(Updated September 2019) What does an X-ray cost? You could be paying $20, or $402.05. We even heard of a $988 X-ray, for which the patient — an insured person! — is being asked to pay $500. You would think something like an X-ray would have fairly uniform pricing. Think again.
Our community members shared five separate apparently identical chest X-rays, with five wildly varying prices. Each one of them came to us via our share form with the CPT code 71010.
This is another post based on our crowdsourcing project in California with KQED public radio in San Francisco and KPCC/Southern California Public Radio in Los Angeles. We have been asking people to share pricing information for mammograms, MRI’s and IUD’s, especially, but we are also collecting prices on anything that’s of interest to our communities.
One thing that’s of interest, apparently, is X-rays.
5 X-rays, 5 prices
Case No. 1: the total bill was $729, and insurance paid $364.18, and the patient paid a $20 co-pay. The provider: Marin General Hospital in Kentfield, Ca. The insurer: UC Care.
Case No. 2: The total bill was $107, insurance paid nothing, and the patient paid $36. Provider: North Cal Imaging in San Leandro. The insurer: Assurant Health.
Case No. 3: The total bill was $117, insurance paid nothing, and the patient paid $117? “This is covered under my insurance, but I have not yet reached my family deductible, so I was totally
out-of-pocket in this case (although I paid from my HSA),” the community member told us via email. (We have made a decision not to publish names in this case.) The provider: Palo Alto Medical Foundation in Palo Alto. The insurer: Premera Blue Cross.
Case No. 4: The total bill was $286, insurance paid $74.36 and the patient paid $211.64. (We assume deductible; no notes were left.) The provider: California Pacific Medical Center: Davies Campus on Castro Street in San Francisco; no insurer was named.
Case No. 5: the total bill was $473, insurance paid nothing, and the patient paid $402.05. Provider: Sutter Health Pacific Campus-Medical Office Bldg on Webster Street, San Francisco. (No details, and no email address so we couldn’t contact the person who shared the data.) The insurer: GWH-Cigna (formerly Great West Healthcare).
X-ray prices, we think, are generally much lower. You could look at our Hospitals Database at this link, and search X-ray in “all states” to see a number of providers’ cash or self-pay prices. Or you could search on “Spine X-ray” in all states, seeing a range from $77 to $172.
This post by Martha Bebinger, our friend at WBUR public radio in Boston, says her request for an estimate on an X-ray for her back netted an estimate of $147. This post by a San Francisco doctor details how he collected estimates ranging from $517 to $73 for an X-ray.
We are not asking the question of whether these X-rays are recommended for treatment. The American Board of Internal Medicine has, in its “Choosing Wisely” campaign, questioned the routine use of chest X-rays for pre-surgical treatment. This isn’t part of our conversation, but you can see some of their work at this link.
The case of the $988 X-ray
The most surprising X-ray charge we have seen: $988 total charge, of which the patient is asked to pay $500.
This is a recent X-ray of his spine for scoliosis or curvature of the spine. (He asked that we not use his name, though he sent us scans of his bills and explanation of benefits).
He said: “It is a garden variety spine curvature check X-Ray. Usually done in four images to show full spine. Takes about 2-3 minutes. No special equipment needed.”
The provider is Sutter Pacific Medical Foundation on Webster Street in San Francisco. The insurer is Cigna. Cigna paid $211, and imposed a $237 “adjustment,” meaning their contracted rate. The provider then billed our community member $500 for the remainder.
After seeing the bill and the explanation of benefits, he said, he showed the bill to his partner, a physician of unnamed specialty, and to a relative, a radiologist, and he said, “Both were shocked by the cost. Estimates on insurance websites are around $50-100 total.”
We are not medical experts, but we agreed with him that this seems like a lot of money, so we did some sleuthing: the bill and explanation of benefits don’t have a CPT code, but multiple online references like this one here provide insight about the CPT code. The cost is $49 in cash here at ZoomCare in Portland, or $90 here at Denville Diagnostics in New Jersey. (We didn’t find a California provider with a listed online price.)
His partner has sought to discuss the bill with provider and payer, with no meaningful success so far.
We find this odd: one thing we’re sure of is that California does not allow “balance billing.” Balance billing restrictions, state by state, are discussed in this extremely useful Kaiser Family Foundation page.
So is this charge a result of the patient being charged the full chargemaster rate and being asked to pay that to meet his deductible? We don’t know. We’re still trying to find out. While many insured people believe that their insurance grants them access to the “negotiated rate” or “contracted rate” that is negotiated in a contract between provider and payer, we are learning that this may not be true: some insurance plans charge the full charged price, which is stipulated in the contract, until you meet a deductible.
The $910 ankle X-ray
A community member shared a $910 X-ray.
He wrote, “there was a $35 co-pay for a DNP at Memorial Family Medicine who examined a ~3 week swollen right ankle, advised a daily 600 mg ibuprofen tablet, elevate the leg at night and wrote a work order for an x-ray which we immediately had done at Memorial Medical Center. It took 5-10 minutes for three views that according to an exam report revealed soft tissue swelling (!), no fracture, intact talar dome and ankle mortise, no degenerative change and small calcaneal spur. When the x-ray and report were returned to the DNP, there was no follow up except to mention that nobody had ever returned results to her like this before. …according to a BCBS spokesperson, the submitted charge of $910 was not unusual, and the plan allowance of $718.90 was by contractual agreement, whatever that means. The deductible for my family calendar was satisfied through this claim, but left me with a bill of $405.33 for an ankle x-ray. My paid monthly premiums for the FEHB program so far this year are $4440. BCBS paid $313.57 and I paid $405.33. Not a bad deal for less than 10 minutes of service.”
This is interesting not just for the size of the charge, but because the insurer actually paid $313.57, in addition to the $405.33 that the patient is asked to pay, allowing the hospital to reap $718.90 for a procedure that commonly costs $100-$200 or much much less.
The patient wrote later: “I have subsequently received a modest, $98.00 charge for a simple ‘reading’ of negative results in the x-rays for which BC/BS paid only $8.00 because the provider who I never contracted was out-of-network.
“All in all, it looks like an institution set up to scam patients and do essentially nothing to solve the medical problem. We only have a pretty good idea of what the problem is not. A thousand bucks and we still have a swollen ankle and we’re back on the street.”
A few days later, another bill: “I received what I presume will be the final and third bill for the three x-ray views of the ankle. Submitted charges were: office visit to ‘eyeball’ and feel the ankle was $161, x-ray technical charge for three views of the ankle-$910 and , $95 for x-ray diagnosis. Such an ineffective and indeed callous operation.”
We can top that: A $1,865.50 X-ray
The community member said: “The Memorial Herman imaging center charged the insurance Co. 1865.5 as per the claims. The member rate for each xray is 419.53+343.56 =762.99. The rest is lost in between somewhere. How can you charge almost 2K for 2 xrays? And how can the insurance bill me 762.99 for 2 xrays? This is outrageous. I asked MH how much the xray woud cost and they could not give an answer. I assumed it would not be very expensive so i went through with xray and wow! Outrageous”
What can you do?
We realize we haven’t answered the question of what an X-ray costs. But what can you do to avoid the $988 X-ray?
When you already have a bill in hand, it’s harder to talk about how much you’ve been charged, or if you think you have been overcharged.
Ask in advance: How much will this cost? How much will this cost me? Take notes. Take names. Take numbers.
Ask: What’s the cash price for that? Is there a prompt-pay discount, a discount for paying up front?
Read: Your insurance plan documents. What’s your responsibility under the plan?
A note: We are often asked in this crowdsourcing prototype project if we believe what we are being told by people who fill out our online form here. The answer: yes, we do. People have told us their bills are confusing, or the coding they see on the bills doesn’t match what we’re collecting, and we believe that. We also believe our contributors’ shares. We have seen wide variations in health-care pricing.