Heidi de Marco / KHN
Danilo Manimtim’s vision was cloudy and blurry – and it was getting worse.
A 73-year-old retired orthopedic surgeon in Fresno, Calif., Knew it was time for cataract surgery. “It’s like running out of car tires because you drive too many cars on them,” he said.
In December 2021, he went to the outpatient department of a local hospital for a general procedure that usually replaces the natural lens of the eye with an artificial one and is designed to restore vision. The outpatient procedure went smoothly and the minimalist recovered in the next few weeks.
Manimtim, who has a job assessing disability claims for the state of California, knows the healthcare system and monitors its health benefits. He knew he had already met his health insurance deductible for the year, so he expected a manageable out-of-pocket cost for surgery. He calculated that the amount of his currency would be about $ 750.
Then came Bill.
Patient: Danilo Manimtim, 73, Fresno, California. Outpatient care is insured by the California Anthem Blue Cross through its employer and is covered by Medicare for hospitalization.
Total bills: The overall charge for surgery, anesthesia, medical supplies, pharmacy and clinical laboratory services was 9,084. The music paid 5,027 and initially billed MinimumTim for 4,057.
Service Provider: St. Agnes Medical Center. It is part of Trinity Health, a non-profit hospital system headquartered in Michigan and has 88 hospitals and 125 emergency care centers across the country. The hospital system has brought in about $ 20.2 billion in revenue in recent fiscal years.
Medical Services: Cataract surgery as an outpatient, involves anesthesia.
Last hour: Minimum’s large bill stems from a simple decision that turned the country’s complex healthcare system into a disaster: he scheduled his surgery at a nearby hospital – a hospital that had to charge about $ 7,000 more than his insurer had to pay.
ManimTim has evidence that it may have been different under his own roof: Four months later, his wife, Marilo ManimTim, 66, received the exact same procedure at an outpatient eye care surgical center called EYE-Q in Fresno. It is half a mile from St. Agnes Medical Center but not affiliated with the hospital.
Both patients have the same insurance coverage through the California Anthem Blue Cross; They had identical cataract surgery; And both providers were on Anthem’s coverage network. Marilo owed 204, while Danilo was on the hook for a wonderful $ 4,057.
“It’s ridiculous, and it seems very unfair,” says Danilo Manimtim. “How could it be so much more expensive than a surgery center? It’s a long walk away, and if I could go there, I could save a lot of money.”
According to Anthem, MinimumTime’s insurance plan, through its employer, the California Public Employees Retirement System, pays $ 2,000 for outpatient cataract surgery. CalPERS has introduced a “reference pricing” system in recent years, where it sets a reasonable price for such a high-quality approach in California. It then only pays up to that amount, encouraging patients to shop for price treats below the bar. For cataract surgery, minimalist plan patients are on the hook for any charge above $ 2,000.
Even for hospital-based care, St. Agnes’s overall charge for cataract surgery is higher, said Dr. Ira Weintrab, chief medical officer at Wellrethums, which analyzes the value of healthcare for employers. “The hospital charges three to four times the amount it normally costs for this surgery, which is about $ 3,000.”
“No one gets 9,000 for cataract surgery,” he added.
If MinimumTem chose Medicare Part B, part of the Medicare program that covers outpatient care, he would probably hook up for about $ 565, a Medicare cost comparison tool shows. Medicare pays a certain amount for the procedures wherever they are performed.
But like many older Americans who are still working, the minimum team has chosen not to sign up for that coverage, instead choosing its employer plan because its monthly premium will be significantly cheaper.
The cost of healthcare often has little to do with the actual cost of providing care and its quality – and patients often face “double the cost” of higher costs and complex benefits, says Anthony Wright, executive director of nonprofit Health Access California. Advocacy team. Often, he said, patients have their own way of figuring out how to use the benefits of their plan.
“You’re wondering what the rationale for our healthcare system is at any cost,” Wright said.
Resolution: After KHN’s search, Anthem contacted the hospital, asking for help for St. Agnes, the minimalist. Although the doctor is responsible for requesting a waiver from CalPERS’s $ 2,000 limit for cataract surgery under the MinimumTime plan, this did not happen before his surgery. Anthem has asked hospitals and doctors to consider the request after the surgery, Anthem spokesman Michael Bowman said.
Kelly Sanchez, a spokeswoman for St. Agnes, told KHN that the hospital and the provider later requested a waiver that would allow the insurer to pay more than the। 2,000 limit, and this was eventually approved by Anthem. It’s about $ 750 – and the hospital is expected to leave Manimtim with a much smaller coinsurance bill off the hook to take him to the collection. The hospital will receive higher payments from Anthem, which will cover a large portion of the remaining $ 4,057 bill.
And that high payout, like all high payouts, contributes to the growing health insurance for all.
Sanchez said the hospital is not in the business of raising prices, but noted that hospitals generally have higher costs and tend to charge more than the benefits to outpatients.
“We never want to do harm or harm to our patients and it extends to our billing practice,” Sanchez said in a prepared statement.
He noted that St. Agnes’s financial aid program is available and encourages patients to ask questions and understand the potential costs before caring. “Every patient’s insurance plan is unique so it is their responsibility to understand the benefits of their plan,” he writes. “It’s still complicated and we recognize that and will continue to work towards greater value transparency.”
Takeway: Bottom line for patients, experts say, be sure to read the fine print of the insurance coverage plan to understand all the responsibilities out of pocket, including premium, deductible, copy and coinsurance. Also, a small number of self-insured large employers are using the reference price, setting a cap on what they will pay for the general procedure. Shop around, and if possible ask about the price at the front end.
“People often focus on premiums because they’re easy to compare, but premiums don’t tell the whole story, and this example illustrates trade-offs,” said Tricia Newman, KFF’s Medicare expert.
Anthem spokesman Bowman urged patients to use the online anthem “Care Finder” to compare patients’ costs and to find a cheaper alternative if one is found. If Manimtim had done it, he might have noticed that it would have been much cheaper to have his cataract surgery at an outpatient surgical center. But the cost of the provider and the details of insurance coverage can be detailed and often do not appear in a patient-friendly manner. The minimum team had tried to explore its advantages before the procedure, he said, but had not received a clear answer from the insurer or the hospital.
There was also advice for MinimumTem consumers: If you get a medical bill and don’t understand the charges, don’t pay now. Instead, call your provider and insurer to find out about the charges and if there are ways to reduce your bill.
“Insurance companies and hospitals need to be made more aware of what options they have to prevent overbilling,” said Manimatim. “A lot of people don’t know it could happen to them.”
Stephanie O’Neill contributed to the audio portrait with this story.
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