(Updated 2022) We got this note from a friend who wanted to find out how much a prostate biopsy cost:
“I am a small business owner, both employer and employee. The employee in me pines for my old health insurance plan. The deductible was low enough that it was always met. The in-network co-pays were fixed and affordable. My costs were my costs no matter what doctors billed my insurance carrier or what they were ultimately paid. Blissful ignorance. Well, maybe not blissful, but I just didn’t really care.
“The employer in me, though, was paying over $2,000 a month for my family of three and also covering the full cost of insurance for most of my staff. Our rates had risen 12 to 19 percent annually for five years running which was, in a word, unsustainable. So last year, facing another double-digit rate increase, I switched to a high-deductible plan. This lowered my insurance bill considerably, but meant that my family would not receive any coverage or reimbursement unless and until we spent over $5,700 in network.
“My education began quickly. An annual physical in January revealed an elevated PSA score, which sent me back to a urologist who had been treating me over a year for a persistent prostate infection. Now he felt a biopsy was the prudent course, and my primary care provider agreed.
“First lesson: Make sure your in-network MD sends lab work to an insurer-approved lab. The prostate biopsy required a clearance exam. Even though I had just had a complete physical and blood workup, my primary doctor had to screen my blood for other factors. He sent my blood to a lab not in favor with Oxford Health. As a result, I was billed at the lab’s flat rate rather than a rate negotiated by the insurer. The damage? Over $600 out of pocket. And the lab refused to accept less.
“Second lesson: Ask your doctor in advance exactly what you will be charged for, as well as how much it will cost. The biopsy was a 15-minute in-office procedure performed under general anesthesia. Here’s what I was billed for, all at Oxford’s special negotiated rates because the doctor was in-network:
Office visit 57
Echo guide 276
Results visit 59
“Note: they billed me for an office visit the day of the procedure. True, the procedure was in the office, but still. Note also: the return visit to hear the biopsy results was something the doctor insisted on when I asked what day I should call for the news. Interestingly, he submitted that one to the insurer as a ‘bladder neck obstruction,’ presumably because they also believe results could have been delivered by phone.
“More than a little stunned by the total of the special Oxford-negotiated rates, I called the doctor’s office about the charges and after much complaining was ultimately referred to a ‘billing specialist’ located somewhere in PA. He rather sheepishly explained that the urologist, anesthesiologist and pathologist are all partners and because reimbursements rates are ‘so low’ they automatically bill Oxford for as much as possible to recoup as much as possible.
“Given that I had to pay out of pocket (something they should have known from my insurance card) he was willing to negotiate. In the end, I paid about a third of the total amount.
“More good news: the biopsy was negative!
“Third lesson: Read what you are asked to sign and don’t sign it if you don’t agree. Next week I go for my every-fifth-year colonoscopy. Yesterday I got a packet from the in-network doctor’s office that included a form they requested I sign and return before the procedure. It said, ‘I am aware that an anesthesiologist who does not participate with my insurance plan will be involved in my care. I understand I may be responsible for payment of additional costs, such as the deductible and co-payment, as specified by my contract…’
Because this doctor is out of network and my out-of-network deductible of $5,700 is far from being met, signing this could obligate me to pay virtually anything the doctor chose to charge. Lo and behold, when I called the office and told them I would be out of pocket for this and thus needed to find a different provider, they suddenly found a way they could bill the anesthesia at an in-network rate.
“Miracle of miracles! Live and learn.”