The 18,000 Breast Biopsy: When Having Insurance Costs You a Bundle | Kaiser Health News

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

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

Reading: How much does a breast biopsy cost with insurance

“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 the Grand Strand Medical Center in Myrtle Beach.

Among many concerns she had leading up to that appointment (the first being a possible cancer diagnosis), yuengling needed to know how much the biopsy would cost. he has a $6,000 annual deductible, the amount his health plan requires him to pay before he starts his contribution, and he didn’t come close to reaching that. Regardless of the cost of the procedure, Yengling knew that she would be watching most of the process.

but the hospital didn’t give him a price. He was told that his providers would not know what type of biopsy needle they needed until the procedure was underway, and that would affect the price.

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

“That’s good. no big deal”, she thought to herself, sure it would be cheaper for her because she had insurance. A Google search indicated it might be closer to $3,000, but Yuengling thought the price seemed reasonable too. she didn’t worry too much about money while she was undergoing the procedure.

He soon brought the good news that he was cancer-free.

then came the bill.

the patient: dani yuengling, now 36, who is covered by cigna through her employer, a mayo clinic human resources contractor.

medical service: ultrasound-guided breast biopsy.

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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 charges, and sterile supplies. Cigna’s in-network negotiated rate was $8,424.14, of which the insurance company paid the hospital $3,254.47. yuengling was billed $5,169.67, the balance of her deductible.

What’s in it: It’s not uncommon for uninsured patients, or any patient willing to pay an out-of-pocket price, to be charged much less for a procedure than patients with health insurance . For the nearly 30% of American workers with high-deductible plans like yuengling, that means using insurance can cost you much more than going uninsured or just taking out a credit card to pay up front.

ge bai, associate professor at the johns hopkins bloomberg school of public health, recently published research on this topic and said that hospitals in the us. uu. they often set their cash prices lower than the prices they charge to treat commercially insured patients.

“We can confidently say this is very common,” said Bai, who advised that all patients, regardless of insurance status, ask about the cash price before undergoing a procedure. “should be a norm.”

grand strand charged yuengling insurance an extraordinarily high price for his procedure. By comparison, according to the federal government’s website, Medicare patients who need an ultrasound-guided biopsy similar to the one Yuengling received would pay only about $300, her 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 Medicare price from Yuengling and her insurer.

Patients with private health insurance who are treated at other hospitals are also often charged less than what yuengling paid for the same procedure: about $3,500 on average, according to fair health consumer, an organization that analyzes health insurance claims.

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

Meanwhile, grand strand medical center spokeswoman caroline preusser blamed “a glitch” related to the hospital’s online calculator for the inaccurate information yuengling received, saying the correct estimate of the cash price for a breast biopsy in the hospital is between $8,000 and $11,500. depending on the exact procedure and equipment used.”

The hospital has removed certain procedures from the payment calculator until they can be corrected, Preusser wrote. she didn’t say how long that would take.

Resolution: yuengling attempted to dispute the charges with the hospital. She called the billing department and was offered a 36% discount, which reduced 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 entire amount to a credit card because she wanted it all to go away.

“I couldn’t sleep. It was driving me crazy. I was having migraines. I was sick to my stomach,” she said. “I hate being in debt. I didn’t want to think about that. obviously that didn’t work because I’m still thinking about it.”

said he repeatedly requested to speak to the hospital’s patient advocate and eventually contacted an outside company, parallon, who audited his bill. she finally received a letter dated May 26 from the hospital’s revenue integrity department. indicated: “after reviewing the charges and his medical file, the following was identified; the charges on his account were appropriate. ”

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

The hospital has requested that yuengling return for a follow-up appointment related to the biopsy. she has refused.

harlow sumerford, a spokeswoman for hca healthcare, told khn in an email that the hospital system apologizes for any confusion caused by the payment calculator “and we are working to fix the problem.”

Bottom line: With a family history of breast cancer, yuengling did well to follow up with her doctor after feeling a lump. after failing to get a clear answer about her costs from the grand strand medical center, she could have taken the extra step to explore what other hospitals in the area charge. although her doctor referred her to the grand strand, she was not required to use that hospital. She could have saved a significant amount of money if she had chosen to have the procedure done elsewhere.

Also, patients like yuengling who have a high-deductible insurance plan should consider paying out-of-pocket 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 School of Law, said she knows of no law that prohibits a patient from doing that. after all, she pointed out, patients with health insurance pay cash prices for prescription drugs all the time. it stands to reason that they can do the same for medical procedures.

but some installations make it difficult. grand strand medical center, for example, offers “self-pay” patients an “uninsured discount,” but that discount is limited to people who “do not have a third-party payment source or do not qualify for medicaid, charity or any other discount program offered by the facility,” according to the hospital’s website. Discount information is only offered to patients who are confirmed to have no health insurance.

In some cases, paying a cash price for a procedure might not make long-term financial sense because none of it would apply to the deductible. patients can save money on a procedure but end up paying their full deductible if unexpected medical expenses increase later in the calendar year.

Insured patients should contact their health plan for a good faith estimate prior to a procedure. Under the no surprises law, health plans are supposed to give members an idea of ​​their total out-of-pocket 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 notes that this part of the law is not yet enforced.

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

yuengling filed her complaint in June.

stephanie o’neill contributed the audio portrait for this article.

bill of the month is a collaborative investigation by khn and npr that dissects and explains medical bills. Do you have an interesting medical bill that you want to share with us? tell us!

lauren sausser: [email protected], @laurenmsausser

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