$18,000 Breast Biopsy: When Insurance Costs You a Bundle

When Danny Yuengling felt a lump in her right chest last summer, she tried to ignore it.

She was 35, the same age as her mother when she was diagnosed with breast cancer in 1997. The disease eventually killed Yuengling’s mother in 2017.

“It was the hardest experience, seeing her suffer,” said Yuengling, who lives in Conway, South Carolina.

After a mammogram confirmed the tumor needed further investigation, Yuengling scheduled a breast biopsy for Valentine’s Day this year at Grand Strand Medical Center in Myrtle Beach.

Among the many concerns she had before that appointment — the first being a possible cancer diagnosis — Yuengling needed to find out the cost of a biopsy. She has an annual deductible of $6,000 — the amount her health plan requires that she pay before her contribution begins — and she wasn’t about to make it. Whatever the cost of the procedure, Yuengling knew she would be on the hook for most of it.

But the hospital won’t give her a price. She was told that her providers would not know what type of biopsy needle they needed until the procedure was done and that would affect the price.

The hospital’s online Patient Payment Estimator showed Yuingling owed an uninsured about $1,400 for the procedure.

“That’s fine. It doesn’t matter,” she thought to herself, confident that it would be cheaper for her because she had insurance. A Google search indicated it might be closer to $3,000, but Yuengling thought the price seemed reasonable, too. She wasn’t too concerned about the money because she had the procedure.

The good news was soon conveyed that she did not have cancer.

Then the bill came.

the patient: Danny Yuengling, 36, covered by Cigna through her employer, human resources contractor at Mayo Clinic.

Medical service: Ultrasound-guided breast biopsy.

Service Provider: Grand Strand Medical Center, a for-profit 403-bed hospital located in Myrtle Beach, South Carolina. It’s one of 182 hospitals owned by Nashville-based HCA Healthcare, which generated $58.7 billion in revenue last year.

Total bill: $17,979 for this procedure, including lab work, pharmacy fees, and sterile supplies. Cigna’s negotiated in-grid price was $8,424.14, of which the insurance company paid the hospital $3,254.47. Yuengling was billed for $5,169.67, which is the balance of the withholding.

What gives: It is not uncommon for uninsured patients—or any patient willing to pay cash—to be charged significantly less for a procedure than patients who have health insurance. For the roughly 30% of American workers with high-deductible plans, such as Yuengling, this means that using insurance can lead to far greater expenses than if they were uninsured or pulled out a credit card for prepayment.

Ge Bai, associate professor at the Johns Hopkins Bloomberg School of Public Health Search this topic He said hospitals in the US often set their cash rates lower than they charge for treating commercially insured patients.

“We can say with very confidence that this is very common,” said Bey, who advised all patients, regardless of their insurance status, to inquire about the cash rate before undergoing the procedure. “It should be the norm.”

The Grand Strand charged Yongling’s insurance a very high price for the operation. In comparison, according to Federal government websiteMedicare patients who require an ultrasound-guided biopsy similar to the one received by Yuengling will pay only about $300 — the required 20% co-insurance for outpatient care. Medicare will pay the hospital the remainder of the bill, about $1,200. The hospital expected more than five times the Medicare price from Yuengling and its insurance company.

Patients in Conway who have private health insurance and who are treated at other hospitals are usually charged less than Yuengling paid for the same procedure — on average about $3,500, according to the fair healthy consumeran organization that analyzes health insurance claims.

And uninsured patients who pay cash and need an ultrasound-guided breast biopsy at nearby Conway Medical Center are likely to owe less — about $2,100, according to Alison Floyd, a spokeswoman for the hospital.

Meanwhile, Grand Strand Medical Center spokeswoman Caroline Preusser blamed a “glitch” in an online hospital calculator for the inaccurate information Yuengling received and said the correct estimate of the cash price for a hospital breast biopsy ranged from $8,000 to $11,500 “depending on on the exact procedure and equipment used.”

Breuser wrote that the hospital removed some procedures from the payment estimator so that they could be corrected. She did not say how long it would take.

the decision: Yuengling tried to oppose the charges against the hospital. I called the billing department and got a 36% discount, which cuts the amount you need to pay to $3,306.29. Grand Strand Medical Center allows patients to set up payment plans, but Yuengling decided to charge the entire amount to a credit card because she wanted to get everything done.

“I couldn’t sleep. It was driving me crazy. I had migraines. I was sick in my stomach,” she said. “I hate having debt. I didn’t want to think about it. Obviously this didn’t work because I was still thinking about it.”

She said she asked on several occasions to speak to the patient’s attorney at the hospital, eventually hooking up to an outside company, Parallon, that did an audit of her bill. She eventually received a letter dated May 26 from the hospital’s revenue integrity department. “After reviewing the charges involved and your medical history, the following has been determined; the charges charged to your account were appropriate,” the statement read.

“I don’t know why I actually expected a different result,” she said.

The hospital requested that Yuengling come back for a follow-up biopsy appointment. I refused.

Harlow Somerford, a spokesperson for HCA Healthcare, told KHN in an email that the hospital system is apologizing for any confusion caused by the payment estimator “and we are working to resolve the issue.”

Takeaway: With a family history of breast cancer, Yuengling was right to follow up with her doctor after feeling a lump. Having failed to get a clear answer on her costs from Grand Strand Medical Center, she could have taken the extra step of exploring what other hospitals in the area were charging. Although her doctor referred her to the Grand Strand, she was not obligated to use this hospital. She could have saved a significant amount of money by choosing to undergo the procedure elsewhere.

Furthermore, patients like Yuengling who have a highly deductible insurance plan should consider paying cash rates for certain procedures and not involve their insurance company at all.

Jacqueline Fox, a health care attorney and professor at the University of South Carolina School of Law, said she was not aware of any law that would prevent a patient from doing so. She noted that patients with health insurance pay cash prices for prescription drugs all the time. It stands to reason that they could do the same for medical procedures.

But some facilities make this difficult. Grand Strand Medical Center, for example, offers “self-pay” patients an “uninsured discount,” but that discount is limited to people who “do not have a third-party payment source or are not eligible for Medicaid, a charitable organization, or another discount program.” provided by the facility,” According to the hospital site. Information about the discount is provided only to patients who are confirmed not to have health insurance.

In some cases, paying a cash price for an action may not make financial sense in the long run because none of that will apply to the deductible. Patients may save money on one procedure but end up paying the full deductible if unexpected medical expenses escalate later during the calendar year.

Insured patients should communicate with their health plan for a good faith estimate prior to the procedure. Under the No Surprises Act, health plans are supposed to give members an idea of ​​their total out-of-pocket costs on demand. Ask for an “advanced explanation of benefits,” said Sabrina Corlett, research professor at Georgetown University’s McCourt School of Public Policy, although she notes that this part of the law has not yet been enforced.

The law also allows no surprises for patients to file a complaint With the federal government regarding their medical bills – whether or not they hold health insurance.

Yuengling filed her complaint in June.

Stephanie O’Neill contributed the audio image to this article.

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