A detailed look into the bill for a routine dermatologist visit:

Addendum: Verbalk posted extremely useful information in his post below.

My wife has white skin, that as it ages develops signs of sun damage. Not really different that any other white person, she is well advised to have skin screenings about once yearly by a dermatologist to sort out the benign skin changes (keratoses) from skin cancers. It was this sort of routine screening she went to twice in 2009. The first visit resulted in removal of two lesions, one by biopsy over concern it may be cancer, and the second erased by cryotherapy. The second visit was follow-up of the first visit, and another lesion was erased at that time.

The bill in SS form is here, in Google Docs. Look but do not change please

Our insurance company BCBS initially denied all claims as 'pre-existing conditions' but after hours with them on the phone, changed their minds and allowed all claims. This bit of BCBS stupidity did have a benefit though: I now know 'list price' and 'in-network' charges for these visits. I am sharing details of the bill with the FW community, because I think it is informative in a number of ways:

1. If you thought outpatient medicine care might be expensive, all I can say is, you have no idea.

2. How much money is a patient saving by using the insurance price-sheet, rather than the list price ? Here is one example. Discounts seem to be 5 - 40% by CPT. I honestly was expecting an average 70% discount off list price. Boy was I wrong.

3. Many (most) services have two charges: the provider, and the facility. I was amazed at the facility related charges.

4. The SS is a view into the complex world of medical billing. Briefly, any number of services are rendered. Each service has a CPT (service code) that carries a list price for people who pay cash out of pocket, or a price an insurance company has negotiated as an in-network charge., meaning predetermined fees for service the providers have agreed to. PPO services (out of network) have a much more bizaare pricing scheme based on 'customary' charges that is not discussed here, or detailed in the SS. Separately, charges are generated for each CPT code for both the provider and the facility. And lastly -- news to me -- the CPT based charges vary by the reason/diagnoses for the service.

This information was non-trivial to collect. Trust me on that point.
Summary of the SS: A visit on 2/20 where the dermatologist looked over the skin, biopsied one lesion that was read by a pathologist, and erased a second, cost $1128 out of pocket, or XXX using the insurance company's pricelist.

The second visit looked at the biopsy site for good healing, and a second lesion was erased. That cost $598 out of pocket, or 348.94 using the BCBS pricelist. The in-network discount was XX% for the first visit, and 41% for the second visit.

As you can see, costs mostly related to in-network charges are still being sorted out. Since it might be months before I know, I decided to post this now since it was already an eye-opener to me.

Post some pics and we will look at her skin for sun damage for free.

tl;dr version: Medical care is expensive.

Facility charges are a straight up scam by hospitals. Lot's of articles have been written about this lately. You can avoid them by going to a non-hospital based faciliy. Basically, if a clinic is with 35 miles of a hospital and can demonstrate some integration with that main provider, they can bill Medicare a hospital facility fee. Medicare originally put some tough registration requirements when the provider-based system was formalized in 2000. Since then, the administration in 2003 decided to not enforce these requirements and make registering these facilities optional. That opened the floodgates for hospitals to add all sorts of dubious off-campus faclities to their billing registers. Some insurers opt not to pay these fees, sometimes sticking the bills with the beneficiary. Medicare pays them blindly. If you feel strongly about this, I suggest writing your congressperson, especially if you live in Seattle since that guy was poking around this issue a few weeks ago.

I had to go to a dermatologist to have a cyst removed on my back. After my insurance paid him, I was left with a $600 bill. The break down on it, when I called to ask cause it looked funny, was thus:

$300 to open me up.
$300 to close me back up.

Yeesh.

If you want to see some Medical Bills, I have plenty of them you can see (and pay).

A funny bill I once got was for this:

Injections
Amount billed: 30.00
Not Covered: 29.46
Covered: 0.54

The Doctor actually tried to bill $30 for an "Injection" but the Insurance would only cover 54 cents for the "Injection." If that's not over billing, then I don't know what is!

I goto a well-regarded University of Michigan dermatologist and pay ~$100 to have moles removed (numbed up, completely removed, cauterized or stitches) and ~$100 for lab work. Thats it, no BS facility fees, office visit fees, etc. I wouldn't expect to pay more as I'm typically in and out within 15 minutes.

Jeeeez i heard a rumor that if you buy those compressed air cans, made to blow dust of your keyboard, turn them upside down and depress you will get liquid nitrogen out of the tube. Rumor, i heard, and would never recommend doing your own q-tip medical procedures ....

And because you thought your insurance would foot the bill, you didnt really shop around or care about the price. You have now figured out the problem of "insurance" and healthcare. These guys can charge whatever they want because 99% of people dont care about the price. Now, Obama wants to give everyone insurance so everyone won't care about price and they will continue to skyrocket.

If you had known about the pricing structure, I am guessing you would have shopped around, correct?

I always know the hospital does a lot of cost shifting to those with better coverage. I never know about how the unions factor into the whole picture until this past week. A friend's wife is starting a new job in the ultrasound department. Required training for her job in the previous job is a 2-year certificate. Starting the new job means you have to get certified within a year or so. Anyway, starting pay is $40 an hour. As part of the cost cutting they have eliminated weekend OT. It was double time, that is, $80 an hour. I start to wonder if the high hourly wage is the result of, (1) the union negotiated it, (2) before all the cost-cuttings the hospital was able to bill as they wish and then able to pay an ultrasound technician that much. This is a hospital that serve a large Medicaid population and frequently come and ask the voters to up the millage.

These topics just make me sad. As an eye surgeon, I hate hearing from patients how I'm a fat cat while at the same time seeing reimbursements cut. If anyone has any question about how costs continue to rise, take a look at these BS fees that some useless administrator figured out how to take advantage of and pad the bill.

$40/hour base salary for a radiology tech is about right but varies tremendously geographically. Also, techs employed by hospitals earn more than those who work for a contracting agency. It may not be rocket science, but good techs are in high demand and it's not child's play either. Repetitive stress injuries are extremely high among ultrasound technicians.

hkgfnt said: VerbalK said: The AVG annual salary of an ultrasound tech is closer to 25 to 30 per hour, uncertified techs probably much less. All hospitals serve a "disproportionately" high medicaid population, so that factoid you heard is likely just propaganda. I have no idea why your hospital is paying 80K plus for an uncertified tech (that would be high for manhatten), but Ill assure you that is not the norm. TESST college churns out plenty of ultrasound techs. PT/OT/SLP practitioners would be more believable. a

I asked my friend if the $40 an hour claim factors in benefits. He said no. May be he was blowing smoke? I did not think ultrasound is that complicated nor highly skilled. Thus my guess about the crazy union.

Now true story about a friend who was in the hospital after a fall. Someone from whatever department dropped off a back brace while he was asleep. The next day someone from PT or whatever came by to show him and the person did not know how to. Finally a real PT person showed up and worked with him on using the device. He was billed for three sessions of PT therapy. My suspicion is this kind of creative billing happens every day.

Next time diagnosis it yourself. Think of the money you save.

You know whats expensive? Call a plumber on Thanksgiving. Its just a pipe, not living tissue.

Red for OP.

Basically the OP has detailed the information on the Explanations of Benefits (EOBs) that arrive like clockwork every time I have ever gone to the doctor. I have always known what the "billed amount" is vs. the "in-network" price. Sometimes there is a much larger Delta, especially for Lab work (I have gotten $350 list prices reduced to $18 bucks by the insurance company).

This is the problem with health insurance. Even though my medical needs are minimal, I can't afford to be a self-pay simply because the rates for self-pay are so astronomical. Of course, if you look at the reasons why these rates are so high, you'll quickly find yourself tracing back to Medicare/Medicaid and other government-run programs that have consistently reduced reimbursements and have defined them as percentages of the cash rate. For example, one year Medicare says they're going to reimburse 20% of the billed amount for Procedure X. The next year, the reimbursement drops to 10%. Is it any surprise that the cash rate doubles?

But not to worry. Government-run health care will be so much more efficient and cost-conscious, right? After all, our fearless leader tells us there is at least $500 billion in fraud, waste, and abuse funds to be recovered from the existing systems. Never mind that those funds will never materialize...

narshe14 said: There's a reason why so many med students are trying to get into dermatology residencies.

Yeah, it's because it just doesn't pay to go into internal medicine, family medicine, and other primary care specialties. If you compare someone who goes through college, medical school, residency, and sometimes fellowship, to a kid who leaves high school for a minimum wage job and modest raises, the guy who starts out flipping burgers comes out ahead until something like their mid 40's.

But anyway, this points out an important thing to realize, and that is that things that a doctor needs to suggest are not always cost effective. It's like blindly going for the undercoating and the tire protectors from a dealership when buying a new car. Usually, doctors won't offer you something totally extraneous, but they will err on the side of caution. Did your wife really need the cryotherapy done by a dermatologist? At all? What were the alternatives?

From the dermatologist's standpoint, it's a no-brainer. A lesion looks benign and is 99.9% likely to stay that way - and if it does change, it will take a very long time before it gets out of control. But you recommend freezing it off because a) it brings in more revenue; b) patient's like having unblemished skin; c) you don't have to worry about it any more; and d) if you leave it, and the patient ignores it because all they hear is "benign", yet comes back 5 years later with bad cancer, guess who's on the hook?

The point? Ask what is happening to you. I would love it if everything was listed out beforehand with the price clearly stated. If you go to the doctor's office for immunizations, and know you're in good health, ask how much they're gonna charge you for having a nurse put a blood pressure cuff on, push a button, and record some numbers. If you bump into something and have some pain in your ribs or elbow, ask the physician how an x-ray is going to change what happens and how much it's going to cost. Would you be willing to pay $200 to "check for rib fractures" if they tell you the treatment for uncomplicated rib fractures is just pain control and taking good deep breaths?

walletlessesque said: okwlater, why do you presume that the detail present on your EOB is present for everybody else ?

I'm not okwlater, but I had the exact same assumption as him. I assumed everybody always got EOBs for services. OP had BCBS, which is the same as me, and we've always received them. I've got BCBS EOBs from 15 years ago that break out charges and approved costs in detail. My dental insurance does the same. I've been seeing detailed EOBs since I was a teenager, and I guess I just figured it was run of the mill for the process (after all, how can you have accountability in the process without it). I guess I was wrong (or perhaps the OP has had EOBs available to him the whole time but unknowingly signed up for online EOBs and never retrieved them).

mikeyboy said: jellyguy11 said: There is no question the system is broken and administration has taken on a role much larger than it needs to. And while I am sorry that physicians in this country have to put up with so much nonsense, specialist MDs have it pretty good. Not as good as they used to, but it's a sweet gig.


Monkey7247 said: These topics just make me sad. As an eye surgeon, I hate hearing from patients how I'm a fat cat while at the same time seeing reimbursements cut. If anyone has any question about how costs continue to rise, take a look at these BS fees that some useless administrator figured out how to take advantage of and pad the bill.

Yeah, sweet gig. Spend 4 years of college, 4 years of med school, 4-5 years of residency and 1-2 years of fellowship (for those counting, how about 15 years total), all while building up $300-500k in debt. I'd say those 10 years of med school and residency are harder than 99% of jobs out there - all for essentially no pay (you pay $40-50k a year in school then get paid about that amount throughout residency). 10 years - that's about 25% of your potential career. Even dermatologists put in their time up front (many have spent at least a year doing research) such that they should be allowed to enjoy the next 20-30 years of their career.

1. Everybody has to go to college for a professional job now.
2. I would gladly pay a tax to make med school affordable (if not free) for Docs willing to specialize in primary care/internal medicine.
3. The residency system is as broken as the rest of the health care system... serves no real purpose other than allowing hospital to use cheap labor and making the medical professionals inordinately scarce due to aritically high entry costs
4. Fellowships are usually reasonably well paid (compared to residency)