I’ve previously written about the power of an HSA, but have yet to write about health care in general.
Health care is a tough topic to write about. In the United States, it’s a polarizing subject. I have many thoughts and feelings about it, but that is not what this post is about.
It’s about understanding your health insurance plan, how to be an advocate for yourself, and how to be a better consumer of healthcare. It’s about lessons I’ve learned recently, as well as throughout time, and how to work within the system we have today.
With that said, I am not a healthcare expert. I am not an investigative reporter focusing on the American healthcare system. I am a healthcare consumer learning like you and trying to make better decisions to avoid unnecessary costs.
My hope is this post inspires you to think about your own healthcare decisions and how they relate to your money.
Recent Healthcare Experience
I am young and healthy, which means I spend very little time thinking about my own healthcare decisions. On the other hand, my dad was diagnosed with Stage IV Lung Cancer about four and a half years ago, which means I spend significant time thinking about the healthcare system and how challenging it is to navigate. Those are stories for another time. Today, the focus will be on my story.
Since I do not use the healthcare system very much, I rarely think before doing something in the healthcare system and recently, that was a mistake. My normal healthcare routine is an annual check-up plus a dermatology visit for a skin check because my family has a history of skin cancer.
The annual check-up does not cost me anything because it is a preventative visit under my health insurance plan with no deductible. The annual skin check is not classified as preventative in our health insurance system (cue: eye roll), which means I pay out of pocket. This last year, it was billed as $287, my health insurance plan had a “discount and payments” of $125.92, therefore, I paid $161.08.
Unless something major happens, I pay very little for healthcare each year. I am incredibly lucky and grateful for it because I know that could easily change.
Throughout my life, I have experienced sudden, rapid heartbeats, but they were very infrequent until this past year when they seemed to be increasing in frequency. After some searching and talking with my partner, Molly, who is a medical student, it seemed like supraventricular tachycardia (SVT). It’s an arrhythmia. Some types are dangerous, but the type I have has minimal risks. I carefully tracked my symptoms this past year, including when they occurred, what I was doing, how long it lasted, and how many beats per minute. Data is important.
I took the data to my primary care provider who also thought it was SVT. He admitted it was low odds we would find anything on an ECG, but suggested we perform an ECG to be safe and refer me to a cardiologist. Without thinking, I said yes to both. The ECG revealed nothing.
Then, I scheduled my cardiology appointment for about a month and a half later. When I arrived, they had me do another ECG. It revealed nothing.
I started to wonder how the two ECG tests would be billed. I did not know I would have another ECG when seeing the cardiologist or I would have skipped the ECG with my primary care provider. I felt stupid for not thinking ahead or asking more questions.
What was the damage?
The ECG was billed for $263, my insurance discount was $78.99, and my out of pocket responsibility was $184.01 both times. The cost for a doctor to read it was $23, my insurance discount was $5.18, and I paid $17.82 both times.
In total, I paid $403.66 for two ECGs when I should have advocated for myself or asked more questions prior to saying yes to those exams. As I think back on it, I should have advocated for one test and only paid $201.83, but I did not think ahead or ask more questions.
What lessons did I learn?
- Ask more questions, particularly around testing
- Review your health care bill and insurance explanation of benefits carefully to plan ahead next time
- Look at costs in advance, if possible (more on that below)
- Don’t expect your healthcare provider to know the cost of the tests they order
Thankfully, I am healthy and there are plenty of scenarios where it could have been ten times as expensive; however, it was a good reminder that I need to be my own healthcare advocate.
How to Compare Costs
Remember how I said earlier that my annual skin check was $287, my insurance paid $125.92, and my out of pocket cost was $161.08? I switched dermatologists last year from the prior year. The prior year, the visit cost $313, insurance paid $69.48, and my out of pocket cost was $243.52. My new dermatologist is about 8% less expensive in terms of the total billing amount, but is about 33% cheaper for me personally. Switching saved me about $82.44.
I had the same insurance plan for both years. By switching to a different provider and medical system, not only was the total amount less, but the insurance discount with that provider was also more. It was a double benefit.
After receiving my ECG bills, I called Premera and asked them to explain the bills and to better understand the split costs between reading the ECG printout and the ECG exam. Or, as the person I spoke with said, “The cost of turning on the machine.” I laughed when he said that because I pictured a $263 light switch. For anyone who has never had an ECG, they hook up electrical sensors to you (Molly would like to clarify it is where they stick sensor pads on your skin to monitor the electrical activity in your heart). It’s more than turning the machine on, but it’s still funny how they split out the cost and label it.
As I was on the call, I was curious about how the cost compared to other providers in the area. I asked if they had that information, and he said he might. After a few minutes on hold, he found another provider in their system and said it was double. DOUBLE! “Wow”, I thought to myself.
Now, I was even more curious about other procedures. I asked if I had access to any of the data, and he said there is a tool online, but it only shows providers who voluntarily show their prices.
Still, it’s something.
I searched for “Skin Lesion Removal (Benign), Scalp, Neck, Feet, Hands, Genitals” because I’ve had to have a few moles removed in the past.
The estimated cost ranged from $100 to $413!
To be fair, I do not know the educational differences, skills, years of practice, etc. between the doctors listed, but I am surprised the same procedure can have an estimated cost that is four times more expensive in the same geographic location.
Using this tool, I can look up most medical services to determine an estimated cost with any provider who has completed the information. Since most medical procedures are recommended to me on the spot, I am not sure how much use I will get out of the tool, but it is nice that it is available.
I suppose I could use it to look up how services compare between the medical system I use and another. For example, apparently, I used to go to the dermatology clinic that was known for expensive care, but I had no idea until someone told me. Had I looked online at different procedures, I may have been able to discover it myself.
Although there are not many good tools in the healthcare space to look up estimated costs of procedures or “fair” costs for procedures, a little progress has been made.
For example, Medicare released a tool to compare national average prices for outpatient procedures.
The problem is that it is not as simple as typing “skin lesion removal” and finding the right procedure. Medicare wants you to be exact.
I had an easier time searching for the medical code of skin lesion removal and then typing it into Medicare to find the proper procedure. Even though I typed “removal of growth”, what I wanted did not show up until I typed “removal of growth (1”.
Once you find the right procedure, it provides the national average price at an ambulatory surgical center and hospital outpatient department. It also includes what Medicare pays. Unfortunately, the tool does not take into account your geographic location or personal health insurance. It probably will not be very helpful in your individual situation because you may live in a higher cost of living city and your health insurance may not cover it. Some people use this tool for help in negotiating prices if they are uninsured or hit with a surprise bill.
The tool is helpful to give you a ballpark cost estimate, but I would never rely on this tool if I were to have a large procedure done. I would talk to the medical provider’s billing department and my health insurance prior to a large procedure.
Another tool you can use is Fair Health Consumer.
You can select medical and hospital costs or dental costs, select whether you are staying in-network, out of network, or uninsured, type your zip code, and then search for the procedure. Their tool is a little more user-friendly than Medicare’s. I was able to type in skin lesion removal and find different procedures.
Searching the same as before, I found the prices below.
I’m not sure why it did not have an in-network price, but if I scrolled down, I could see a local price comparison of the surrounding areas for out-of-network and in-network prices.
Again, I would not rely on a tool like this to make a decision, but it can tell you a rough estimate of what the procedure might cost.
Another tool I’ve heard mentioned is Health Care Blue Book. Unfortunately, they are making changes to their tool, and it is not currently available.
Finding costs is challenging. There is no way around it. Online tools can give you the roughest of estimates, but before having anything done, the best action is to talk with your provider about what needs to be done, including medical billing codes, speak with the facility to determine the cost, and then talk with your insurance company to see what is approved and what discounts are available to reach a final estimated cost.
Steps You Can Take to Prepare and Reduce the Likelihood of Expensive, Surprise Bills
As may imagine, there is no foolproof plan to avoid expensive, surprise medical bills; however, there are steps you can take to reduce your chances of it happening to you.
- Review your insurance plan and what it covers.
If you do not know what your insurance covers, you are going to be surprised. Review your insurance coverage and try answering the following questions:
- What counts as preventative?
- For non-preventative care, how much will your insurer pay?
- What is your deductible?
- What is your coinsurance amount?
- What is your out-of-pocket maximum?
Looking through my health insurance, a hearing exam is not covered. Preventative lab work is paid 100% by the insurance company. Diagnostic lab work is paid 100% by me until I reach my $2,500 deductible and then the insurance company pays 80% while I pay 20% until my out-of-pocket maximum is met.
- Ask for billing codes before procedures and get preauthorization before having procedures done
Prior to having a procedure done, confirm with your insurance company that they will cover it. I realize this is not always possible in emergency situations, but in non-emergency situations, you can. Your doctor may not know the billing code, in which case, you may need to ask more questions or talk to your insurance company.
- Ask if all tests and doctors are in-network
Sometimes, people see their doctor who orders a lab and then they discover a lab may be out-of-network, resulting in a higher price. Even doctors may be out-of-network without you realizing. If your primary care doctor refers you to a specialist, ensure they are in-network.
Despite taking many careful steps to avoid surprise bills, this woman confirmed her surgeon was in-network and what was covered by her plan, but received an unexpected bill because her anesthesiologist was out-of-network.
- Research which hospitals are in-network and if the ER physicians are also in-network
You don’t always have a choice of where you will go in an emergency, but if you do, knowing which hospitals are in-network could help.
Some hospitals keep ER physicians on staff while others contract through a different company. It’s possible your hospital may be in-network while the ER physicians are out of network. You can read more about these problems here. It’s not just ER physicians, but anesthesiologists, radiologists, pathologists, and other specialties.
Unfortunately, many ambulance companies are not in-network and are the source of surprise billing.
If you still end up with a surprise bill, consider negotiating with the provider or filing an appeal with the insurance company.
Summary – Final Thoughts
Health insurance and medical care is complicated in the United States. The complexity can lead to spending more on healthcare than anticipated.
I was reminded of that during my last few visits to my primary care doctor and cardiologist.
Although there is no perfect or even average tool to shop around, there are resources that allow you to compare costs. I would start with your health insurer if they offer a tool, and then use one of the websites listed above.
The more you know, the less likely you are to be surprised by a medical bill. Do not be afraid of asking questions – lots of questions! If you don’t ask about in-network providers, whether labs will be in-network, or billing code procedures, you may be in for a rude awakening when you open a medical bill.
Lastly, don’t forget to update your address with your medical providers if you move. There are stories every year of people who find out a medical bill from years ago went to collections because they moved and their credit score was hurt.
If you have tips or a story you want to share about your healthcare experience, please post it in the comments below.