Cost of Surgery (Something isnt right)

[audreytn]

In Dec of 2015 I was quoted $27,XXX for GRS, Hospital Stay, Breast Aug and Anesthesia Fee's by Dr. Rumer's office.  Granted it was through a different hospital. I dont remember who it was through...Delaware County Hospital maybe?

Anyhow, I guess she switched hospitals as I had my surgery at Hahnemann.

Anyways, this came in the mail today and I was completely shocked because it's about 6 times what I was originally quoted.  Surely this must be some sort of mistake? 


I just can't see this being right when I was quoted 6 times less that 18 months ago. 

If it is right, then I'm wondering if there might be some fraud going on the part of the hospital. I was only in the hospital for 2.5 days before I went to Dr. Rumers facility.  Checked in at 6 am on  a Wednesday morning and checked out at noon on Friday.

I paid $6,550 as my max out of pocket (deductible was $5,500) through Cigna.





Anyone else have any other insight perhaps?

[Dena]

When you are in the hospital and have insurance, you use the price the insurance company negotiated with the hospital. Even if your insurance doesn't cover anything, you are paying the price the insurance policy would pay. You might want to check with Dr Rumer and/or your insurance company but I suspect the insurance company will only be charged the 27k price. This is why it's really important to have some form of insurance as it keeps you from getting stuck with a bill like that.

[audreytn]

But are these surgeries really $100K+?

I mean Thailand offers everything for $20K. I know stuff is cheaper over there.

[Dena]

When a hospital deals with an insurance company, they are pretty sure they are going to get paid one way or another. When they deal with a person without insurance, they may get stuck with the bill. I saw a story where a guy cooking meth suffered extreme burns and the hospital got stuck with the bill for about a third of a million to save the guys life as drug dealers don't normally have insurance. It's one of the disadvantages of having business involved in healthcare instead of community or church backed medical care.

[EmmaLoo]

Somewhere you can find the EOB -  explanation of benefits, but you'll also see the contracted payment rate that Cigma actually paid. It will probably be closer to the normal fees you might expect. Your max out of pocket is just that. Thats what you should be the paying in the end.

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[audreytn]

Cigna paid $85,000 as an adjusted rate.  thats still 3x the amount quoted to me by Dr. Rumer originally.

[jentay1367]

Gee...makes you  wonder why our monthly premiums look like mortgage payments, huh?

[EmmaLoo]

Cigna paid $85,000 as an adjusted rate.  thats still 3x the amount quoted to me by Dr. Rumer originally.

Im floored they paid that much. My surgery cost was billed at 50k less than yours and I thought it was outrageous too. The contracted rate will probably be less than 30k through. Im still waiting to see the totals.

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[Barb99]

Amazing, our health care system is most definitely broken! I had surgery with Dr. Rumer and used Hahnemann hospital. I did not use insurance. My total bill was 26K that included all hospital charges and drugs, this was December last year.
It's crazy how our system works, or should I say doesn't work.

[audreytn]

Amazing, our health care system is most definitely broken! I had surgery with Dr. Rumer and used Hahnemann hospital. I did not use insurance. My total bill was 26K that included all hospital charges and drugs, this was December last year.
It's crazy how our system works, or should I say doesn't work.

this definitely makes me think there is a mistake somewhere!

[warlockmaker]

I thought the original price of usd 27,xxx was really cheap for a USA based srs and BA and hospital. On the other hand a final invoice of usd 100k seems high. I tend to think this is something in the way Dr and insurance companies work together in the usa. Did you inform them you had medical insurance?  My ex wife who is american had these issues in a non related surgery. Standard operating procedures and II guess after you pay the deductable it doesnt matter.

[Barb99]

Our system in the US is very screwed up, it's all about making money although how they do that is a mystery.
I have to have CT scans done once a year. I have it done at a local imaging center and they charge the insurance company a bit over $4000, I pay $1000 of that out of pocket.
I have asked them how much it would be if I did not use insurance and just payed cash, they say they can't tell me that.
Last time I had to have it done I went to another place, claimed no insurance and asked how much. It was $625 total cost. How can the price range for a simple CAT scan run from $600 - $4000? I think the whole system is a scam run by the insurance companies.

[Gail20]

Our system in the US is very screwed up, it's all about making money although how they do that is a mystery.
I have to have CT scans done once a year. I have it done at a local imaging center and they charge the insurance company a bit over $4000, I pay $1000 of that out of pocket.
I have asked them how much it would be if I did not use insurance and just payed cash, they say they can't tell me that.
Last time I had to have it done I went to another place, claimed no insurance and asked how much. It was $625 total cost. How can the price range for a simple CAT scan run from $600 - $4000? I think the whole system is a scam run by the insurance companies.

Pricing 101: Providers jack the price up so that they can then give the Insurance Companies a big discount. Those without Insurance coverage then, in most instances, have to pay the jacked up price.  But in a few cases, some providers will only charge an individual without Insurance a more "realistic price". If Insurance companies knew they were doing this they would likely be upset and demand a bigger Discount. . .

[AnneK]

Our system in the US is very screwed up

In fact,it's the most expensive in the developed world.  I always wonder what madness in the U.S. is blocking a proper heath care system, where patients don't run the risk of bankruptcy.  I live in Canada where we have a health care program.  While it's not perfect, proper health care is available to all and GCS is covered.  What is missing is dental and drug coverage.  Even with those, there are some exceptions where certain groups are covered.

[AnonyMs]

Health is one of those things I can't understand about the USA. I understand on a certain level why it's like it is, but at the same time it seems insane. Education seems to be following the same path.

[Brooke]

I have seen similar issues with Medicare reimbursement.

It's all about the contracted rate. A provider can bill insurance companies whatever they want, but that doesn't mean they will get that amount.

For instance I get physical therapy on a regular basis. My PT bills Medicare around $300/visit. However Medicare's contacted rate (which both parties agreed to) is about $120.

When a doctor or hospital contacts with an insurance company as an in network provider there is typically very little leverage the smaller offices have. A take it or leave it.

Larger providers like hospitals have more leverage, but only if they are contracted as in network. Often times individual procedures will have different contracted rates that have been negotiated.

I imagine what is happening in this case is:
Hospital is looking at average market rates in the area for BA and GCS. As it is in the interest for all hospitals and surgeons in a given region to set their market rate high, it thus forces insurance companies to base their reimbursement at a higher price. This is often the average rate between the lowest priced provider and highest priced provider in a given region.

So. If the lowest advertised price to insurance companies for GCS is $70,000 and the highest is $150,000 the reimbursement that insurance companies might for be willing to pay is $110,000 assuming there are only two providers in the area/region.

These prices might also be different for in network vs out of network.

Basically it pays for all providers offering A particular procedure in a given region to set all of this prices quite high, thus inflating the market rate.

If one provider put their bid out to insurance companies for say $27,000 and the highest bid was still $150,000 the reimbursement rate could then be set $88,500 again assuming there are only two providers in the area.

Often times for rare procedures that are infrequent, and thus not every doctor can perform them, and not every insurance plan will cover them the provider will have a cash price that is in reach for a large portion of their potential patients, giving them a regular steam of clients/patients.

They then use the much higher reimbursement rate from insurers to offset the low reimbursement of cash pay patients. This both makes their average reimbursement rate much higher, potentially offsetting any losses while allowing patients without insurance the opportunity to have the same procedure.

Hopefully that makes sense on why the statement you received was so much higher than what you were quoted as (I assume) a cash price.


~Brooke~

[Rachel]

I paid $30,000 up front to Dr. McGinn for GCS and a BA. The day of the GCS the hospital chose the use my pre-approved insurance. The certified check to Lower Buck Hospital was returned. My cost for GCS and a BA (still have not had that yet due to a complication) was about $5,000.

I do not remember what the hospital charged Aetna for my BA and GCS costs. I do know I was in the perioperative acute care unit for about 1/2 a day and ICU for about 1.5 days. That bill was $86,450. Aetna paid $43,000 and my cost was $17.90.

I was told by Papillion to pay for the hospital up front because the cost can be many times more that what Dr. McGinn had negotiated with the hospital. My cost for the GCS and a BA from Aetna was going to be $5,000 regardless of what the hospital charged (the max of my annual deductible)

I schedule my BA 5/15/2017 when I have my labiaplasty. .