The $18,000 breast biopsy: When you have insurance it costs you a fortune

When Dani Yuengling felt a lump in her right breast 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 killed Yuengling’s mother in 2017.

“It was very difficult to see him suffer,” said Yuengling, who lives in Conway, South Carolina.

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

Among the many challenges he had before his appointment – the first being a cancer diagnosis – Yuengling had to find out how much a biopsy would cost. She has a $6,000 annual deductible — the amount her health plan requires her to pay before she can cover her services — and she was about to hit the jackpot. No matter what the price, Yuengling knew that he would use it often.

But the hospital did not give him the price. He was told that his providers would not know what type of needle he needed until after the procedure and that could affect the cost.

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

“It’s fine. No problem,” he thought to himself, confident that it would be cheaper for him since he had insurance. A Google search showed it could be closer to $3,000, but Yuengling thought the price seemed reasonable. He wasn’t worried about money when he was doing the surgery.

It soon brought the good news that he was cancer free.

Then the bill came.

Sick: Dani Yuengling, now 36, who is covered by Cigna through her employer, who works at Mayo Clinic.

Medical Services: Breast examination guided by ultrasound.

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

Total bill: $17,979 for the procedure, including lab work, pharmacy charges, and incidentals. Cigna’s in-network copay was $8,424.14, while the insurance company paid the hospital $3,254.47. Yuengling charged her $5,169.67, the amount she had withdrawn.

What it offers: It’s not uncommon for uninsured patients — or any patient willing to pay a premium — to be charged less than patients with health insurance. For the roughly 30% of American workers with low-cost plans, such as Yuengling, that means using insurance can bring in more money than if they went uninsured or just pulled out a credit card to pay in advance.

Ge Bai, associate professor at the Johns Hopkins Bloomberg School of Public Health, recently published. research on this topic and said that hospitals in the US often lower their premium rates than the rates they pay to treat patients with commercial insurance.

“We can say with confidence that this is common,” said Bai, who advised that all patients, regardless of their insurance, ask about the cost of the insurance before making it. “It should be normal.”

Grand Strand paid Yuengling’s insurance premiums for its actions. In comparison, according to federal government website, Medicare patients who need an ultrasound-guided biopsy similar to the one Yuengling received pay about $300 — 20% of their outpatient costs. Medicare pays the hospital the remaining amount, about $1,200. The hospital expects more than five times the cost of Medicare from Yuengling and its insurance.

Patients in Conway with health insurance who are treated at other hospitals are billed less than what Yuengling paid for the same procedure — about $3,500, according to Fair Health Consumeran organization that analyzes health insurance costs.

And uninsured patients who pay premium rates and need an ultrasound-guided mammogram at nearby Conway Medical Center are expected to pay less — about $2,100, according to Allyson Floyd, a spokeswoman for the hospital.

Meanwhile, Grand Strand Medical Center spokeswoman Caroline Preusser blamed a “problem” involving the online calculator for the wrong information Yuengling received and said the accurate estimate of the cost of breast augmentation at the hospital is between $8,000 and $11,500 “depending on the exact procedure and equipment.” which are used.”

The hospital withdrew other procedures from auditors until they were corrected, Preusser wrote. He did not say how long it would take.

Conflict: Yuengling tried to dispute the charges with the hospital. He called the billing department and was offered a 36% discount, bringing the amount he needed to pay down 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 to get the whole thing out of the way.

“I couldn’t sleep. It made me crazy. I had migraines. I was sick to my stomach,” she said. “I hated being in debt. I didn’t want to think about it. Obviously, it didn’t work because I kept thinking about it.”

He said he made several requests to speak to a patient care provider at the hospital and was eventually contacted by an outside company, Parallon, which conducted an audit of his bill. He then received a letter dated May 26 from the Revenue Integrity Department at the hospital. It said: “After reviewing the charges in question and your medical history, the following was determined; Your account balance was appropriate.”

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

The hospital has asked Yuengling to come back for another biopsy. He refused.

Harlow Sumerford, a spokeswoman for HCA Healthcare, told KHN in an email that the hospital apologizes for the confusion caused by the accountants “and we are working to correct the situation.”

The Takeaway: With a family history of breast cancer, Yuengling was right to follow up with her doctor after hearing the lump. When he couldn’t get a clear answer on the cost from Grand Strand Medical Center, he could take steps to find out what other hospitals in the area charge. Although his doctor referred him to the Grand Strand, he was not forced to use that hospital. He could have saved a lot of money by choosing to have another surgery.

In addition, patients like Yuengling who have low-cost insurance should consider paying for other options rather than contacting their insurance company at all.

Jacqueline Fox, a health care lawyer and professor at the University of South Carolina School of Law, said she is not aware of any law that would prevent a patient from doing this. Besides, he said, patients with health insurance usually pay for prescription drugs. It stands to reason that they would do the same in the medical field.

But some devices make this difficult. Grand Strand Medical Center, for example, offers “self-pay” patients a “non-insured discount,” but the discount is limited to people who “have no source of income from another person or are ineligible for Medicaid, Charity or any other discount program that provides it,” according to the hospital’s website. Only patients who are certified as not having health insurance are given discount information.

In some cases, paying the premium may not make sense in the long run because there is nothing to use for the deductible. Patients can save money on only one policy but pay the full amount if unexpected medical expenses rise over the course of the year.

Insured patients must approach their health plan to demonstrate good faith before starting a plan. Under the No Surprises Act, health plans must provide members with an estimate of their total out-of-pocket costs upon request. Ask for the “Advanced Explanation of Benefits,” said Sabrina Corlette, a research professor at Georgetown University’s McCourt School of Public Policy, though she says this part of the law is not used.

The No Surprises Act also allows patients filing a complaint and the federal government regarding their medical bills – whether they have health insurance or not.

Yuengling filed his complaint in June.

Stephanie O’Neill contributed the image and article.

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This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an independent news conference, is a program of the Kaiser Family Foundation, a health research organization not affiliated with Kaiser Permanente.