for a colonoscopy and this has me feeling even less in-control of my medical costs. It will be coded diagnostic due to previous blips (which is why skipping it is NOT an option) and I have had zero success in finding out what the 2 facilities I'm considering will charge, all-in. The facilities tell me to ask my insurance company. The insurance company tells me to ask the facility. I have a $6K deductible so it's completely out-of-pocket and I'm finding it maddening that no one will give me an answer.

The problem with getting estimates on a diagnostic procedure is they likely don't know all the procedures you will have unless they don't find anything. My insurance company has estimates for procedures by provider. However, it only covers the on procedure you input... not associated ones that may be done. I've had several insurers that had tools like this to compare estimated expenses. My PCP usually points me to reasonably affordable testing facilities.

 

[easysurfer]

I find it interesting that my supposedly "crummy" pre-ACA HDHP/HSA health insurance that costs about half what I'd pay on the exchange, totally covered my recent colonoscopy. No co-pay, nothing. It was just included.

My thought is that whether a doctor is in-network or not trumps the "crummy" or "not crummy" insurance. A couple of years ago, for my physical I was surprised to see that the cost of my physical with my doctor was not covered. I thought all preventative procedures were covered post ACA, but apparently not as he wasn't in-network.

 

[athena53]

The problem with getting estimates on a diagnostic procedure is they likely don't know all the procedures you will have unless they don't find anything. My insurance company has estimates for procedures by provider. However, it only covers the on procedure you input... not associated ones that may be done.

Yeah, that's a good point. In each of the previous tests they found something that needed to be excised. I can see how that isn't predictable. From one doc's office, though, all I could get was the self-pay rate for HIS fees. Costs for the hospital where it would be done? No, they couldn't tell me. The other doc operates in a free-standing facility so I may have better luck there, but I sent a question to their informational e-mail address and apparently no one answers e-mails.

 

[athena53]

A hopeful update: I called the hospital and the young man who reviewed the file said that this is a "known issue" and he's registered my objection and sent it somewhere to be resolved. The fact that he said it's a known issue gives me some hope they'll waive it.

 

[Brat]

In today's news there is a mention of a study about the utility of computer assisted mammography vs not computer assisted mammography. The computer assistance did not find more breast cancers. The other interesting fact is that 90% of mammograms are computer assisted and cost more. Computer-Aided Mammograms Bloat Costs, Don't Save Lives: Study - NBC News Doubtless the health care industry will question these results loudly.

 

[Lsbcal]

Another terrible defect in our health care system: not knowing costs ahead of time and not knowing whether insurance or medicare will cover it.

Had a $1700 bill recently that fell into this category.

Grrr...

 

[Theseus]

I have an outstanding bill from radiologist from 6 months ago that is being a PITA. I'm not sure exactly how it works to tell the truth, but best I can understand is they are a third party contracted by specialist doctor I saw, or perhaps contracted by the hospital where CTScan was done? Point is, I never initiated a request for their service, except by way of being scheduled for CTScan as part of a routine-for-me followup. I was familiar with this radiology practice being on the high side in their billing amounts, averaging about 280% of what insurance says it is worth. My state says no balance billing is permissible for HMO plans, so I'll not pay them a cent more than what the insurance says they have coming - and I made that point clear to them in response to their screwed up billing.

First and second EOB for this bill was coded as the usual "Contracted preferred provider agreement" so OK, even though I was given no choice on who was providing the service, at least they are covered under my plan. Coding also indicated "Precertification/authorization/notification absent. Service was not authorized." which seemed odd, since the CTScan charge from the hospital was approved. I thought it might simply be a screwup, as the doctor who had ordered the scan the previous fall had retired, perhaps the new doc's office hadn't gotten all the i's dotted and t's crossed. Called the insurance co, and the <insert foul language here> rep I spoke with proclaimed it was obviously a mistake for the scan to have been covered, but he would correct that post-haste. Quite helpful, oh yeah! Called back and spoke with a different rep, and was advised the scan was covered, and it may be possible to do a retroactive authorization for the radiologist's charges.

Since the EOB stated I owe nothing, and balance billing is not allowed I suppose I could have just done nothing and just tell the radiologist to buzz off. But I contacted the 'new' specialists office and clued them in, and they took care of making the authorization work. Eventually I received a third EOB, with a more reasonable 41.6% of the initial charge due (deductible had not yet been met). Told the radiologists billing people I was not about to pay them anything until they get the bill right, and since for some reason the service was not pre-authorized (remember I had no part in arranging for them to provide service) I saw that as their problem - but did tell them the insurance company advises retroactive authorization may be possible.

So, the radiologist's billing still wants the entire amount, and seems to think I should take care of retroactive authorization. Actually, I did - but they for some reason seem to be unable to correlate the EOB properly. At this point, I hope they turn it over to a collection agency. Then I will file a complaint with the state insurance commissioner's office over the illegal balance billing.

 

[athena53]

In today's news there is a mention of a study about the utility of computer assisted mammography vs not computer assisted mammography. The computer assistance did not find more breast cancers. The other interesting fact is that 90% of mammograms are computer assisted and cost more. Computer-Aided Mammograms Bloat Costs, Don't Save Lives: Study - NBC News Doubtless the health care industry will question these results loudly.

Yeah, DH pointed that out to me in our morning paper!

The hospital got back to me and they're reversing the charge for $200 but I will be billed $31 for the computer-aided analysis. She said they should have notified me of the $31 when I selected the 3-D version. They blamed it on their new computer system; my guess is that there was a negotiated rate of $31 with my insurer but the software didn't recognize it.

Still a transparency issue, of course, but at least the $$s are smaller. If I go back there next year I'm gonna tell them not to bother with the computer assist!

 

[gauss]

Wow- were they ostrich boots?

Yes, I do have the bill from the hospital. I'm non-confrontational and I hate Voice Menu Hell, but I'm going to call them tomorrow. I'll keep you posted.

If you don't like to negotiate AND
Your bill is over $200 AND
You are dealing with a faceless entity THEN

You may wish to use the services of medical bill negotiation service.

It seems that they charge you about 1/3 of the total of what they save you on the bill.

Here are a couple of references:

https://healthcarebluebook.com/page_BillNegotiation.aspx

https://www.copatient.com/


Seems like a possible way to "outsource" the stress & hassle of this sort of thing WITHOUT rolling over and paying the full bill.

-gauss

 

[Brat]

I understand how knowledgeable professionals can assume that 'computer assisted' should result in better outcomes. If any of you Google 'computer aided mammograms' you will see many journals advocating that approach. HOWEVER just because it seems like it should doesn't mean it is.

I checked out (cancer) The Emperor of All Maladies on line (am in my 2nd re-read) where the importance of 'show me the numbers' vs 'it makes sense to me' approaches to health care are manifest.

Time to decline to pay more until a diagnostic scheme or treatment is proven to provide a better outcome.

 

[travelover]

The latest edition of Consumer Reports has suggestions on how to avoid unexpected medical charges including what to do if you don't take the precautions suggested and have to negotiate the bill. Most of the suggestions have been discussed on this forum in the past.

CR is behind a paywall, but most libraries carry it.