• Wed. Sep 21st, 2022

The $18,000 breast biopsy: when insurance costs you dearly

ByElla E. Kidwell

Aug 23, 2022

When Dani Yuengling felt a lump in her right breast last summer, she tried to ignore it.

She was 35, the same age as her mother when she was diagnosed with breast cancer in 1997. The disease eventually killed Yuengling’s mother in 2017.

“It was the hardest experience watching her suffer,” said Yuengling, who lives in Conway, South Carolina.

After a mammogram confirmed the lump needed further investigation, Yuengling scheduled a breast biopsy for Valentine’s Day this year at Grand Strand Medical Center in Myrtle Beach.

Among the many concerns she had before this appointment – ​​the first being a potential cancer diagnosis – Yuengling needed to know how much the biopsy would cost. She has an annual deductible of $6,000 — the amount her health plan requires her to pay before her contribution kicks in — and she was nowhere near reaching that amount. Whatever the cost of the procedure, Yuengling knew she would be responsible for most of it.

But the hospital wouldn’t give him a price. He was told that his suppliers wouldn’t know what type of biopsy needle they needed until the procedure was underway and that would impact the price.

The hospital’s online “Patient Payment Estimator” showed that Yuengling, an uninsured patient, owed about $1,400 for the procedure.

“That’s fine. That’s okay,” she thought, convinced it would be cheaper for her because she had insurance. A Google search indicated it might be closer to 3,000 $, but Yuengling thought that price also seemed reasonable, and she wasn’t too worried about the money while she was undergoing the procedure.

This quickly brought the good news that she did not have cancer.

Then the bill came.

The patient: Dani Yuengling, now 36, who is covered by Cigna through her employer, a human resources contractor for the Mayo Clinic.

Medical service: An ultrasound-guided breast biopsy.

Service provider: Grand Strand Medical Center, a 403-bed, for-profit hospital in Myrtle Beach, South Carolina. It is one of 182 hospitals owned by Nashville-based HCA Healthcare, which generated $58.7 billion in revenue last year.

Total bill: $17,979 for the procedure, including lab work, pharmacy fees and sterile supplies. The negotiated rate in Cigna’s network was $8,424.14, of which the insurance company paid the hospital $3,254.47. Yuengling was billed $5,169.67, the balance of its deductible.

Which give: It’s not uncommon for uninsured patients — or any patient willing to pay a cash prize — to be charged significantly less for a procedure than patients with health insurance. For nearly 30% of American workers with high-deductible plans, like Yuengling, this means that using insurance can lead to far greater expenses than if they were uninsured or had just took out a credit card to pay in advance.

Ge Bai, an associate professor at the Johns Hopkins Bloomberg School of Public Health, recently published research on this topic and said that US hospitals often set their cash prices at prices lower than the prices they charge to treat patients. commercially insured.

“We can say with certainty that this is very common,” said Bai, who advised all patients, regardless of insurance status, to inquire about the cash price before undergoing surgery. “That should be a standard.”

Dani Yuengling lost his mother to breast cancer and takes his health seriously. But after a frustrating experience with a very high bill for a biopsy, she is reluctant to seek follow-up care.(Gavin McIntyre for KHN)

Grand Strand charged Yuengling’s insurance an extraordinarily high price for its intervention. By comparison, according to the federal government’s website, Medicare patients who need an ultrasound-guided biopsy similar to the one Yuengling received would only pay around $300 – their required 20% coinsurance for outpatient care. . Medicare would pay the hospital the rest of the bill, about $1,200. The hospital expected more than five times the price of Medicare from Yuengling and his insurer.

Conway patients with private health insurance who are treated at other hospitals are typically charged less than what Yuengling paid for the same procedure — on average about $3,500, according to Fair Health Consumer, an organization that analyzes claims. health insurance.

And uninsured patients who pay cash prices and need an ultrasound-guided breast biopsy at nearby Conway Medical Center would likely owe even less — about $2,100, according to hospital spokeswoman Allyson Floyd.

Meanwhile, Grand Strand Medical Center spokeswoman Caroline Preusser blamed “an issue” involving the hospital’s online calculator for inaccurate information received by Yuengling and said the correct estimate of the price at Cash for an in-hospital breast biopsy is between $8,000 and $11,500″ depending on the exact procedure and equipment used.

The hospital has removed some procedures from the payment estimator until they can be corrected, Preusser wrote. She didn’t say how long it would take.

Resolution: Yuengling tried to dispute the charges with the hospital. She called the billing department and was offered a 36% discount, reducing the amount she had to pay to $3,306.29. Grand Strand Medical Center allows patients to set up payment plans, but Yuengling decided to charge the full amount to a credit card because she wanted it all to go away.

“I couldn’t sleep. It was driving me crazy. I had migraines. I had a stomach ache,” she said. “I hate being in debt. I didn’t want to think about it. Obviously , it didn’t work because I’m still thinking about it.

She said she repeatedly asked to speak to the hospital’s patient advocate and was eventually put in touch with an outside company, Parallon, who audited her bill. She eventually received a letter dated May 26 from the hospital’s revenue integrity department. He said: ‘After a review of the charges in question and your medical records, the following has been identified; The charges on your account were appropriate. »

“I don’t know why I expected a different result,” she said.

The hospital requested that Yuengling return for a follow-up appointment related to the biopsy. She refused.

Harlow Sumerford, a spokesperson for HCA Healthcare, told KHN in an email that the hospital system apologizes for any confusion caused by the payment estimator “and we are working to resolve the issue.”

A photo shows Dani Yuengling standing outside.
(Gavin McIntyre for KHN)

Takeaway meals: With a family history of breast cancer, Yuengling was right to see her doctor after feeling a lump. After failing to get a clear answer on her costs from Grand Strand Medical Center, she could have taken an extra step to explore what other hospitals in the area are charging. Although her doctor referred her to Grand Strand, she was under no obligation to use this hospital. She could have saved a significant amount of money by choosing to have the procedure done elsewhere.

Additionally, patients like Yuengling who have a high-deductible insurance plan should consider paying cash prices for certain procedures and not involving their insurance company at all.

Jacqueline Fox, a health care attorney and professor at the University of South Carolina Law School, said she was not aware of any law prohibiting a patient from doing so. After all, she pointed out, patients with health insurance pay cash prices for prescription drugs all the time. It stands to reason that they could do the same for medical procedures.

But some facilities make this difficult. Grand Strand Medical Center, for example, offers “self-paid” patients an “uninsured discount,” but that discount is limited to people who have “no third-party payment source or are not eligible for Medicaid, Charity or any other discount program offered by the facility,” according to the hospital’s website. Only patients with confirmed lack of health insurance are offered information about the discount.

In some cases, paying a cash price for a procedure may not make financial sense in the long run because none of it would be applied to the deductible. Patients can save money on a procedure, but end up paying their entire deductible if unexpected medical expenses rise later in the calendar year.

Insured patients should contact their health plan for a good faith estimate before a procedure. Under the No Surprises Act, health plans are supposed to give members an idea of ​​their total costs upon request. Ask for an “advanced explanation of benefits,” said Sabrina Corlette, a research professor at Georgetown University’s McCourt School of Public Policy, though she points out that this part of the law is not yet enforced.

The No Surprises Act also allows patients to file complaints with the federal government about their medical bills, whether or not they have health insurance.

Yuengling filed her lawsuit in June.

A photo shows Dani Yuengling seated at a table, looking to the left.
(Gavin McIntyre for KHN)

Stephanie O’Neill contributed the audio portrait with this article.

Bill of the Month is a participatory survey conducted by KHN and NPR who dissects and explains medical bills. Do you have an interesting medical bill that you want to share with us? Tell us about it!

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