Managing healthcare costs in the US

[bmjohnson35]

I thought I would share some info in the hopes it may help others. I apologize in advance for my long-winded explanation.

I have ulcerative colitis and I'm due for a colonoscopy this year.  We have insurance coverage through the ACA.  It's an HMO policy.  The doctor obtained approval for the procedure and I scheduled the procedure around Sept.  When I arrived to the hospital for the pre-checks and final paperwork, the hospital worker informed me that the amount I would pay out of pocket was $2700.  This was much higher than expected.  Upon further investigation, I was told that the procedure was being billed as diagnostic instead of preventive, due to my medical history.  Although I have never had cancer, I do gave UC and a history of polyps.  I have a zero deductible, but as a diagnostic and because it was being performed as an outpatient service at local hospital, I had to pay 40% of the charge up to my maximum out of pocket, which is $3k (I had already spent $300 toward it earlier in the year).  According to the scheduler, the hospital was charging $27k for the procedure, which takes around 45 minutes. The insurance allowed $14k and I was essentially paying $2700 toward the 40% of $14k. After considering my options, I canceled the procedure.  I told my doctor that I would reschedule the procedure next year after I researched my options. 

I recently sat down with my ACA agent and chose a policy with better coverage that would reduced the cost around $1k out of pocket, per person.  My wife is also due for a colonoscopy, so this would result in a savings of $2k in our out-of-pocket costs.  Since signing up for the new coverage, I found Colonoscopy Assist Online, which will save us an additional $1k each by scheduling through one of their doctors, resulting in a savings of $3k over what it would have cost us through our existing insurance/doctor.  This option means we will pay in cash and not use the insurance at all.  This organization provides a flat rate cost of $1225 for all of the costs associated with the procedure, including removal of polyps and pathology/laboratory fees.

I have recently found out that health insurance companies will code this procedure as diagnostic if you have ever had polyps removed in the past.  Furthermore, if you have a "preventive screening" scheduled and they find polyps, the insurance will still code it as diagnostic, even if you don't have any history of polyps.  The difference between preventive screening and diagnostic is significant.  A screening is usually zero charge.

We will probably switch back to our existing aca policy for 2023.  This is our first major procedure in 2 yrs and we typically don't go to the doctor for more than annual physicals.  We try to eat well and exercise regularly.  During my research, I found that my previous doctor would charge around $1700 cash for the procedure, but they wouldn't provide a firm quote. Our insurance won't allow us to use them.  This was still $1k less than what I was quoted with insurance with my existing doctor.  I also had a recommendation for another doctor that used our existing insurance.  They use a surgical center instead of the hospital, but they wouldn't provide a cash price and they wouldn't provide an estimate until we were on the schedule for the procedure.

This long-winded story serves as a reminder that you can save a lot of money on healthcare in the US by simply researching alternatives.  Don't accept the first price provided.

[ixtap]

You can also challenge coding. I went to a clinic for travel immunizations, all considered preventative. The Dr asked about my diabetes and I responded "I am dealing with that with my primary care physician." He still coded it as a diabetes follow up. Oh, hell no. I am not paying hundreds of dollars because you asked a question unrelated to my current visit.

[DaMa]

This has always been an issue with "preventive" procedures like colonoscopies and mammograms, even before the ACA.  Once they are considered diagnostic, they are no longer covered at 100%.  For most people, it's during the test that it changes (on finding a polyp or a breast tumor) so they don't even know to shop ahead of time.

[bmjohnson35]

You can also challenge coding. I went to a clinic for travel immunizations, all considered preventative. The Dr asked about my diabetes and I responded "I am dealing with that with my primary care physician." He still coded it as a diabetes follow up. Oh, hell no. I am not paying hundreds of dollars because you asked a question unrelated to my current visit.

Agreed. When I was working, I rarely fought the insurance company.  Now that I'm retired, if I feel it's worth my time, I will fight it. The more I learn, I find the whole healthcare industry generally jacked up. It's easy to come up with example after example of excess, mismanagement and waste. Our main strategy is to utilize preventive care and live a healthy lifestyle so we can minimize the need for professional healthcare.

[rantk81]

I don't have the link... but "White Coat Investor" made an enormously long and detailed thread on the Bogleheads forum on this topic.  If anyone has the link handy (or is good at searching), it might be a benefit to post it here.  It's an excellent read.

[jrhampt]

This is interesting info...I had 3 colonoscopies this year (family history of colon cancer, last two colonoscopies in hospital setting and all with polyp removal) and also noticed that while the first one was covered as preventative, the other two were not and were considerably more expensive in terms of out of pocket bills. 

Another thing I was disappointed to see this with is mammograms - I have dense tissue and was recommended to get an ultrasound mammogram in addition to the regular one.  However, the ultrasound mammogram is apparently not covered as preventative.  Of course, I didn't know this until I got the bill afterwards.  I did try calling my insurer, but they were no help.

[lifeisshort123]

Isn’t that maddening? The test is free until you actually need it…. Healthcare policy in the US is so complicated and insane…. Even getting a simple understanding of your cost before you purchase the test, procedure, treatment, prescription, etc. seems to be the least we can do…

I’m not saying we need universal healthcare, but transparency in costs would be nice….

[Reynold]

This long-winded story serves as a reminder that you can save a lot of money on healthcare in the US by simply researching alternatives.  Don't accept the first price provided.

The one part of this I would quibble with is that it was "simple" for you to research alternatives.  As you found out, it is annoyingly common to not even be able to get a price quote until you are going in for a procedure, if then.  My DW had identical surgical procedures done on the left and right side a couple of months apart, with out of pocket charges to us of about $1000 more for one surgery than the other, because the hospital used a different outside lab for a sample they sent out in each case. 

We actually walked out of a surgical center one time because they would not accept our modification of their standard agreement to pay whatever they charged, even though they were in network for our insurance and were not supposed to balance bill.  I doubt we could even do that today, because all of the agreements you sign are electronic, and you can't modify them. 

She averages about 2 hours of research and followup on billing per doctor visit at this point. . .  I'm not looking forward to going on ACA when I retire early near and eventually run out of COBRA, coverage is even more limited where we live than my company insurance plan.  No non-emergency coverage out of state, for example, so much for snowbirding. 

[JupiterGreen]

It costs my partner over a grand (maybe 2, I blocked it out it was so absurd) and we have very good insurance here in the U S of A. I'd do just about anything for single payer healthcare. Wish I could laugh at the absurdity of the US "healthcare" but it's criminal and that's no joke.

Edit: I didn't answer your question. Frankly, I don't know how to manage or prepare for healthcare in the US. It kind of feels like Russian roulette. it sounds like you are doing what you can though. I'm glad you learned about the bill before the procedure, that doesn't always happen (as someone already mentioned). So I'd say you handled it the best you could have. There are HSAs, but one can only set aside so much $ in those.

[RWTL]

Some general thoughts around outpatient procedures....

1. As you stated, it depends on how it is coded.  You can ask this prior to the visit, but the backend coders will determine separately.

2. Having a procedure in a non-hospital based clinic will be less expensive in general.  Hospital based clinics charge a facility fee in addition to the physician fees.  Just because it is not "at the hospital" doesn't mean it is non-hospital based.  You have to ask if it is a hospital based clinic or not.

3. Sometimes you can negotiate the pricing up front.  Especially if you are a cash patient.

All that said, it is frustrating at how opaque the system is - by design. 

[Abe]

As a doctor, I agree this is stupid and painful. It's mostly due to hospitals / group practices haggling with insurance companies like some bazaar. Unfortunately, since you have UC and the procedure is a bit more involved than standard screenings, it doesn't qualify as a screening colonoscopy. They are required, however, to provide clear pricing: https://www.cms.gov/hospital-price-transparency . I would get quotes from multiple clinics.

If it helps, the codes to ask for prices are (keep in mind they should only code one procedure):
45378 – Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
45380 – Colonoscopy, flexible; with biopsy, single or multiple
45381 – Colonoscopy, flexible; with directed submucosal injection(s), any substance
45382 – Colonoscopy, flexible; with control of bleeding, any method
45384 – Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
45385 – Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45388 – Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)
45390 – Colonoscopy, flexible; with endoscopic mucosal resection

Hope this helps, sorry this system is so dumb.

[bmjohnson35]

I have decided to use local facility through online national network and I'm not using my insurance at all.  It's an all-inclusive flat rate. Copy & Pasted info from website below:

What does our colonoscopy flat rate include?
Our flat rate is an all-inclusive rate. It includes all costs related to the procedure and there are no hidden charges. The price includes:

1) Physician fees
2) Facility or Hospital fees
3) Sedation or Anesthesia costs
4) Removal of polyps and taking of biopsies
5) Pathology Cost (Pathologist and Laboratory fees)

Note: Our fee includes the removal and pathology lab fees for an unlimited number of polyps and biopsies.
This is important, as normally colonoscopy costs stated do not include pathology lab fees.

The flat rate does not include prep meds, follow-up consultations or any follow-up care. 

 

[JupiterGreen]

I have decided to use local facility through online national network and I'm not using my insurance at all.  It's an all-inclusive flat rate. Copy & Pasted info from website below:

What does our colonoscopy flat rate include?
Our flat rate is an all-inclusive rate. It includes all costs related to the procedure and there are no hidden charges. The price includes:

1) Physician fees
2) Facility or Hospital fees
3) Sedation or Anesthesia costs
4) Removal of polyps and taking of biopsies
5) Pathology Cost (Pathologist and Laboratory fees)

Note: Our fee includes the removal and pathology lab fees for an unlimited number of polyps and biopsies.
This is important, as normally colonoscopy costs stated do not include pathology lab fees.

The flat rate does not include prep meds, follow-up consultations or any follow-up care.

How are you dealing with the prep and follow up? How much less expensive is this? I’m definitely going to look into it, thank you.

[RWTL]

I have decided to use local facility through online national network and I'm not using my insurance at all.  It's an all-inclusive flat rate. Copy & Pasted info from website below:

What does our colonoscopy flat rate include?
Our flat rate is an all-inclusive rate. It includes all costs related to the procedure and there are no hidden charges. The price includes:

1) Physician fees
2) Facility or Hospital fees
3) Sedation or Anesthesia costs
4) Removal of polyps and taking of biopsies
5) Pathology Cost (Pathologist and Laboratory fees)

Note: Our fee includes the removal and pathology lab fees for an unlimited number of polyps and biopsies.
This is important, as normally colonoscopy costs stated do not include pathology lab fees.

The flat rate does not include prep meds, follow-up consultations or any follow-up care.

Something to also consider - check to make sure that an anesthesiologist or CRNA is administering the anesthesia and monitoring you during the procedure.  I wouldn't have an endoscopy if the GI doc or assistant is administering the anesthesia.

[bmjohnson35]

I have decided to use local facility through online national network and I'm not using my insurance at all.  It's an all-inclusive flat rate. Copy & Pasted info from website below:

What does our colonoscopy flat rate include?
Our flat rate is an all-inclusive rate. It includes all costs related to the procedure and there are no hidden charges. The price includes:

1) Physician fees
2) Facility or Hospital fees
3) Sedation or Anesthesia costs
4) Removal of polyps and taking of biopsies
5) Pathology Cost (Pathologist and Laboratory fees)

Note: Our fee includes the removal and pathology lab fees for an unlimited number of polyps and biopsies.
This is important, as normally colonoscopy costs stated do not include pathology lab fees.

The flat rate does not include prep meds, follow-up consultations or any follow-up care.

How are you dealing with the prep and follow up? How much less expensive is this? I’m definitely going to look into it, thank you.

I already have prep meds from earlier cancelled appt. The cost is $1225 at this particular location.  I should get the results directly and will follow-up with my specialist, if needed.

[bmjohnson35]

I have decided to use local facility through online national network and I'm not using my insurance at all.  It's an all-inclusive flat rate. Copy & Pasted info from website below:

What does our colonoscopy flat rate include?
Our flat rate is an all-inclusive rate. It includes all costs related to the procedure and there are no hidden charges. The price includes:

1) Physician fees
2) Facility or Hospital fees
3) Sedation or Anesthesia costs
4) Removal of polyps and taking of biopsies
5) Pathology Cost (Pathologist and Laboratory fees)

Note: Our fee includes the removal and pathology lab fees for an unlimited number of polyps and biopsies.
This is important, as normally colonoscopy costs stated do not include pathology lab fees.

The flat rate does not include prep meds, follow-up consultations or any follow-up care.

Something to also consider - check to make sure that an anesthesiologist or CRNA is administering the anesthesia and monitoring you during the procedure.  I wouldn't have an endoscopy if the GI doc or assistant is administering the anesthesia.

Good to know. I will find out before I book it.  Thanks.

[Sailor Sam]

It costs my partner over a grand (maybe 2, I blocked it out it was so absurd) and we have very good insurance here in the U S of A. I'd do just about anything for single payer healthcare. Wish I could laugh at the absurdity of the US "healthcare" but it's criminal and that's no joke.

I strongly & deeply agree with you. However, as a person who gets “single payer” government insurance and has experienced equal levels of evil and/or banal absurdities, Imma go a step further. We need to tear this bullshit down to it’s roots, strip out the insurance companies, and start the fuck over.

Bolted = my emphasis.

[Must_ache]

This long-winded story serves as a reminder that you can save a lot of money on healthcare in the US by simply researching alternatives.  Don't accept the first price provided.

The first thing I thought was, "how much would this cost in London".  A quick google suggests 2005 pounds ($2,426). 

Then I found this:

https://www.treatmentabroad.com/costs/general-surgery/colonoscopy

Which suggests that in France you can get it done for 543 pounds ($657).  At that price I would seriously consider having a medical vacation.  You could take a day to recover and give yourself several days of tourism for the price of the out-of-pocket over here.  And we wonder why healthcare prices are high, because there isn't enough competitive incentive. 

[Michael in ABQ]

I can't really think of another market for goods and services where the consumer and provider are so separated. It's no wonder it's so dysfunctional. There is basically no price for healthcare that the market can use to make decisions. Is Doctor A charging $50 per office visit while Doctor B is charging $150 per visit? Does Doctor B promise shorter wait times or better quality of care? Since a third-party (insurance company or government in some form or fashion) is paying for almost all healthcare costs with completely opaque pricing and rules we as consumers have no idea. I know there's some new regulations that are supposed to make that pricing more transparent but it's still very opaque to the average consumer (or even the well-informed consumer).


I've been fortunate to have healthcare through the National Guard that is both fairly cheap and provides excellent coverage with minimal out of pocket expenses. It's frankly something that will probably keep me from retiring for another decade since I'm self-employed and only have to pay about $250/month for family coverage and maybe a few hundred extra per year in out-of-pocket expenses.

[Reynold]

As a doctor, I agree this is stupid and painful. It's mostly due to hospitals / group practices haggling with insurance companies like some bazaar. Unfortunately, since you have UC and the procedure is a bit more involved than standard screenings, it doesn't qualify as a screening colonoscopy. They are required, however, to provide clear pricing: https://www.cms.gov/hospital-price-transparency . I would get quotes from multiple clinics.

If it helps, the codes to ask for prices are (keep in mind they should only code one procedure):
45378 – Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
45380 – Colonoscopy, flexible; with biopsy, single or multiple
45381 – Colonoscopy, flexible; with directed submucosal injection(s), any substance
45382 – Colonoscopy, flexible; with control of bleeding, any method
45384 – Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
45385 – Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45388 – Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)
45390 – Colonoscopy, flexible; with endoscopic mucosal resection

Hope this helps, sorry this system is so dumb.

Not that I am any kind of medical expert, but am I correct in my interpretation of the above that they would not necessarily know which code they are using until they have completed the procedure?  Code 45382 in particular, requiring "control of bleeding"?  And if during the procedure with bleeding control they find a polyp and remove it by hot biopsy forceps, does code 45384 replace or add to 45382? 

Which is probably why when we ask this question we get the generic answer "we won't know what code we are billing until we bill it". . .  Not very helpful for price shopping. 

[Abe]

45390 is the most expensive and 45378 is the least. Ask for those specific codes’ prices to get an idea. You are correct we won’t know which code applies until we’re done
with the procedure, but we have to choose only one

[JupiterGreen]

I am completely ignorant on this subject and just assume we will look into ACA once we leave our jobs. But maybe there is another way. Does anyone know if there is any way to get healthcare in the US after retirement that is not Medicaid or ACA? Government or state jobs? Are there any part time jobs that offer continued healthcare after a certain amount of years worked? We are getting in our 50s so not really early retirees, though I might consider working somewhere longer than planned if it would allow continued healthcare after separation from work. Any idea of how to start researching this? Our jobs do not allow us to continue healthcare once we separate even though we have been with them a significant number of years.

[jim555]

I am completely ignorant on this subject and just assume we will look into ACA once we leave our jobs. But maybe there is another way. Does anyone know if there is any way to get healthcare in the US after retirement that is not Medicaid or ACA? Government or state jobs? Are there any part time jobs that offer continued healthcare after a certain amount of years worked? We are getting in our 50s so not really early retirees, though I might consider working somewhere longer than planned if it would allow continued healthcare after separation from work. Any idea of how to start researching this? Our jobs do not allow us to continue healthcare once we separate even though we have been with them a significant number of years.

Pre Medicare ACA / Medicaid are the only avenues.  Some people do health share plans, but they have no legal obligation to pay a dime and are not insurance.  The best way to keep costs contained is have low income.  Silver plans (only Silver) under 250% FPL have cost sharing reductions that greatly reduce out of pocket costs.  Stay in the subsidy zone and the benchmark plan is capped at a percentage of income.

For an estimate of ACA subsidies...
https://www.kff.org/interactive/subsidy-calculator/

[reeshau]

You can also look for an individual insurance policy, which existed before the ACA came into place.  They are not subject to the same minimums / mandatory coverage of ACA plans, but of course are not subsidized, either.  If you aren't likely to get ACA subsidies or have specific medical situations, it might make sense.

[JoJo]

I've chosen to do a health share plan as long as they don't bring back the penalty for not having ACA coverage.  There are a multitude of reasons I prefer health share to ACA: 
* WAY cheaper... like $200/mo vs. $500/mo. 
* I am nomadic so the in and out of network doesn't matter... the ACA plans in my mailbox state are super narrow networks. 
* They also cover me internationally, that being said, I also get travel insurance as a back-up since its relatively cheap.  Many ACA plans have 0 coverage outside the US. 

That being said, the health share has some exclusions, but they are things I have a low probability of needed to utilize. 

[lifeisshort123]

The other thing to note, which is maddening, is that ACA premiums are not paid PRE tax, they are paid POST tax dollars, though you can expense them as medical expenses if they exceed a certain percentage of your income if you itemize.

There are additional self-employed ways to take the deduction on a pre-tax basis.