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

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

She was 35, the same age her mother was 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 lump needed further investigation, Yuengling scheduled a breast biopsy at Grand Strand Medical Center in Myrtle Beach for Valentine’s Day this year.

Among her many worries before that appointment — the first being a possible cancer diagnosis — Yuengling needed to know how much the biopsy would cost. He has a $6,000 annual deductible — the amount he must pay before his contributions to his health plan kick in — and he wasn’t close to hitting it. Whatever the procedure cost, Yuengling knew he would be on the hook for most of it.

But the hospital won’t pay for it. He was told that his suppliers did not know what type of biopsy needle they needed until the procedure was underway and that would affect the price.

The hospital’s online “Patient Payment Estimator” showed Yuengling said an uninsured patient would owe about $1,400 for the procedure.

“That’s fine. No big deal,” he thought to himself, confident that it would be cheaper for him since he had insurance. A Google search indicated it might be closer to $3,000, but Yuengling thought that price seemed reasonable as well. He wasn’t too bothered about money going through this process.

This soon brought the good news that she did not have cancer.

Then came the bill.

the patient: Dani Yuengling, now 36, who is covered by Cigna through her employer, a human resources contractor at the Mayo Clinic.

Medical Services: An ultrasound-guided breast biopsy.

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

Total Bill: $17,979 for the procedure including lab work, pharmacy charges and sterile supplies. The signator’s in-network negotiated rate was $8,424.14, of which the insurance company paid the hospital $3,254.47. Yuengling was billed $5,169.67, the balance of his cut.

Last hour: It’s not unusual for uninsured patients — or any patient willing to pay cash — to be charged much less for a procedure than patients with health insurance. For about 30% of American workers, high-deductible plans, such as Yuengling’s, mean that using insurance can be a huge expense if they don’t have insurance or just take out a credit card to pay in advance.

Ji Bai, an associate professor at the Johns Hopkins Bloomberg School of Public Health, recently published research on the topic and said that hospitals in the United States often lower their out-of-pocket costs for treating commercially insured patients.

“We can say with great confidence it’s very common,” said Bai, who recommends that all patients, regardless of their insurance status, ask about the cash price before undergoing a procedure. “It should be a norm.”

One photo shows Dani Yuengling sitting on a chair outside, looking away from the camera.
Dani Yuengling lost her mother to breast cancer and takes her health seriously. But after a frustrating experience with an exorbitant bill for a biopsy, she is reluctant to seek follow-up care.(Gavin McIntyre for KHN)

Grand Strand charged Yuengling’s insurance an extraordinarily high price for its approach. By comparison, Medicare patients who need an ultrasound-guided biopsy similar to the one Yuengling received will pay about $300 — 20% of the coinsurance they need for outpatient care, according to the federal government’s website. 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 his insurer.

Conway patients with private health insurance who are treated at other hospitals are also typically charged less than what Yuengling paid for the same procedure — about $3,500 on average, according to Fair Health Consumers, a company that analyzes health insurance claims.

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

Meanwhile, Grand Strand Medical Center spokeswoman Carolyn Preusser Yuengling blamed “an error” involving the hospital’s online calculator for the wrong information, and said the hospital’s accurate estimate of the cash price for a breast biopsy ranges from $8,000 to $11,500. Used.”

The hospital has removed certain procedures from the payment estimator until they can be corrected, Preusser wrote. He did not say how long it would take.

Resolution: Yuengling tried to dispute the hospital’s allegations. He called the billing department and was given a 36% discount, reducing the amount he needed to pay to $3,306.29. Grand Strand Medical Center allows patients to set up payment plans, but Yuengling decided to charge the full amount to a credit card because she wanted the whole thing to go away.

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

He said he requested to speak with the hospital’s patient advocate on multiple occasions and eventually engaged an outside company, Paralon, which conducted an audit of his bills. Finally he received a letter dated May 26 from the hospital’s revenue integrity department. It said: “After analyzing the complaint and reviewing your medical records, the following were identified; The charge to your account was correct.”

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

The hospital requested Yuengling to return for a follow-up appointment regarding the biopsy. He refused.

Harlow Summerford, a spokeswoman for HCA Health Care, told KHN in an email that the hospital system apologizes for any confusion caused by the payment estimator “and we are working to resolve the issue.”

In one photo, Dani Yuengling stands outside.
(Gavin McIntyre for KHN)

Takeaway: With a family history of breast cancer, Yuengling was right to contact her doctor after experiencing a lump. After failing to get a clear answer about her costs from Grand Strand Medical Center, she could have taken an extra step to explore what other hospitals in the area charge. Although her physician referred her to Grand Strand, she was not obligated to use that hospital. He could have saved a significant amount of money by choosing the procedure elsewhere.

Additionally, patients like Yuengling who have a high-deductible insurance plan should consider paying cash for certain procedures and not involving their insurance company at all.

Jacqueline Fox, a health care attorney and a professor at the University of South Carolina School of Law, said she is not aware of any laws that would prohibit a patient from doing this. After all, he noted, patients with health insurance always pay cash for prescription drugs. It stands to reason that they can do the same for medical procedures.

But some advantages make it difficult. Grand Strand Medical Center, for example, offers an “uninsured discount” to “self-pay” patients, but that discount is limited to people who “have no third-party payer source of payment or do not qualify for Medicaid, charity or any other discount program.” benefit offer,” according to the hospital’s website. Only patients with no health insurance are given information about the discount.

In some cases, paying cash for a procedure may not make financial sense in the long run because none of it will be applied toward deductibles. Patients can save money on a procedure but pay their full deductible if unexpected medical expenses rise later in the calendar year.

Insured patients should contact their health plan for a good-faith estimate before a procedure. Under the No Surprises Act, health plans are supposed to give members an idea of ​​their total out-of-pocket costs upon request. Ask for “improved interpretation of benefits,” said Sabrina Corlett, a research professor at Georgetown University’s McCourt School of Public Policy, though she noted that this part of the law is still not being enforced.

The No Surprises Act allows patients to file complaints with the federal government regarding their medical bills — whether they carry health insurance or not.

Yuengling filed her complaint in June.

One photo shows Dani Yuengling sitting at a table looking left.
(Gavin McIntyre for KHN)

Stephanie O’Neill contributed the audio portrait accompanying this article.

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