THCB

How Much Is My Colonoscopy Going to Cost? $600? $5,400?

How much does a colonoscopy cost? Well, that depends.

If you’re uninsured, this is a big question. We’ve learned that cash or self-pay prices can range from $600 to over $5,400, so it pays to ask.

If you’re insured, you may think it doesn’t matter. Routine, preventive screening colonoscopies are to be covered free with no co-insurance or co-payment under the Affordable Care Act.

However, we’re learning that with colonoscopies, as with mammograms, people are being asked to pay sometimes. It’s not clear to us in every case that they should pay, and since we don’t know all the details of these events, we can only offer some general thoughts. We’ve also heard from Medicare enrollees without supplemental Medicare policies that they think they’re responsible for 20 percent of the charged price — so 20 percent of $600 vs. 20 percent of $5,400 is a big deal.

If you’re on a high-deductible plan and the charge to you will be, say, $3,600, you can probably ask around and find a lower rate.

A thorough view of some colonoscopy billing issues is in this article in The New York Times by Libby Rosenthal, who has been covering health costs for the paper. We’ve heard also about in-network providers using out-of-network anesthesiologists, so it pays to pay attention.

Things to watch out for in billing

If you’re planning a colonoscopy, you might want to ask for the price in advance. Make sure that the price quoted to you includes everything: doctor’s fee, anesthesiology, lab tests and facility fee (sometimes but not always) are the main charges. Sometimes the doctor will charge an additional pre-procedure consultation fee, and sometimes the solution for “prep” to clean your system out is included, while sometimes it’s not.

Doctor’s fee. When we survey for prices, often we are quoted only a doctor’s fee, with anesthesiology and facility fee separate. Some doctors do this in their offices; some do it at different sites (a GI clinic, a hospital) and each of those sites can have a different fee. When we’re looking for prices, we always ask what’s included.

Also, make sure your doctor is in network, if you’re insured.

Anesthesiology. Sometimes this is a full general anesthetic, and sometimes it is a light dose of anesthesia resulting in what is called “twilight,” where you’ll be sleepy but able to respond to commands, essentially sedated. Generally with twilight you forget everything immediately.

There is a large body of research suggesting that full general anesthetic is wasteful for procedures like a colonoscopy, but it continues to be offered fairly frequently. A small number of people do it with no anesthesia or sedation.

“Between 2003 and 2009, the proportion of GI procedures involving anesthesia providers doubled, and overall payments for GI anesthesia tripled,”   a recent study by the Rand Corporation found.

Anesthesia can be pricey, and it’s important to be sure that the provider is in network — so make a point of asking, even if you are at an in-network doctor’s office, or other location. We hear a lot of complaints about this.

What happened to me: I asked in advance to make sure the anesthesiologist and everything else would be in network. Then when I arrived in the morning for my appointment, the receptionist gave me a form to sign guaranteeing that I would pay everything that wasn’t covered by insurance, including any out-of-network anesthesiologist or lab fees.  I refused to sign it, saying that I’d checked in advance to make sure everybody and everything was in network. They didn’t insist, and the anesthesiologist (twilight, by the way) was indeed in network. My out of pocket was $30 for anesthesiology, my standard co-pay (before the Affordable Care Act).

Lab tests. The providers generally don’t reveal in advance what lab tests will cost;  they will say that charge depends, often on what they choose to remove for testing during the procedure. We have heard labs estimated in advance to be as low as $50 and as high as “we can’t tell you in advance.”

What happened to me: I had $250 in lab charges, all covered except for a $30 co-pay (before the Affordable Care Act); my girlfriend’s lab charges were $950, about the highest I’ve heard. For her, it was completely covered, but of course that’s not always true.

Facility fee. This is a growing issue: a doctor’s office could be just an office, but it could be a facility. The facility fee is applied by hospitals, gastrointestinal ambulatory surgery centers, and just about anything that feels that it’s a facility.

In my case, there was no facility fee; the procedure took place in a doctor’s office. My girlfriend’s took place at a GI center, not her doctor’s office, and the biggest line item on the bill was $2,700, for the facility fee, of which the insurer paid a bit less than half. She was not asked to pay the balance.

Some insurers will refuse to pay a facility fee from an in-network provider. Some insurers will pay only a part of the facility fee, and depending on your insurance plan or your state’s policies on balance billing, you might be responsible for some or all of that fee.

So it pays to ask up front, “Is there a facility fee? How much is that? Is it covered by my insurance? Does there have to be a facility fee?” When we were collecting prices, we learned that some places would quote us only a facility fee, adding that the doctor fees varied by provider, and so did the anesthesiology fees. Most places said labs were extra and unpredictable.

Pre-procedure consultation. Not every provider charges this. Mine did, and it was $250. I saw a nurse, and got a checklist. My insurance company covered the whole thing, with a $30 co-pay.

Prep stuff. The medication you’re asked to drink to clean out your system is not free. We have heard prices as low as $12.10 over the counter, and as high as $38 — actually, both from the same person, which I wrote about in this blog post.

Insurers’ predictions: A grain of salt

If you’re insured, you could look at the insurance company’s prediction of prices.

My insurance company predicted this: “Estimated Treatment Cost: $1,464-3,609; Plan Responsibility: $1,125-2,952; Member Responsibility: $339-657.” My actual experience:  Bill totaled $2,797; plan paid $2,263.85; my co-pay was $120 ($30 for the consultation, $30 for the doctor, $30 for the anesthesiologist, and $30 for lab fees). I have no records on what the prep stuff cost.

My girlfriend’s experience: Bill totaled $5,544, plan paid $2,750.08, her copay was 0. (She had a different provider and has a different insurance plan; this was also pre-A.C.A.) Also, depending on your plan, under the Affordable Care Act, you should not pay anything for a routine preventive colonoscopy.

Why is it so hard to find the cost of a colonoscopy?

When we survey on colonoscopies, we ask for the following component parts of the procedure:

Doctor’s fee, for the person actually performing the exam.

Anesthesiology.

Facility fee, if any. This is a growing issue: a doctor’s office could be just an office, but it could be a facility. The facility fee is applied by hospitals, gastrointestinal ambulatory surgery centers, and just about anything that feels that it’s a facility. Lab fees.

Consultation.

Any other charges (prep liquid, for example).

In our surveys, often we are told only one or two of these charges: Statements like these are common.

“That’s the facility fee for doing it here; the doctors all charge their own rates.”

“The anesthesiologist can’t predict in advance how much they’ll need or how long they’ll take, so we can’t tell you that.”

“We can’t tell labs in advance.”

“That’s a price for facility fee, doctor and anesthesiologist. Labs run between $50 and $250 usually.”

“We don’t quote prices in advance.”

“That’s the doctor’s fee — there might be a facility fee, depending on where he does it. We don’t know until he tells us.”

We’ve written about this before several times, here and here.

O.K., so how much does a colonoscopy cost?

Here are  colonoscopy price lists for the New York area, and here are colonoscopy price lists for the Los Angeles area.

Here are  colonoscopy price lists for the San Francisco area. And here are Texas cities: colonoscopy price lists for the Houston areathe Dallas-Fort Worth areathe San Antonio area and the Austin area.

A cautionary note: the billed price, as always in the health-care marketplace, can be a price that’s not actually real.

“In Keene, N.H., Matt Meyer’s colonoscopy was billed at $7,563.56,” Rosenthal wrote in her New York Times piece. “Maggie Christ of Chappaqua, N.Y., received $9,142.84 in bills for the procedure. In Durham, N.C., the charges for Curtiss Devereux came to $19,438, which included a polyp removal. While their insurers negotiated down the price, the final tab for each test was more than $3,500.”

The charged price for a medical procedure (often called the Chargemaster price) is seldom the price that is actually paid. What is actually paid is either set by law and administrative rules, in the case of government payers like Medicare and Medicaid, or governed by contracts, in the case of non-government insurance plans like Blue Cross, United HealthCare and so on.

If you ask for a cash or self-pay rate, that will often be considerably lower than the regularly charged price, reflecting cash discounts if they exist, and increasingly they do.

Livongo’s Post Ad Banner 728*90
Spread the love

88 replies »

  1. I checked that my colonoscopy would be covered at 100% as a preventative screening. I was told that it would be covered by United Health Care and by the doctor. UHC did not pay for the screening, no-one can explain to me why it wasn’t covered and I’ve been getting the runaround for the past two weeks.

    Under the ACA preventative colorectal cancer screenings, a colonoscopy, are meant to be covered at 100%. Even if a colon polyp is found and removed it still has to paid at 100% – this was a recent change to the ACA within the past year or so, after many consumers complained about screenings being changed to diagnostic when a polyp or some other issue is found and then having to pay all these unexpected costs. Although, all future colonoscopies will be considered diagnostic if a polyp is found, but now you’ll at least know you’ll have to pay and can shop around for the best price.

    UHC documentation found on the web supports that my colonoscopy was meant to be covered at 100% even though I had 2 colon polyps removed. “Preventive v. Diagnostic Colonoscopy. UnitedHealthcare has determined that a colonoscopy performed on a person without symptoms will be considered preventive, rather than diagnostic, even if a polyp is found and removed during the procedure. While the removal of a polyp during a preventive screening colonoscopy will not convert the procedure to a diagnostic colonoscopy, all future colonoscopies are then considered diagnostic because the time intervals between future colonoscopies would be shortened.”

    I believe that insurance companies are purposefully lying to their customers and are in violation of the ACA. Please, please do some research. If you are having a routine screening because you turned 50 or earlier if you are high risk because of family history your insurance is meant to pay for your colonoscopy.

    Here is what I ended up having to pay: Surgical center fee – $400. Doctor fee – $700. Labs for 2 colon polyps and biopsies – $200. Total $1300

    I opted for light sedation, this can be given by the doctor. This significantly reduces the cost vs. propofol and the cost of an anaesthesiologist, which can add hundreds of dollars to the cost. I opted for light sedation because no-one could tell me if the anaesthesiologist was in-network. Honestly, even though I was wide awake and talked to the doctor and nurse and remember everything – I couldn’t feel anything and wasn’t traumatized.

    Also, I do recommend trying to price the procedure even if it’s going to covered by insurance. Some of the prices I’ve read about are just crazy and if you’re insurance is going to stiff you, don’t you want to pay the least amount out of pocket.

  2. I feel 100% shafted by my insurance company & physician’s office regarding my colonoscopy.

    I am 52, in excellent health (height/weight, lifestyle, etc) and go in for stomach/lower gi issues to my PCP. He refers me to gastro doc who schedules colonoscopy, removes a single polyp which is benign.

    Before the procedure I call Carefirst BCBS with code from gastro doc’s office manager and am told the procedure is covered 100% including the anesth.

    Fast forward to one month later, I have nearly a $1000 bill from gastro doc and more than $500 from anesth doc…WTH? …turns out my routine colonoscopy is now a diagnostic colonoscopy and I have to pay ALL of it out of pocket.

    Not only do I have premiums which have more than DOUBLED in 2 YEARS and a DEDUCTIBLE which has more than DOUBLED in 2 YEARS (THANKS OBAMA), I can’t even get a stupid routine procedure covered. It’s all on me.

    “Routine, preventive screening colonoscopies are to be covered free with no co-insurance or co-payment under the Affordable Care Act.” is horsesh!t because if you have ONE polyp removed, it is suddenly surgical and the whole bill is completely yours.

    Anyone have any suggestions?

  3. I’m glad I’m sat on the other side of the Atlantic. This week I’ve had a Polyp removal by Colonoscopy, and a Gastroscopy session, Last week I had a Sigmoidoscopy, Total charge $0 thanks to the NHS. The US system is so far beyond insane it’s untrue

  4. Are these charges up to date? But it does give clear idea How it might cost. thank you. now I can reconsider my options.

  5. I went back to the same doctor that had done these procedures previously. Having had the procedure before I had in mind the costs I paid previously, about $600 with plops removed 5 years ago. So I was shocked when the EBO came and said my responsibility was $2550. Total bill from hospital $12,267 in Warwick NY. The insurance company said it was normal for the hospital to change the code from preventative to diagnostic. Why? Because they can. Reviewing the charges, the Hospital charges for the Colonoscopy with biopsy $3,485 and Colonoscopy with removal of Lesion $3,485. I asked Insurance company if this was double billing and why they would pay double billing and they gave me the same reason, it’s how the hospitals charge. There were separate charges for the Pathology lab and Anesthesiologist from rthe hospital. This does not include my doctors invoices Colonoscopy with Lesion removal $867 and Colonoscopy with Biopsy $749. All these numbers were not paid by the Insurer but were reduced. I am keeping these papers handy for my next procedure and will ask more questions of the doctor and hospital about these issues. Won’t be using the same doctor and probably not be doing it in a hospital. I will see if I can get the information about these cost before scheduling

  6. 12 hours before my procedure I discover I cannot drink the prep fluid. It’s a long story, but it ends with I cannot drink it. So. I called their answering machine and gave them as much detail as I could, letting them know I would not be there tomorrow. How much do you think they’ll charge me?

  7. @Richard Citron, I feel comfortable saying that many of these comments — maybe even most — are from people who would love to have what you have described instead of the Rube Goldberg contraption which passes for health care in America. Many of us have watched in dismay for years as it got cobbled together. Unfortunately the toothpaste is all out of the tube and not likely to be stuffed back in. Heck, ACA is the best we could do after literally decades of bipartisan efforts to correct the built-in glitches of profit-driven provider enterprises encrusted with profit-driven insurance and revenue-sucking lobbies everywhere you look.

    To coin a phrase, you fight with the resources you have. The dreams of Paul Starr, Alain Enthoven and others have been picked as clean as a holiday turkey, and we still have a raft of hard-core Randians trying to recycle the carcass.

    Meantime, my personal response to the colonoscopy challenge is telling my PCP that absent identifiable symptoms, I’m not having any more. And even then, I want a sigmoidoscopy, thank you, unless two doctors are convinced they really need to go further.

    Welcome to The Health Care Blog. We have one of the smartest groups of commentators anywhere.

  8. As I read through all this … forcing myself once again to keep my eyes open, I could not help but reflect on this statement from Barry Carol in response, “The big impediment to price discovery in the commercial insurance sector is the confidentiality agreements that preclude disclosure of actual contract reimbursement rates. We need to get rid of those.” NO, what we (the long abused American health care recipient) needs “to get rid of” is private health care insurance altogether and move into this new-ish century by joining the rest of the civilized world by created a taxpayer funded, government administered universal health care system covering the entire population in the country that will render private health care insurance irrelevant … as well it should be. Private health care insurance adds nothing but higher costs to everyone and every institution involved, contributes literally nothing positive and increases health care risk to everyon. Norway started off universal national health care in 1912 and for almost fifty years now every other first world nation … and many others as well … have offered this totally rational approach to all of its citizens. Listening to or reading these unending discussions has me thinking I am listening to cavemen discussing how to find better ways how to drag stuff around from one place to another on dragging sticks, as native Americans did before Europeans showed up with the wheel. Hey, the wheel has already been invented! Don’t like the idea of adopting an idea that is “foreign”? Try calling it something else, like maybe The All-American Stars & Stripes Universal Health Care System, Best Damned System Ever Invented System”. Whatever. Just do it already. This is all so tiring to watch. Not to mention an ongoing threat to everyone still living over there.

  9. I have UHC. They pay 100% for a colonoscopy coded as Preventative . If a biopsy is taken, the coding is changed to Diagnostic and they hit you for 20% of the cost, So, in reality, you are being punished for having something wrong found in your body (as if it were your own fault), which is the purpose for the procedure in the first place. This way of thinking is absurd, a Catch-22.

  10. Great information Margaret. I had small polyps removed at each of my two previous colonoscopies. As such, future procedures are no longer considered preventative. Any additional advice for those in such situations? I’m currently in an HMO, but will be changing to high deductible HSA soon. Trying to decide if it’s better to wait until the plan changes.

  11. Here is what Tx Blue Cross Blue Shield told my husband whose PCP told him to get a colonoscopy for a look see since he was over 50.
    BC BS told him the procedure is no charge as preventative but if any abnormalities are found the price goes up a fair amt since the procedure has then changed to diagnostic.
    I think that is the biggest insurance scam ever. If the doc takes one polyp biopsy the whole procedure is no longer routine. How did they get away with that.

  12. You would think that shoving a camera up someones ass would be a standard procedure. Why can’t the medical profession come to an agreement on a standardized price? I mean, it shouldn’t be all that different from getting the oil changed on your car; $19.99, any make or model. I feel like I should be able to walk into any clinic and pay a set fee for a procedure that takes about 30 minutes. Why does it have to be so complicated? I’ll tell you why. Anything that is overly complicated is that way by design, it’s because you’re getting screwed.

  13. MY GI doctor expects full payment up front from patient, then submit the insurance paperwork (to which I find, is now considered “a curtesy” by them to even do for ya)..WHEN/IF insurance company pays..the GI folks re-imburse us..Last time I did that kind of thing was with an emergency ORAL surgery for a bad tooth..I never did get get all my money reimbursed. the oral surgeon kept most of that money too. THAT bugger got almost 1000.00 for 1 easy emergency extraction..to which I paid over 3/4 …I got just 200 or so dollars reimbursed. Frankly, I think it is fraud/against the law to swindle people with such an expectation. Im seriously considering canceling the entire colonoscopy thing..and just let any possible cancers, etc take its course

  14. I work in the medical insurance field and part of my job which is very unique, is when the Drs office calls for an authorization I check to see where they want to do the procedure. If the request comes in for a hospital setting I ask if the procedure can be done at a free standing surgery center. 99% of the time it can be. The Dr schedules the procedure at the hospital for his convenience only. He normally has special days and hours reserved at the hospital and that is the reason he wants to go to the hospital plus he may be getting some kind of financial incentive from the hospital to bring all his patients there. Most members dont read or understand their Summary Plan Description booklet. This is where the big mistake is made. You need to take the time to read your summary and understand the difference between having the procedure done at a hospital vs a surgery center. Anything done at a hospital is always much, much higher than having it done at the FREE STANDING SURGERY CENTER. It cannot be related to the hospital in any way. If it is then the billing Tax ID # will be the same and fall under the hospital contrct. If you are contracting with any of the major carriers the contracts for each Dr and facility are different. You can even have two Drs in the same building with different contracts. I always recommend to my members to stay away from the hospital for all basic tests and outpatient surgery. Since members dont take the time to read their SPD they panic and run to the closest ER for services. This is a very expensive decision. When I go to enrollment meetings I ask if they have a car, of course they all do. I then ask, what do you do when you are having problems with your car. They advise they take it to the shop for diagnostic testing and have the mechanic call them back with an estimate before they proceed. Medicine is no different. When you go to the Dr for a severe pain in your knee and the Dr writes an RX for an MRI at your local hospital, off you go without asking any questions and assumes that the Drs office is going to take care of everything. This is the biggest mistake that members makes. At that point if you have read your SPD you would let the Dr know that you do not want to have the test done at the hospital but rather the free standing radiology or lab site down the street where your covered will be a lot higher and very little out of your ppocket if any. My plan pays 100% if your use the freestanding lab and freestanding radiology sites. This is an incentive for the patient as it is a win win for both the member and the self funded Trust that I work for. We share the savings with the members by paying 100% of the negotiated rates. Even if I know that the facility is no contracting I will reach out to the facility, let them know the reduced benefits if the member goes to their facility. I am very successful at getting the facilities to accept a negotiated rate and usually ends up paying 100% of the negotiated rate. This is something that I am very passionate about and ask myself every day, why dont the members take the time to read their SPD or call and ask. I could write a book about this.

  15. There is definitely a compliance issue with preventive care.

    What we have also noticed is that a preventive screening colonoscopy, scheduled as such, is different from a diagnostic colonoscopy, scheduled to investigate a problem.

    In this case, though, it might also be that the colonoscopy was free but the endoscopy (together with the colonoscopy) was not.

  16. Thanks Jeanne for the link.

    Could it be that a colonoscopy is considered to be a step beyond
    ‘colorectal cancer screening?

    Or else the insurance plan here is just ignoring the law. Individual health plans have had a spotty record on compliance for a long time.

  17. thanks Jenny.

    Anyone who gets angry at reading about your experience should read the NY Times articles by Eizabeth Rosenthal. See her June 1, 2013 piece entitled
    “Colonoscopies explain why US leads the world in health care expenditures.”

    She notes that Medicare pays $511 for the actual colonoscopy, and something extra for anesthesiology. Germany pays about $1000 for the whole procedure.

    What a savage reflection on health care price-gouging. I am not impressed by an insurance company which “negotiates” a hospital fee of $4,284 for a non acute procedure or two.

    The best solution would be to publish all Medicare rates very widely.
    Also to establish health courts, where if a medical provider charged more than 150% of Medicare they would have to justify what they actually did.

  18. I arrived at this site after opening my EOB. I have a high deductible and I met that early this year with a broken ankle. After meeting my deductible, I am responsible for 20% of negotiated rates, 40% for “non-preferred”. Note that this is NOT out of network.

    I had a colonoscopy and endoscopy.
    Hospital fees billed: 5025.
    Member rate: 4284.
    My portion: 1035.

    CRNA billed: 980.
    Member rate: 573.
    My portion: 0

    Pathology (I think) billed: 780.
    Member rate: 355.
    My portion: 141.

    Physician: 1815.
    Member rate: 428.
    My portion: 285.

    total billed; 8600
    member rate: 5640
    my portion: 1461

    Note that I have already met my dedcutible AND the colonoscopy for which I am supposed to have free (all screenings are supposed to be 100% covered).This is probably why the anesthesia was covered, but I was charged for the colonoscopy.

  19. Jeanne,

    I would be happy to discuss this further. How d I get in touch with you?

  20. Jeanne, you are correct about the need for consumer finance protection in health care.
    I favor federal action, because if we leave things to the states, we will have the same foot-dragging by red states that has been part of health insurance for the last 50 years.
    (Arizona did not even have Medicaid until the 1980’s. And more to the point, progressive laws like AB 774 in California (that limits hospital bills for any uninsured person under 300% of poverty) only exist in about 6 or 7 states.
    The mere existence of a federal consumer bureau will moderate hospital bills. These institutions are not afraid of individual patients, but they are afraid of bad publicity.
    Overall, the economic world still runs on fear and greed. Hospitals have had no fear, so their greed has come to the fore.

  21. That I can believe. It was my good fortune to be working for a health care system, so they didn’t have any of those reservations. It was one of those “non-profits,” but awash with resources, both capital and human. The emphasis was maintaining a good image in the community, while serving as mother ship for a host of very much FOR-profit businesses — both medical and non-medical — scattered across the campus and in close proximity.

    Yes, HR departments are a pain in the butt. Gone are the days when companies had quaint ideas about taking care of employees, especially if that involves training and developing them, mentoring them up the ranks. Or funding one of those now-obsolete pension plans. Of all the expenses on any company’s balance sheet, the costliest are always the people. But that’s a discussion for a different forum. Sorry.

  22. This is always a good first stop if you can make it.

    But we are hearing increasingly that employers don’t want to get into these conversations and will avoid at all costs.

    They just don’t want to be in the business of deciding this kind of thing for their employees. Plus HR departments have been slashed to the bone, at the same time that deductibles and coinsurances have risen to historic heights.

  23. Thanks for this. Maybe we are getting to the point where there will be consumer finance protection–what a great case, in fact, for the federal Consumer FInance Protection Bureau.

    Or maybe it should be a state function? Actually, that’s the heart of the problem, isn’t it: who should regulate? who can regulate effectively?

    New Jersey’s attempt to protect the little guy sort of worked but sort of backfired (see above).

    Also, I may be wrong about this, but it looks to me (a relative newbie in the health space) that there is a mass of regulation but a lot of it is ineffective or frequently circumvented. Or has unintended consequences, like HIPAA.

    Maybe that’s because incentives are misaligned and it’s always someone else’s money — so regulations with the best of intentions can cause new and different, even less tractable problems. I reference New Jersey again.

  24. Good point about employer’s group insurance. I had a problem when I was referred to an out-of-network provider by a mistake that was not discovered until three appointments later. I discovered when I appealed that the bills would be paid anyway (but I was to find an in-network provider instead). But the decision had to wait until the next meeting of the committee dealing with mistakes — there were so many mistakes and exceptions that there was a committee with that job description!

    When one or my kids had an insurance problem I advised her not to waste time dealing with the insurance company — take it directly to HR instead. She did so, and the problem evaporated within hours. The insurance company’s customer is not the insured but the company selecting their company as TPA. Keeping the company happy is far more important than satisfying the so-called beneficiaries.

  25. Thanks for continued work in this area, June. I just caught this string of posts a few days late.

    One partial solution would be this:

    When you were quoted $600 for your colonoscopy, then if there were no complications that price should have been binding on the clinic and/or the insurer.

    Auto repair shops have operated that way for years. I believe that most locales have consumer protection laws which obligate them to operate that way (and car insurers force them to so do.) Any auto shop owner that is tempted to overcharge will lose customers and could face legal charges.

    America has not imposed that kind of control on hospitals and surgeons.
    This is understandable. For years many hospitals were more or less charitable quasi-public institutions, and Dr Marcus Welby was never on TV referring bills to a collection agency.

    Also, many if not most Americans had health plans with zero or negligible deductibles, and never saw a bill so they never had to argue about one.
    (In 1977 I had a claim denied, so I went to my large employer and asked them to put some pressure on Blue Cross. The denial was promptly reversed.)

    Anyways, the time has come for public regulators to shed all deference toward hospitals and surgeons and anesthetists.

    As Barry has said, if the procedure is an emergency there must be legal price limits. For discretionary care, the quote should be binding.

    If a patient would prefer to trust their referring physician and not inquire about prices beforehand, that too is understandable. But if they get gouged, they should be able to file a claim against their doctor (and never see him or her again.) Not much different from auto repair.

  26. Kathy, that is astounding. That’s the highest we’ve heard!

    Please do tell us here at THCB of the charges/payments, and also …. We have a Knight-funded project in California with our public radio partners (KQED and KPCC) in which you can both share and compare prices for common medical procedures in our crowdsourced database at this link:

    http://blogs.kqed.org/stateofhealth/2014/06/23/share-your-bill-make-health-costs-transparent-in-california/

    What others paid (prices marked “crowdsourced,”) or our survey prices (not marked) should assure you that you are paying top dollar!

  27. My husband just had his 3rd colonoscopy at Stanford Hospital & Clinics (Palo Alto CA). I nearly fell over when I saw that Stanford was claiming total charges of $11,630!!! And that does not include the doctor’s charge. I called customer service for clarification learned that total charges for his 2010 (identical procedure) was $5612. We suspect coding was incorrect so we are getting copies of all documentation related to these procedures to compare codes. I am learning that if you go to a major hospital for any type of service the charges are typically uplifted by 100%+.
    Will post outcome of colonoscopy charges later.

  28. Another Perspective,

    My insurance is with traditional Medicare + a supplemental insurance plan. The actual amounts paid for my colonoscopy which I listed early in this thread totaled $1,555.75 all in. The procedure was done in a community hospital with an anesthesiologist present and included a biopsy. Even at 125% of Medicare, the total amount paid would still have been a bit under $2,000. If it were done in a surgical center, it would have cost less and, in a doctor’s office, even less than that. However, with my other medical issues, I would be afraid to have the procedure done in a doctor’s office and felt more comfortable in the hospital in case of complications.

    I still think it shouldn’t be all that hard to quote a bundled price or, at worst, one price without a biopsy + pathology report and one price with it. The difference between the two shouldn’t be more than a few hundred dollars, in my opinion. If anything, costs should be lower in a rural area because underlying costs are probably lower for staff and real estate though the patient may have to travel a considerable distance to have the procedure done.

  29. “In order to keep administrative costs down how do you implement an automated claims processing system which minimizes the need for human intervention while protect against egregious charges?”

    Fix the prices, other industrialized countries do that.

    “egregious charges” – ““how much is x service going to cost”. That is a very reasonable question. However, an equally important question is how much SHOULD x procedure cost?”

    Seems you have no problem using the word “egregious”, so a reasonable person can recognize gouging.

    “What about in rural America where the nearest gastroenterologist might be over 100 miles away..is $5,000 unreasonable?”

    Settle on the service cost first, not the travel cost. Rural America gets to get screwed even after traveling that 100 miles.

  30. Wait, you paid $10k? I would love to know more. Can you email me?

    Also to your comment below (somehow system won’t let me comment on that comment) about what it should cost: that’s a thorny one.

    Since the provider (doc, hospital, lab) performing the test knows what their costs are, and what their business model is, etc., their idea of what it should cost would naturally differ from the idea of a payer, be it a patient or an insurer.

    So what should it cost? Does reference pricing solve this? Who sets the reference price? Must it be adhered to?

    It would be easier, in our view, to make all prices visible. That way, if I want a $10,000 colonoscopy, I can have one. If that results in a $9,000 co-insurance bill for me, then so be it — as long as I know up front. Maybe I prefer the $500 one. Just let me know, and I can make the choice.

  31. Unfortunately we did end up paying the $10k bill. This situation exposes one of the dilemmas in the insurance industry. In order to keep administrative costs down how do you implement an automated claims processing system which minimizes the need for human intervention while protect against egregious charges?

    The contract covering thefacility involved in this situation allowed for billed charges reimbursement for preventive services. Having never seen a $10k colonoscopy we did expect to see abuses of this magnitude.

    One last comment on the topic of costs. This blog, and many others, and the question “how much is x service going to cost”. That is a very reasonable question. However, an equally important question is how much SHOULD x procedure cost? This is the question that I am trying to solve and there is very little concensus. Should a routine screening colonoscopy cost no more than $1,000 in total? $1,500? $2,000? What about in rural America where the nearest gastroenterologist might be over 100 miles away..is $5,000 unreasonable?

  32. That this insurer was paying 10K for a colonoscopy is just one small example of why most docs have lost all interest in saving money for “the system.”

  33. Up until Health Matching Insurance, a patented product offered by National Prosperity Life and Health
    Don Levit
    Treasurer of NPLH

  34. Wait, so you actually paid $10k for a colonoscopy? Yikes. Perhaps in New Jersey? Barry Carol, come over here and listen!

    On the discounted cash rate, we are really interested in this. We can’t find statutory or contract language either allowing or prohibiting, but we hear about this all the time. A lot of people tell us that it’s illegal or prohibited or unethical, but it’s so widespread that it can’t be.

    It’s not surprising that this practice gives rise to the patient changing their mind (or misunderstanding) and then making a claim.

    If all of us here, putative experts, have differing views on what’s legal and what’s allowed, imagine the poor patient.

  35. “I subscribe to the philosophy that providers need to charge patients the same regardless of their ability to pay.”

    Sounds like an insurer.

    “I work for an insurance company (non-profit)’

    Sounds like BCBS?, no stellar performance there for insured.

    Bet your plan is just fine thanks.

  36. @ JeanneFromClearhealthcosts,

    “How will insurers then distinguish themselves?”

    They only “distinguish” now with less coverage. The risk is the risk, we only need paper pushers, not insurance companies.

  37. Jeanne,

    When I use the term “cost” I refer to the allowances established by the provider contracts – which includes the contracted rates and coding adjustments which might occur.

    The $10k allowance was certainly an eye-opener and has led to efferorts to reign in these costs.

    With respect to the question regarding a discounted cash rate…this is a slippery slope and often leads to many problems. While I have yet to find exact statutory language, I subscribe to the philosophy that providers need to charge patients the same regardless of their ability to pay. Inflating charge for the purposes of maximizing insurance reimbursement viewed negatively – and at least by our contracts prohibited. Another scenario which has come up previously is the patient who wants the cash discount and then changes their mind and submits the bill for coverage. We process the claim and suddenly the patient owes more than their cash discount. However, because our contract is between the provider and insurance company, we cannot recognize the agreement between the patient and provider.

    Of course, this only deals with “charges”. There is nothing prohibiting a provider from offering a discount for patients who have an inability to pay due to hardship, chritable reason or on an occassional basis.

  38. I’m signing off for now. Since I hit Medicare all this insurance talk bores me. This was the year that I allowed myself to be kidnapped by an MA plan I trust, leaving my wife with original Medicare. (We have different needs.)

    Meantime, it’s well past noon and I’ve spent so much time here I’m behind over 500 Twitter messages. (Not to mention learning in a timely way that Brad Pitt and Angelina Jolie got married!)
    I’ll check back later.

  39. We’re hearing from a number of insured people who are being asked to pay the sticker price, not the negotiated rate.

    It seems to depend on the plan document. There are definitely plans out there that have you paying the higher rate.

    Two people from our #PriceCheck community are quoted here; we have heard from others as well.

    “I was told procedure would be 1850. I have a 7500 deductible. So I talked to the office mgr who said if I paid upfront and agreed not to report the procedure to Blue Cross, that it would be $580.”

    On our Facebook page, one contributor wrote, “I was going to be billed $830 through my PPO for an MRI. The cash price? $500.”

  40. My understanding is that if a patient pays a provider claim out-of-pocket without submitting it through the insurer’s claims system, it will not count toward the deductible or out-of-pocket maximum amount. I think the only fair way for it to work is for the claim to be submitted to insurance, the member gets an EOB with both the charged and allowed (contract rate) amount. If the bill is below the deductible, the insurer will pay nothing and the member will pay the contract rate and it will count toward the deductible and out-of-pocket maximum amount. It shouldn’t matter whether the member pays the bill out of a health savings account or his regular checking account. The bottom line though is that just because the deductible hasn’t been met yet doesn’t mean that the member should be liable for the full list price until it is met or pay a cash price and hot have it count toward the deductible. That’s ridiculous. Besides, if the provider accepts assignment, I think that means he accepts the contract rate as full payment whether it’s paid by the insurer after the deductible is satisfied or the member before it’s satisfied.

  41. Jeanne,

    It doesn’t get much more egregious than this. If it were up to me, I would fix this excessive billing problem in the following way: If the patient seeking emergency care is insured but out-of-network, the insurer would not have to pay any more than the lowest hospital in network rate or 125% of Medicare, whichever is lower. If the hospital has no commercial insurance contracts, then the charge would be limited to 125% of Medicare.

    There is a long term secular trend away from hospital based care. Many hospitals that claim insurers are not paying enough to cover their costs have high costs because their occupancy rates are persistently too low. Hospitals are high fixed cost businesses. They probably need an average occupancy rate at least in the mid-to-high 60’s to breakeven assuming a respectable payer mix. If there are too many hospital beds in a market to sustain economic occupancy rates for all market participants, some will have to downsize or close. If necessary, freestanding emergency rooms can fill some of the care gap but with the same limitations on allowable charges for both patients and insurers.

    Well intentioned laws often have unintended consequences and there are plenty of greedy people who will exploit loopholes to profit at the expense of others. This is not something we have to live with and we shouldn’t.

  42. Thanks so much. This is fascinating.

    When you say “cost” you mean charge? or payment? I have heard of very few, if any, providers getting $10k for a colonoscopy.

    Cost transparency: thanks for this. This kind of explains why the cost estimators are fuzzy.

    Also, Another Perspective, I have a question for you on John Ballard’s comment above about insured people paying a discounted cash rate and not submitting that charge to insurers. Do you have any experiences with that?

  43. An insurer-provider-patient question. From what these individuals are telling us, quite often the lower rate is accompanied by a request/condition that the patient not use this payment for meeting their deductible, though apparently the bill can indeed be paid via an HSA.

    I’m not 100 percent clear why insurers would uniformly oppose this. If they are not being asked to pay the claim, then maybe it’s OK with them? That reduces their outlay.

    Some of this presumably is governed by contractual clauses. But we’re hearing enough of it to know that it’s at least semi-public and must therefore not be 1) illegal 2) against contract or 3) otherwise impermissible by law or contract in every case.

    Any insurers here who can shed light? >Another Perspective,< from elsewhere on this chain?

  44. I think I understand. For someone (presumably with a high deductible plan) willing to pay cash, the provider offers a discounted rate in return for administrative costs associated with filing an insurance claim on behalf of the patient. Presumably the patient is still free to use the charge for insurance purposes on the way to reaching that high deductible, but will file the claim personally.

    This makes even more sense from a cash flow standpoint — today’s cash is more valuable than 30, 60 or 90 days hence, not to mention occasional “oops” for out of network or other administrative flubs. All you need to do is relocate to California. LOL

    Several years ago I worked for a health care system in my post-retirement life for five years. In one of their big town hall meetings I was chatting with a couple of people from the ED and they mentioned if someone offered to pay cash they could get an immediate 50% discount for services. I brightened immediately and said “That’s great! They need to get the word out so more people will know that.”
    The response was quick and clear. “No. That would make our life even more hectic. Lots more people would want to go to the ED for treatment and we already have more to do than we can handle.” Lower charges were available, but it was a well-kept secret.

    I have anecdotes as well about people with minor problems who got a lower rate from a private doctor when they said they would be paying personally because they didn’t have insurance. That, of course, was pre-ACA. We’re not supposed to mention such things any more since private insurance now has a lock, one way or another, on all medical care. I hope those providers in California don’t get in trouble for circumventing the system. You know there must be a paper trail.

  45. I work for an insurance company (non-profit) and cost data for screening colonoscopies was one of my projects last year. In 2012 the average cost for a screening colonoscopy for our members ranged from ~$800 per episode to over $10,000. The biggest cost variable involved anesthesia. Cases which included the presence of an anesthetist resulted in costs 2-3 times higher than conscious sedation. I had a discussion with the CFO of one facility as t why the use a CRNA for every screening colonoscopy and was told “we employ the CRNA and he’s gotta do something”.

    More recently we have seen costs rise with the use of propofol. The gastro society has taken the position that propfol can be safely adminstered by a properly trained technician. The anesthesiology sociatey has taken the position that only an anesthetist should administer propofol.

    I’m also in charge of the cost transparency initiatives for my company. The episode costs are derived from historical data which, of course, means that the costs are probably not reflective of current prices. Then there is the cost variability with each case. As a result we end up displaying a range of costs to our members rather than a single figure.

  46. “Starts to sound like “Medicare for all.””

    Exactly! Why should there be any advantage of one network over another? Patients don’t get any narrow network advantages.

  47. Very nicely written and reasoned!

    I think what you ask for is coming: we are seeing in California that providers are competing to deliver services at low cash rates to people who have reasonably good insurance policies but high deductibles. This means in many cases, that individuals are responsible for the sticker price and not the negotiated rate until they meet their deductible. So if the provider offers a low cash rate (and don’t submit to insurance), everybody wins.

    So, providers can distinguish themselves by offering a cash rate that approaches the negotiated rate. Once they’ve done that for one person, it becomes easier to do it for many, both top end and low end of the market.

  48. Jeanne:
    Well Medicare plus a certain percentage for all
    Insurers will have to get a bit more creative in distinguishing themselves rather than the biggest bully wins
    Mature people who are concerned about the future do
    not handle conflict that way!
    Don Levit

  49. Now we’re getting somewhere. To Jeanne’s point, Medicare and Medicaid separate the private sector sheep from the goats. Many private sector providers simply refuse to have anything to do with either — and that, of course, is their option. I have no problem with that. I presume that medical care presents a continuum of goods and services just as any other market-based system. Those with more money can afford more than those with less.

    Dentistry illustrates the principle well. Little to no dental care is at the low end of the business (extractions for toothache) and top of the line care for those at the top end (root canals, caps, implants and whatever for those who can afford to pay).

    I don’t know what arrangements are made to reimburse Medicare Advantage for what they do, but I do know that when I opted for that private sector alternative to Medicare (along with about a third of my peers) the same amount continues to be taken from Social Security for Part B. Since my co-pays are very low and my premium non-existent (so far) the private sector must have room to keep the wagon out of the ditch.

    My point is that it’s okay for prices to be all over the place. There is bound to be as much variance in health care as any other (I hate this damn word) commodity. The private-public argument is never going away as long as some people have more assets than others.

    As usual, I’m arguing the case for the low end of the so-called “market.” My hope is that over time there can be some semblance of reality to charges for all medical care. When I say there is a difference between costs and prices the distinction escapes most people, but that is not just a matter of semantics. It has to do with arithmetic and accounting — concepts as obscure to many medical professionals as interpreting imaging and lab results are to accountants.

    As long as the contest is between providers and insurers the results will have more to do with money than medicine. Ms. Jeanne’s link to the New Jersey link is about for-profit versus non-profit hospitals as an acquisition wave sweeps through the health care sector — all in the name of profits.

    If and when I see providers competition among providers to see who can best deliver needed care at reasonable rates to the so-called “under-served” parts of the country I will be more impressed.

  50. Standardized rates, hmmm.

    Savings for insurers: means lower health-care costs.

    Don, do you think this is politically palatable?

    As you point out, if all the networks are paying the same, then there’s no advantage to a provider to join one network over another.

    Starts to sound like “Medicare for all.”

  51. While the rates may need to be adjusted for fairness and accuracy imagine the savings insurers will incur for not spending time to negotiate every procedure with every provider
    In addition by standardizing rates no insurer will have a competitive advantage with network discounts
    According to Milliman an actuarial
    Firm we have worked with the last 3 years designing our patented Health
    Matching Insurance network discounts are the biggest price advantage large insurers have over their competitors
    Don Levit

  52. I agree with everything you said — adding that a lot of things you might regard as non-shoppable actually are shoppable.

    The NJ legislation you mentioned was intended to help the little guy, but it actually has wound up benefiting some very big, very moneyed players. This piece talks about how that Bayonne hospital and others have used that law and flipped the out-of- network charges back on insurers. It’s fascinating.

    http://www.northjersey.com/news/as-investors-buy-struggling-hospitals-big-change-comes-to-new-jersey-health-care-1.1072639

    Barry, I’m interested in your take on the situation as described in this piece.

  53. While I’ve argued in favor of price transparency for a long time now, it’s only potentially useful for care that can be scheduled well in advance which would allow time for price and quality shopping. I’ve also long suggested that we need special rules that apply to care that must be delivered under emergency conditions for which price shopping is not feasible.

    Limiting charges for care that must be delivered under emergency conditions, whether the patient is uninsured or out-of-network, to 125% of Medicare is sensible and reasonable in my opinion. In NJ, the legislature passed a law a few years back that limits how much the uninsured can be charged to 115% of Medicare if their income is less than 500% of the federal poverty level (FPL). This law applies to non-emergency care as well I think.

    Legislators originally wanted to limit charges to 100% of Medicare but hospitals pushed back claiming that Medicare only reimbursed them for 91% of their costs on average. So, the compromise payment level of 115% of Medicare was sufficient to allow hospitals a 4.7% operating margin. Personally, I don’t think anyone should be liable for hospital chargemaster rates no matter how wealthy they are unless they agree in advance to pay them as some mega wealthy patients from other countries do.

  54. Good points, gents.

    It’s also a bit hard to get a clean read on the public-private equation when private insurers like Aetna are managing Medicare and Medicaid programs, because of course they’re charging for their expertise.

    And great reporters like Charlie Ornstein over at ProPublic keep documenting how Medicare and Medicaid have ineffective oversight.

  55. Profits IS health care in the U.S.

    And health care is profits. I couldn’t have said it better.

    I suspect lawyerdoctor’s remark above was intended to be sarcastic, but it actually describes the missions of insurance (which is private) as well as social safety nets (which are public). Both are risk management systems for costs and health care. The difference is that social safety nets don’t need to generate additional profits for shareholders and investors. When safety nets lower costs they are in effect lowering taxes. But when private insurers and providers reduce costs the aim is to trim costs while increasing profits.

    The question remains: Which system delivers the best care at an optimal price point.

  56. They acknowledge that it is far from perfect, and in fact call for a complete reexamination of Medicare rates to orient back toward primary care and away from wildly expensive specialty care.

    They point out, though, that the Medicare fee schedules build in geographic variations, and use a coding system that’s basically working for the nation’s biggest buyer of medical care, the government.

  57. I know CapRock. Smart folks. There’s a lot going on in that sector for the self-insured: Mike Dendy at Advanced Medical Pricing Systems, Woody Waters at ELAP, Jeff McPeters at GPATPA, and the Phia Group, to name a few.

    Self-insured employers who are able to step outside of the BUCA (Blue Cross, United Health care, Cigna, Aetna) circle are finding amazing new models to work with and ways to save money.

  58. “There’s a thought-provoking article in Health Affairs calling for payments to be capped at 125 percent of Medicare:”

    “Use Medicare rates as the base line index for everybody.”

    Why is that the magic number?

  59. “World’s best health care!!!! *eyes roll* *head slowly shakes*”

    “This is a conversation about profits, not health care.
    Quit trying to distract from the issue.”

    Snarky this morning John. Don’t you think profits in those other systems are less? Don’t you think their patients don’t have to travel the maze of U.S. costs, or worry about OOP?

    Profits IS health care in the U.S.

  60. Jeanne;
    I saw that interesting article
    The TPA we are currently working with Cap Rock uses a similar fee schedule for some of its clients
    Imagine the cost savings if pre negotiation efforts are no longer needed
    Don Levit
    Treasurer of National Prosperity Life and Health

  61. Love it!
    Use Medicare rates as the base line index for everybody.
    Few should object to using a group with the highest overall healthcare costs. Especially with a 25% lard factor added for good measure.
    What’s not to like?
    (Anything is better than looking at actual costs… er, transparency.)
    ~~~~~~~~
    Keep up the good work, Jeanne. And don’t mind me. I’m just an old guy throwing spitwads.

  62. There’s a thought-provoking article in Health Affairs calling for payments to be capped at 125 percent of Medicare:

    We think transparency is a better and more palatable solution than price-fixing. But it’s great to see that this is being discussed: it shows us that the problems of pricing are front and center now, among opinion leaders like Elliott Fisher and his colleagues at Dartmouth.

    (link: http://healthaffairs.org/blog/2014/08/26/the-125-percent-solution-fixing-variations-in-health-care-prices/)

  63. Again, how much would a colostomy cost in Canada and Europe? Would you even need to check in advance.

  64. This is great, but in our experience those advance estimates turn out to be surprisingly inaccurate. It’s not clear why, but we hear more often than not that the information just isn’t true.

    Have you ever done this? What were the results?

  65. That’s a great list. Here’s one of our community members from PriceCheck:
    Charged price
    $5104

    Insurance paid
    $3454

    You paid
    $1650

    Insurer: Kaiser Permanente
    Kaiser Permanente Medical Center
    280 West MacArthur Boulevard, Oakland, CA 94611

    (510) 752-1000
    I called Kaiser before the procedure to inquire how much it would cost me on my plan. They were vague and would not give me a fixed price, but I was told if there were no special circumstances (in the end, it turned out there were none), it would be around $600 on my plan. Imagine my surprise when I received a bill for $360 for Professional Services, and $1,290 for the hospital bill (my share of each), for a total of $1,650 out-of-pocket. I am on a high-deductible plan, so I paid for 100% of my share. That’s in addition to the $5,532 I pay in annual premiums. I’m disgusted with the fact that Kaiser was unable to tell me what this procedure would cost. If they do not know the cost, until the procedure is completed, then who does?

  66. “The big impediment to price discovery in the commercial insurance sector is the confidentiality agreements that preclude disclosure of actual contract reimbursement rates”

    There are no confidentiality agreements regarding fee schedules between insurers and patients.

    Patients should call their insurer, tell them where and by whom their procedure will be performed, demand the contracted fee, and how much the insurer will pay. Don’t get off the phone until they give that information.

  67. I had my most recent colonoscopy at my local community hospital in central NJ four months ago. The following is a list of charges at list price followed by what was actually paid by Medicare and my Medicare supplemental insurance plan combined according to my EOB:

    Drugs / Other: List price, $9.00. Paid by insurance: $0.00

    Sterile Supply: List price: $245.00 Paid by insurance: $0.00

    Venipuncture: List price: $17.00 Paid by insurance: $0.00

    Pathology Lab Examination of Tissue: List price: $1,482.00 Paid by insurance: $115.17

    Hospital Facility Charge: List price: $4,101.00 Paid by insurance: $890.34

    Pathologists Fee: List price: $495.00 Paid by insurance: $109.17

    Gastroenterologist Fee: List price: $800.00 Paid by insurance: $275.92

    Anesthesiologist Fee: List price: $1,530.00 Paid by insurance: $165.15

    Total Charges at List price: $8,679.00 Paid by insurance: $1,555.75 (17.9% of list price).

    I didn’t have to pay anything out-of-pocket. It’s also worth noting that the actual procedure took only 20 minutes to perform.

    The big impediment to price discovery in the commercial insurance sector is the confidentiality agreements that preclude disclosure of actual contract reimbursement rates. We need to get rid of those. There is also no reason why a bundled price can’t be quoted even though sometimes there will be polyps and sometimes there won’t be. Occasionally there will be complications. Those factors could easily be built into the bundled price in my opinion.

    As for out-of-network care, I’ve recently been told by an expert that most hospitals now require all doctors who practice within the hospital to be members of the same insurance networks that the hospital itself participates in.

  68. Yes, what you said!

    Also, while the ACA requires all preventive care to be covered, like mammograms and colonoscopies, a number of people are being asked to cover co-insurance, deductible and whatnot.
    You can see this on our crowdsourcing tool in California here:
    http://blogs.kqed.org/stateofhealth/2014/06/23/share-your-bill-make-health-costs-transparent-in-california/

    If you search on colonoscopy within 100 miles of 94103, San Francisco, you’ll see more eye-opening numbers. Yikes.

  69. This of course would be why the colonoscopy is often used a metaphor for the health care system, very colorful, rather painful, you close your eyes and try not to think about what’s happening

Leave a Reply

Your email address will not be published. Required fields are marked *