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Medical Estimates Are Meaningless As Providers Can Charge Thousands More Than You Expect
By
Caroline Lewis
Published Nov 27, 2019
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By
Caroline Lewis
Published Nov 27, 2019
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The strange sensation of numbness and discomfort in Daniel Martinez’s right leg first drove him to see a doctor to figure out what was wrong last May. A neurologist in Westchester, near where Martinez works as an engineer at IBM, conducted a series of tests involving little electric shocks that resulted in a diagnosis with severe neuropathy, or nerve damage, and a bill for $624.
The doctor in Westchester recommended that Martinez follow up with someone who specializes in neuropathy, which he did this year, visiting a neurologist at NYU Langone Health in Manhattan. The doctor at NYU Langone said he was skeptical of the first physician’s assessment and wanted to re-do the tests himself. Knowing from past experience that the tests wouldn’t be cheap, Martinez opted to do his homework first.
Under his high-deductible plan, Martinez has to spend $5,800 on medical care this year before his insurance starts paying claims; he hadn’t even approached that amount in September, when the tests at NYU Langone were scheduled to take place. So, he gathered the medical codes for the procedures—an electromyography and nerve conduction tests—and called his insurer, Empire Blue Cross Blue Shield, for an estimate. He says the insurance rep he spoke to calculated that, at most, he would have to pay a little under $1,000 out of pocket. Martinez also signed up for MyChart, NYU Langone’s patient app, which he says invited him to pay about $1,150 for the tests in advance—more than his insurer had quoted him, but in the same ballpark, at least.
It wasn’t until after he got the tests that Martinez realized how empty those estimates had been; he ended up getting charged nearly $3,600 all told.
“Even though they tell you something, it means nothing because the estimate doesn’t need to be accurate,” Martinez says. “My estimate was less than a third of what they charged me.”
Martinez reached out to Gothamist/WNYC after hearing about our health care price transparency project, #PriceCheckNYC, on the Brian Lehrer Show earlier this month. In partnership with ClearHealthCosts, we are inviting readers and listeners to share their recent medical bills and health care stories so we can shed some light on an industry that is often intentionally opaque.
There’s no law requiring hospitals and insurers to offer accurate estimates, something Martinez says he was reminded of by staff at NYU Langone when he sought to contest his charges. New Yorkers apparently have more rights when it comes to getting an estimate for work done on their cars. An auto-body shop has to provide a detailed estimate for labor and parts upon request and get the customer’s permission to do repairs that exceed the quoted price, according to the New York DMV. Health care estimates, on the other hand, can be thousands of dollars off without hospitals or insurers being held accountable.
For Martinez, the issue isn’t whether he can afford to pay for the tests, but whether the price is fair.
“This is to me as if you went to the supermarket and the cashier wanted to charge you $200 for a carton of milk,” the Harlem resident wrote in an email to Gothamist. “And if you can't afford it, they can accommodate monthly installments. But even if you could pay it, why would you pay $200 for a carton of milk?”
Martinez was particularly alarmed by the fact that he seemed to be billed twice for the same procedures. He first received a bill for $1,332.24 for physician services and then a second bill for $2,265.40 for hospital services. This isn’t uncommon. A patient going in for a surgery, for example, may receive separate bills from the surgeon, the anesthesiologist and the hospital itself for things like operating room services. A visit to a doctor at a hospital can also incur a separate charge (sometimes known as a facility fee), making it difficult to keep track of costs. But even if a patient is super informed about the ins and outs of health care billing and attempts to get cost estimates from each separate entity in advance, they can still end up paying far more than what they are quoted.
Anthem, the company that owns Empire BCBS, was unable to find a record of the call in which Martinez received an estimate for his neuropathy tests but a spokesperson noted that during other calls with him, representatives “answered questions about his plan, what providers were in network and online tools we offer to assist with planning care—including highlighting a cost estimator tool on our website.”
The spokesperson added, “In keeping with Anthem’s goal of ensuring access to high quality, affordable health care, we encourage members to reach out with questions about their benefits and coverage.”
“NYU Langone makes every effort to educate our patients about the potential cost of their visit using a patient charge estimator tool prior to their scheduled service. The majority of the time, there are only minor differences between the estimated and actual cost billed, depending on a few variables," an NYU Langone spokesperson told Gothamist.
The spokesperson continued, "Our hospital services fee is comparable to other hospitals with similar facilities. It includes the use of the facility and support staff, procedures, treatment fees, lab fees, supplies and other factors that may impact care. Depending on the patient’s individual benefits plan, there may or may not be a cost associated with these charges.”
The variability of health care billing makes it easy for both health care providers and insurers to shirk responsibility for knowing exactly what something will cost. There may be multiple billing codes that a hospital can use for the same type of procedure, for instance, and hospitals negotiate different rates with each health plan. The amount a patient ultimately ends up paying out of pocket is further complicated by factors such as their plan design and how much of their annual deductible they’ve paid.
But the complexity of health care billing shouldn’t be used to let the health system off the hook for keeping patients informed about their costs, says Sabrina Corlette, a research professor who founded and co-directs the Center on Health Insurance Reforms at Georgetown University’s McCourt School of Public Policy.
“It’s not difficult for a hospital to really know how much it will cost them to deliver a service or what the negotiated rate is with a given health plan for a service,” says Corlette. “It’s just not in their interest to be transparent about that.”
While in the past, many health care providers have directed patients to their insurers to get cost estimates, hospitals are increasingly facing pressure to provide accurate information as well, and some are developing sophisticated online cost calculators in conjunction with dedicated cost estimate help lines. But the stakes for getting the price right still seem to be higher for patients than for hospitals or insurers.
After unsuccessfully attempting to get his bills reduced himself, Martinez enlisted the help of one of NYU Langone’s patient advocates—a position many hospitals now have to help address patients’ complaints and assist them with navigating the system. The advocate contacted the neurology department, which promptly got in touch with Martinez to tell him there was nothing they could do other than allow him to pay his bill in installments. He’s now waiting to hear the results of the advocate’s attempt to contact the hospital’s billing department on his behalf.
The inherent uncertainty about what he will pay for any given medical visit has already affected Martinez’s thinking when it comes to accessing care. Recently, in the midst of his neuropathy billing saga, Martinez’s son injured his arm playing soccer.
“The first day, we didn’t do anything,” Martinez says. “I was agonizing over whether to take him to the emergency room or urgent care.” He says he called his insurer and was told an urgent care center would likely be able to offer appropriate care for less money.
Still, Martinez felt on edge.
“I do all my homework,” he says, “but I wouldn’t trust anybody now.”
This story has been updated with a statement from NYU Langone.
Tagged
pricechecknyc
NYU langone
health insurance
clearhealthcosts
Caroline Lewis
Caroline Lewis is on the health care beat for WNYC and Gothamist. She has covered COVID, a nurses' strike, the overdose crisis and New York’s marijuana legalization effort, and spent a year investigating patients' medical bills. She always wants to hear about how everyday New Yorkers experience the health system. Got a tip? Email [email protected].
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