Am I Getting Ripped Off?
October 27, 2006 11:38 AM   Subscribe

How can I make sure I'm not being overcharged for surgery and/or ripped off by my health insurance company?

I recently had minor outpatient surgery and I'm trying to figure out how to make sure everything is on the up-and-up from both the hospital/doctors and the insurance company.

I don't have any specific reason to suspect getting ripped off, but I've heard so many horror stories about medical overcharging - and had personal experience getting shafted by health insurance companies - that I'd at least like to make sure nothing egregious is going on.

I've gotten itemized bills for the surgery, but a) many of the items might as well be Greek to me, and b) for the few that I've asked about, the response has been simply "That's what we charge for that." What other options are there? (Ideally low- or no-cost.)

With the insurance company, things are even more confusing: certain amounts allowed and other not, for no clear reason, and there are "discounts" they apparent get from, or negotiate out of, the hospital. There is very little effort put into making any of it comprehensible. I hesitate to file a challenge without good reason, so my rates don't go up. What else can I do?

Or should I just let it all go? Is $8,000 for an inguinal hernia repair reasonable?
posted by gottabefunky to Health & Fitness (6 answers total)
Depending upon a lot of variables, 8K for a hernia might be reasonable. The main thing you should be concerned with is the amount you are liable for; the insurance company will worry about the rest. You don't mention what, if any your share of the bill is; what is normal will depend on the type of insurance (HMO, PPO, traditional, etc.), the terms of your contract with them, and the terms of their agreement with the hospital and doctor. You are correct to state that it is not a comprehensible system.
posted by TedW at 12:02 PM on October 27, 2006

If the hospital billing department is unhelpful then ask to speak to their ombudsman (customer relations supervisor) and explain that you want a more detailed itemized bill and dispute all the little charges like "sanitary care products: $124" (a box of kleenex)
posted by StarForce5 at 12:05 PM on October 27, 2006

Yeesh, figuring this stuff out is a nightmare but it helps to break it down :

As a first step, I suggest reviewing your specific insurance plan. Know your deductibles, copays, and coverage limits even before you get into what the hospital is charging.

Next, collect all the EOBs (Explanation of Benefits) from your insurance company (This shows everything they paid the clinic / hospital on your behalf.)

Then review any bill the hospital is sending directly to you. This should be the remainder of the total bill after the insurance company paid to your coverage limit on the EOBs.

If anything is unclear, then I suggest contacting your insurance carrier and asking them to explain everything you are expected to pay since they can see the total bill and know what your coverage limits are. Write everything down. Don't sound like your have a problem yet, just sound confused. You can call back later to challenge if you feel like something is amiss.

Hope this helped...
posted by dendrite at 12:08 PM on October 27, 2006

Hospitals/outpt surgery centers and insurance companies often have pre-negotiated rates that will be paid for procedures. So there is a "retail" rate, which would be the cash price if you appeared and had a bag of money to pay for your surgery. But the insurance co. gets the "wholesale" rate because of pre-negotiated contracts for services, lab fees, supplies, pharmacy, room and board, etc. The general exceptions to this rule are anesthesiology (and maybe radiology and pathology). Of course you want anesthesia during your procedure, but most anesthesiologists do not participate in insurance plans, so the insurance plan will have to pay the retail rates to them. (I'm not sure why these folks don't usually participate in insurance plans.)
What usually happens is: shortly after your surgery, you get a bill from the hospital for the surgical services, supplies, pharmacy, etc. You will also get a separate bill from the anesthesiologist for services rendered. You will then have a period while the insurance co. reviews the claims and pays the claims. You will then get an EOB, or explanation of benefits, which shows the event, the charges associated with it, what the insurance co. paid and why. If you have a PPO or POS, and you stayed in network, you will probably be fine. If you have an HMO and stayed in network you will also be fine. Now, if you went outside your network, either in the hospital or surgical center you chose, or your doctor or surgeon for the procedure, you will have to pay a certain percentage. You have governing documents provided by the insurance co. that can help you figure this out.
So... as far as if you're getting ripped off, unless you are paying cash for the services, it probably doesn't matter, since your insurance probably has a pre- negotiated rate. However, if you notice charges on your itemized hospital/surgical center bill that you don't recognize, like the famous line item of the $75 Tylenol, bring this to the hospital's attention as well as your insurer.
Also, if you are really concerned about this, there are individuals who you can hire to review your bills and EOBs to make sure everything is working as it should. They usually call themselves "patient advocates" or something like that.
posted by FergieBelle at 8:01 AM on October 28, 2006

Anesthesiology, radiology, and pathology are handled differently in many insurance plans, but are usually covered; that is certainly the case in my hospital, where all physicians are part of one group practice, which negotiates with insurers for all of us.
posted by TedW at 1:50 PM on October 28, 2006

If all else fails, just ask for a discount. I know it sounds stupid, but I've seen it work.
posted by IndigoJones at 5:50 PM on October 29, 2006

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