How can this cost so much?
November 14, 2015 2:55 PM   Subscribe

Medically billing question: did I cost myself big by not asking enough questions, or was this doctor acting unusually?

I feel naive writing this question, but for the most part, I haven't visited a traditional doctor as an adult thanks to school health centers and the like and I really have no idea how to handle the cost side.

I visited an ob-gyn that a locator service (compass) recommended to me when I asked for a provider who inserted a specific type of IUD. Before I visited, the office asked for my insurance info and let me know that it was covered at 100%.

I (thought) I was relatively savvy - I mean, I know what a CPT code and a HCPCS code is, and I (kind of) knew how many specific things are billed during a visit like that - but I didn't process that covering the IUD and covering the visit to insert it would miss so many of the procedures that the doctor did without any extra indication or consultation. For instance, he asked that I come for a 1-month follow-up; he also did external and transvaginal ultrasounds at both the insertion and the follow-up. I wasn't really given a chance to say no to either of those, for instance, he said something like "okay, now I'm just going to do a quick check with the ultrasound" rather than "I'd like to do a quick check with the ultrasound, okay?", a difference which ended up costing me about $500 between the two visits (and probably a total of 5 minutes' worth of procedures - in total, I was billed for two external u/s, two transvaginal u/s, two office visits, and a pregnancy test). He also asked me to pee in a cup, so I did, and then only afterwards did I think to ask "hey, why are you having me do this?" at which point he said they always do a pregnancy test just in case. I literally had no idea that test was happening - but then, that was billed.

Am I just terrible at healthcare? Should I have been asking (and denying) about every procedure he did, or should he have been asking me? It's a little frustrating because it looks like the ultrasound isn't even particularly necessary for my perfectly standard insertion, but I never would have known to come armed with that knowledge (I had no idea that it would happen). Should I just expect that a procedure like this would come with a mountain of unexpected charges? How should I handle a situation like this next time?

Like many people, I'm on a high-deductible plan which means that I'm prepared to pay that much for healthcare in a year but it hurts to pay so much for a routine thing that I naively assumed would be covered as preventative.
posted by R a c h e l to Health & Fitness (20 answers total) 4 users marked this as a favorite
Many doctors (unfortunately) assume that all patients have extensive health insurance with minimal co-pays and deductibles. Hence, they assume they are doing you a favor by checking everything possible (as they assume it has minimal cost). Further, extra tests/procedures minimize their liability, so they have an incentive to push them if there's no reason not to.

I've found that by simply mentioning to my doctors (I am a male who has no experience with ob-gyns) that I am on a high-deductible plan switches them to minimizing unneeded tests and providing at least some reference to the pros/cons of picking a given service.

I apologize if this is excessively obvious, but I am mentioning it because nowhere in your question do you indicate that you told the provider in question that you were on a budget. This should not be necessary in an ideal world, but it is necessary in this world.
posted by saeculorum at 3:09 PM on November 14, 2015 [5 favorites]

Yeah it seems odd that he did the ultrasounds. For my IUD, there were no ultrasounds although there was a one month check. I wonder if he was concerned about an error at placement.
posted by Kalmya at 3:09 PM on November 14, 2015 [1 favorite]

Best answer: Should I have been asking (and denying) about every procedure he did, or should he have been asking me?

Unfortunately, yes. I would fire a practice over this--doing unnecessary procedures on clients is unethical even if it were free, which it's not.

It's gross, isn't it? You pretty much have to be defensive every. single. time. you see a healthcare provider, no matter how minor the reason. I've had to refuse pregnancy testing for a tetanus booster (news flash! If I had been pregnant it would have been even more important for my tetanus to be up to date!). I had a PA try to require a blood pressure check (again, I refused) when I was there for her to look at earwax.
posted by Violet Hour at 3:13 PM on November 14, 2015 [4 favorites]

(You should report this provider to your insurance company, too, even though they won't be paying for it. Requiring an ultrasound for IUD insertion is not normal and smacks of padding the bill. Even if they're just overly cautious--well, there's already waaay to many barriers to people getting IUDs. Good gyns aren't afraid of IUDs.)
posted by Violet Hour at 3:22 PM on November 14, 2015 [3 favorites]

Response by poster: For the record, there was nothing unusual that happened and I never got any indication other than "ok, yep, looks good, all set."
posted by R a c h e l at 3:25 PM on November 14, 2015

I have been to a lot of different doctors over the years and I can't think of a single time that an extra procedure was added that wasn't prefaced by the provider saying, "wait, let me check what insurance you have and make sure it's covered." Literally just yesterday I was at the gynecologist and when she asked if I wanted an STD test and said sure, she first typed some things into her computer to make sure I didn't have to pay extra for it.

So yes and no. 1) You really do have to be informed and advocate for yourself but 2) this doctor was also doing nonstandard things.

I agree that you should report the doctor to your insurance company.
posted by phunniemee at 3:46 PM on November 14, 2015 [2 favorites]

Best answer: You can and should fight this. Start with the doctor's office. "Hey, I was under the impression that the IUD insertion was 100% covered and yet there are all these additional charges. Help me understand what's going on." You know when a great time to discuss test costs and standards of care? When your feet are in stirrups and some guy has his hands in your vagina. They told you it was 100% covered. It should be.

Start with them and see what they say. Start out playing it straight and escalate as necessary.

I had to fight for months to get an exam for my baby re-coded because my regular doctor was out but "[So and so] is here to fill in, would you like to see him?" Sure. Did some very standard tests. Made sure that baby was okay with just a cold and sent me on my way. Got a bill for $900. It took many rounds with the doctor's office and my insurance provider to get the fees waived. Apparently the fill-in doctor was coded differently and so it appeared to my insurer that I had taken her to the hospital instead of our regular clinic. Although, still, WTF? You can fight this.
posted by amanda at 3:50 PM on November 14, 2015 [17 favorites]

Best answer: I haven't figured out health insurance either. But as a reference point, my insurance company always puts my copay way too high for ob/gyn visits, and then always reduces the charges after I call to complain (I only ever pay for the pregnancy test, ~$10). I figured it might be the ob/gym office that is just bad at coding the charges...?

FYI, I've had IUDs inserted without ultrasound (family planning clinic) and with ultrasound (ob/gyn office). However, they never charged for the ultrasound separately -- I believe they considered it part of the IUD insertion fee (which is substantial for a 3-minute procedure).
posted by yonglin at 4:25 PM on November 14, 2015 [1 favorite]

Unfortunately sometimes you have to ask before going into an appointment what they'll do, how much they will charge, if it's covered, etc (especially for any procedures). I'd definitely call the office and your insurance because you were under the impression that it was covered. Maybe just make this part of your routine, especially if you have a high deductible plan. And yes, you can stop someone before they do something and ask if it will be covered, etc. It's within your rights as a patient to stop a procedure.

All that said, I think you should get a new doctor. My doctor's office called in a panic when my insurance wouldn't come up the day before my implant because it's expensive otherwise. Luckily it was all sorted out (I think the system was down.) But they cared enough to make sure that it was all set right so I wouldn't owe anything.

In addition, I'm unclear if you're talking about a pregnancy test before insertion or at the 1-month checkin. A test before birth control is standard - but again I feel like that should be covered as part of the procedure costs.
posted by Crystalinne at 4:36 PM on November 14, 2015

One time I got charged for a sample my doctor took when I did a routine skin check at the dermatologist. I was mad because I specifically asked to make sure my insurance would cover it, but they sent it to an out-of-network lab to get tested or something. I had to call my insurance company and complain, and they did something where they made an exception because sometimes out-of-network labs can be covered if they determine it's necessary for quality.

I would probably also try the doctor's office and tell them you're being billed for things the doctor just went ahead and did without letting you know if it was preventative care or not. I don't know which health care you have, but when I had Aetna, this was a constant problem of me being billed for things I assumed were part of my care. None of my other health insurance companies have been so awful as Aetna.
posted by AppleTurnover at 4:56 PM on November 14, 2015

First, look at your EOB and make sure there weren't denials that shouldn't be there (I have a high-deductible plan now and the insurance company has screwed up several times - claiming a visit wasn't done by an in-network PCP when it clearly was is their favorite tactic). Then, if everything looks like it was processed correctly by your insurance, complain to the doctor's office. It is generally understood that "covered 100%" includes the visit.
posted by muddgirl at 4:57 PM on November 14, 2015 [1 favorite]

...and if the doctor's office says they can't help you, a last resort would be to appeal the insurance decision not to cover the prep work and the follow up visit. You were told the procedure would be covered 100% as preventative medicine and your doctor led you to believe that the prep and follow-up were medically necessary for insertion of the IUD.
posted by muddgirl at 5:01 PM on November 14, 2015

Absolutely fire the Dr!
I can't speak to the billing piece as I haven't lived in the US for ~ 7 years, but as someone who's currently pregnant, I've gotten a lot of practice saying "is this medically necessary?" during 'routine' visits.
posted by dotparker at 5:16 PM on November 14, 2015

Regarding appealing the insurance decision, that's hopeless. I had a similar situation, where I was told visits to a podiatrist were covered, only to later be billed for them. I wasted many hours trying to determine who messed up; did the insurance company tell the podiatrists office the visits were covered in error? Did the podiatrist's office fail to check? Should my GP not have referred me in the first place?

But ultimately, your insurance company has very detailed documentation about what they will and won't cover. They don't care that you were told something different verbally. They won't pay. The doctor's office wants their money, and if they can't get it from the insurance company, they will come after you for it. Aggressively. No one cares about fair or unfair. The patient loses, always. And it's always all about money.

Thus is "health" (sic) "care" (sick!) in America.
posted by mysterious_stranger at 5:26 PM on November 14, 2015

Every time I've had a transvaginal ultrasound I've had to schedule it in advance so that I could show up with a full bladder. It sounds to me like egregious bill padding to do two ultrasounds and to do one of them ineffectively. I am not a medical professional but I have been subjected to this procedure multiple times for legitimate medical reasons. For the transvaginal t's never been a spur of the moment thing like a regular ultrasound can be. In fact - Ive been in waiting rooms waiting for the procedure and women who show up unprepared are instructed to chug water and have to wait for about an hour until they're ready.

I'd totally fire the guy and I'm sorry.
posted by rdnnyc at 6:04 PM on November 14, 2015 [1 favorite]

Unfortunately, most doctors are like this. Even mechanics are better than highly educated doctors about communicating with the customer! "This valve is going to cost $200 to replace, but can wait another year. This thingamabob in your engine costs $300 to replace and I would really recommend replacing it now, do you want me to go ahead?" A similar conversation should also occur at a doctor's office, but unfortunately it NEVER EVER does. And worst of all, they look at you like you're crazy when you ask how much a procedure will cost. Their response is always "well it depends on your insurance." And then I tell them my insurance. And they respond "well we have a pre-agreed upon price with the insurance company." But when I ask them what that price is, they NEVER tell me. I have to ask them several times what THEIR costs is, in the worst case scenario. So if the money was a huge issue, I would have had to pause, call my insurance company, and find out how much of that procedure they cover before proceeding. There was one time I got a bill for a procedure that the doctor did NOT mention was part of the treatment (it was the actual cost of preparing the medication solution (which was very expensive), while they only previously told me the cost of the actual medication (which was relatively cheap), the receptionist even had the nerve to say to me "well we don't have time to go into the details with every patient when they ask the cost." WHAT?!? I EVEN TOOK THE TIME TO ASK BEFORE DECIDING WHETHER I WANT THE TREATMENT. And they STILL were able to hide the cost from me.

It is the worst.

Dentists, in my experience, have been much better telling me the cost and explaining the risk/benefit of getting or not getting a procedure done.
posted by at 8:28 PM on November 14, 2015 [4 favorites]

Every time I've had a transvaginal ultrasound I've had to schedule it in advance so that I could show up with a full bladder. It sounds to me like egregious bill padding to do two ultrasounds and to do one of them ineffectively.

When I had a transvaginal ultrasound while trying to get an IUD (I was on track but then missed an appointment, and never managed to reschedule) I thought that I was supposed to have some urine in my bladder. It turned out that I was supposed to have an empty bladder for it. So I don't think that you can assume this was a pointless and ineffective ultrasound based on that.
posted by kinddieserzeit at 8:44 PM on November 14, 2015 [1 favorite]

Best answer: Definitely talk to the doctor's office's billing dept. It's possible that they didn't bill properly. It's also possible that they just fucked up and didn't check your insurance.

If you end up being on the hook for the fee, ask what the typical patient cost is when insurance pays the rest, and tell them you want them to mark the bill down to that. If they won't mark it down to the typical copay/coinsurance, ask them to mark it down to a typical contracted price. The thing that's *really* fucked about insurance is that usually insurance doesn't actually pay the "list price" because they have agreed-upon rates in their contract. So the "list price" for a procedure, for example, is $100. But the contract price with Insurance Company X is $75, with the patient portion being $25. You can try to convince them to charge you only $25 or at least only $75, because they never would have gotten the $100 anyways.

If the amount is still high and more than you are able/comfortable to pay at once, tell them you need to be put on a payment plan (i.e. installment plan).
posted by radioamy at 12:04 AM on November 15, 2015

Best answer: The confusion about the bladder might be due to a misunderstanding of 'transvaginal ultrasound'. A full bladder helps with interpretation of a transabdominal pelvic ultrasound. An empty bladder is better if it's being done transvaginally (with a wand inside the vagina). However, either type of ultrasound can be done with any amount of urine in the bladder and you'll still most likely see any major issue, and can most likely be used to confirm IUD placement - this does not apply to other reasons for doing a pelvic ultrasound that might require a more detailed look.

You can see the basic steps of IUD insertion for medical professionals here. Not only is pregnancy testing prior to placement an absolute requirement (it would be very bad medical practice to place an IUD in a person who was already pregnant, and unfortunately, patients saying they are not pregnant is a very unreliable way to determine pregnancy status), but STI screening prior to placement is recommended for many women as well.

Transvaginal ultrasound is not routinely needed for IUD insertions, but it may be done in certain cases to check position, especially with a difficult insertion (see slide 24). This is considered a medically necessary cost by at least some insurance companies.Whether it was medically necessary in your case depends on the details of why it was done and how it was coded. I try to give other providers the benefit of the doubt. I agree with the comments suggesting that the best place to start is to ask your doctor why certain things were done and to see if you can get fees waived or decreased.

I also agree that it is a good idea to tell your doctor that you are on a budget, although I do not agree with trying to decline or argue them out of doing tests without a discussion. It is a physician's job to determine which tests are necessary, not the patient's - a patient in most cases does not have the training to be able to determine this for themselves (that's what you're paying us for!) and when patients start declining tests and procedures, I think it can cause physicians to cut corners and not do things that they actually should be doing. Be an informed consumer but don't try to actually make the decision on which tests are necessary yourself - ask your doctor why each test is necessary, and if they cannot explain it well enough to you and work with you to arrive at a plan you can agree upon together, getting a new doctor is a good idea.

But when I ask them what that price is, they NEVER tell me.
I agree with you that this is a ridiculous and unfortunate system, but most doctors do not know what the costs of the tests or procedures are, because doctors don't do their own billing, and because the cost is different for each insurance company and it would be impossible to memorize that many different prices for the hundreds or thousands of different tests and procedures that we do.
posted by treehorn+bunny at 12:50 AM on November 15, 2015 [7 favorites]

it would be impossible to memorize that many different prices for the hundreds or thousands of different tests and procedures that we do.

So true. And this is what makes the recommendation that consumers be informed is such a non-starter in the healthcare discussion. There's no way to be informed on this level. The best you can do is ask the providers and the insurers and then listen to your physician. The fact that they all have skin in the game of how much your care will charge is such a horrorshow.

Anyway, this is why I do recommend just starting with the doctor. Be calm and reasonable. Work your way up the chain. You can also start with your insurer. Do the same, calm and reasonable. See what they can do for you in the first steps. I did have to escalate in my case and it took a number of calls. But, also, at both the insurer and the doctor's office, I got calls back and some folks seemed genuine about helping. Eventually, the doctor's office just wrote it off. However, they didn't do this until after my husband called and said, "Hey, we've been clients here for X years. We have a baby now and we'd like to continue being clients. You're stressing out my wife." So, as always, YMMV. Good luck with this. I think you are owed some relief of this debt.
posted by amanda at 7:47 AM on November 15, 2015

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