How much does a breast ultrasound cost, $95.81 or $800? A breast biopsy, $700 or $2,500?

Filed Under: Costs, Health plans, Patients

A commenter over on my TED talk page wanted me to know how easy it is for people to find out prices in advance — in short, saying that anybody who wants a price will have no trouble finding it.

At about the same time, this arrived in my inbox, so I asked the writer if we could post it on our site under our “A friend writes” series. She said yes, though asked that her name not be used. Here it is.

A friend writes:

Health care costs are a complete mystery. Though I can monitor my sore throat for a few days instead of paying $25 for my doctor visit, most of the serious money situations remain shrouded in mystery.

I recently experienced an infection in my breast and saw my regular provider. She ordered antibiotics and I requested $4 prescriptions. So far, so good.

I knew there would be a $25 office visit fee, and $4 for each antibiotic ordered. The problem was on a subsequent visit when my provider felt there should be more improvement and wanted me to have an ultrasound.

Helpful advice: Look for a standalone facility

Through some confusion in the doctor’s office, I ended up without an appointment, so I took that opportunity to check with my employer’s insurance broker.

I also connected with a friend who sells self-insurance to local businesses. He encouraged me to look for a “stand-alone facility” rather than “pay for the overhead with the traditional brick and mortar”. Both suggested using my insurer’s website to check out the negotiated rates my insurer has with different providers.

That website was not particularly easy to navigate. One problem was that you had to know exactly how the provider would report the procedure.

You had to pick through similarly worded procedures to ‘match’ what you thought your doctor was ordering. I found a provider 90 minutes from home with a negotiated rate of $95.81. My usual provider’s negotiated rate was over $800, located 40 minutes from my house. I chose to drive the extra distance to save money.

After an inconclusive ultrasound, I received a second course of antibiotics and another appointment in three weeks.

And now, a biopsy. Same script.

This time, I again used the insurer website, but could not find the procedure, another ultrasound but including a biopsy.

I contacted the ultrasound provider, and this time, I received a code for the procedure. I still was unable to find the procedure on the insurer’s website as there was no ability to enter the codes and I fumbled through every ultrasound procedure.

I finally called the insurer’s customer service. First, they told me that the provider was out of network and I would have to pay the full cost of the procedure ($2,500).

After I found the provider on the insurer’s website, I gave the customer service rep another name that the provider uses. The rep continued to look for the insurer’s negotiated rates for that provider, coming back on the line several times to let me know he was still working to get the information.

After 50 minutes with customer service, they gave me the negotiated rates for the provider.

Why did my insurer struggle to provide their negotiated rate, when they knew the provider and had the codes for the procedure?

This is what it’s like to look for prices

Although I know what I will pay out of pocket for this upcoming procedure (roughly $700), I cannot easily determine whether another provider would offer the same procedure at a better rate.

Choosing another provider would likely mean they would want their own ultrasounds done again (more $ for me).

Unless I choose a few providers and get the negotiated rates of each, I am at the mercy of the medical establishment. How much time would I spend on the phone with the insurer getting the negotiated rates of each provider?

In what other area of our lives are we expected to show up where someone directs us, and pay whatever is billed? If we want people to serve as their own advocates or as equal players in containing health care costs, how can we help insureds make informed decisions? Without provider and procedure codes, we follow the directions of our medical providers who send us where it is closest or where they send all their patients.

Based on my lengthy call with my insurer, their customer service does not have ready access to information that allows patients to operate as equal partners in the process.

Public policy: The HSA argument

This is connected with public policy.

Congress introduced Health Saving Accounts (HSA) in 2003. This was supposed to be a way for insured people to take control of their own health spending. The tax benefits are unparalleled. Money is socked away pretax, and using the funds for approved medical expenses is likewise tax-free.

The limits are cost adjusted and usually cover your medical expenses each year. Participants have multiple options such as electing a $5,000 deductible and paying a lesser premium vs. choosing a $3,000 deductible and paying more. Based on the plan, once you meet your deductible, many items are covered 100%. There are limitations (i.e. no prescription plan until you meet your deductible) and other benefits, but that information is available from your plan administrator or numerous IRS (and others) publications.

But when you look at my experience, you will see the gap in the logic.

While the HSA offers patients an opportunity to participate in cost management, the lack of transparency and helpful tools means I can only participate to the extent of the structures in place.