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Hit with a 6-figure surgical bill, patient challenges insurer, system

At Lown Institute conference, offers tips for surgery candidates

March 8, 2015 (San Diego, CA)— If Peter Drier knew then what he knows now, he might have resorted to becoming a medical tourist for relief of his herniated disc. What he discovered after his surgery in New York last year, was a fat, unreasonable bill from the assistant surgeon who performed part of his procedure. Because Drier was “morally outraged” about the $117,000 fee—especially after his insurer paid up, no questions asked—he felt compelled to find out why.

He immersed himself in hours of self-directed study into the world of provider billing practices and payments searching for grounds for a reversal decision, only to learn that the charges were indeed allowed. The reason: As an out-of-network provider, the assistant could bill separately—with no known limits to his charges. Drier, 37, had hand-picked his surgeon, but could not do the same for the assistant surgeon, who is customarily assigned by the primary surgeon.

To add insult to injury, Drier also learned that that fee represented 20 times more than what his primary surgeon was paid, and 35 times what the rate for Medicare would have been.

Here are questions and tips that patients should consider asking of insurers, surgeons or facilities before undergoing a procedure:

  1. How much will the procedure cost? What portion do I pay, if any?
  2. Understand your deductibles, co-pays and out of pocket numbers for your insurance plan.
  3. Ask if your surgeon’s assistant, or anyone else involved in the procedure, is outside your insurance network. Be extra careful of “consults.”
  4. If laboratory work is being sent, ask whether it’s in-network. If possible, insist that it is.
  5. Does the cost of the procedure include fees for anesthesia, operating room time and various medical tests required during surgery?
  6. Do you have coverage for home health services, special equipment or rehab facilities, if needed?
  7. Find out how much you may be responsible for paying for prescriptions.

The Drier case, which attracted attention from The New York Times, also exemplifies the quandary that patients face when they enter the healthcare system. Providers say they do not know what costs will be incurred, who is responsible for them, and in Drier’s case, what physician or ancillary service might become involved and bill separately. High deductibles, co-pays and co-insurance further complicate the mosaic of who pays what.

Even though Drier did inquire about costs ahead of time, no one, not even his doctor, could provide any information. “Every year our insurance premiums go up,” complains Drier. “And these increased costs are related to what doctors and hospitals are getting paid. I did have the best medical care in the world—but at outrageous cost.”

Transparent costs remain crucial for patients, considering that medical expenses are the principal drivers for bankruptcy in the United States.

To hear about Drier’s experience, attend Tuesday’s plenary session at the Lown Institute’s third annual conference, Road to RightCare: Engage, Organize, Transform, at the Omni San Diego Hotel. The session will be moderated by Steven Weinberger, MD, FACP, executive vice president and chief executive officer, American College of Physicians.


About the Lown Institute

The Lown Institute, a nonprofit, action-driven think tank in Boston, is dedicated to transforming the culture of medicine and building a healthcare system that is affordable, effective, personal and just. The Institute was founded by renowned cardiologist and Nobel Peace Prize recipient, Bernard Lown, MD, and supports his vision for compassionate healthcare. Visit www.LownInstitute.org and follow us on Twitter at @LownInstitute.

 

Contact:

Margie Coloian
Director of Communications
Office: 617-992-9349
mcoloian@LownInstitute.org

 

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