Outpatient surgery more than a 4 day c-section?!?

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I'm trying to wrap my head around some hospital charges. 

In August my wife had a scheduled C section and then spent 4 nights in the hospital.
In September I had scheduled outpatient umbilical hernia surgery and was in the hospital for 4 hours (about half of which was just sitting in the recovery room) 

We both went to the same hospital - her hospital charges were $12,200 & mine were $14,560! How is that even remotely defendable from the hospital? We either got a deal on the csection or screwed on the outpatient.

 NOTE: neither one of us had any complications/extra charges and these bills did not include the doctor or anesthesia charges.

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no, but I've paid for 2

imbatman (Oct. 25, 2016 @ 2:37p) |

Maybe -- the OP was not specific on purpose, but even if that was the adjusted insurance portion the math still works ou... (more)

RedWolfe01 (Oct. 25, 2016 @ 2:56p) |

I think your larger point about competitive pricing for maternity care is valid.

Just so we're on the same page, there ar... (more)

doveroftke (Oct. 25, 2016 @ 3:34p) |

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what is the charges after insurance adjustment?

Hers was $7900 and mine was $5500. I assumed the insurance adjustments would be based on certain charges that would be lower if the original bill was lower. Even with adjustments prices still seem mismatched.

nic3456 said:   Hers was $7900 and mine was $5500. I assumed the insurance adjustments would be based on certain charges that would be lower if the original bill was lower. Even with adjustments prices still seem mismatched.
well the overnight stays are basically just medical hotel rooom

It's sad when a major purpose of an insurance contract is to circumvent absurd prices on medical services.

had you already met or approached the deductibles prior to either procedure? Do you share the same insurance? How many staff, surgical techs, assistants, nurses, etc, were neede for your procedure vs. your wife's C-section? Possible explanation: Different wards of the hospital are sometimes relatively independent/autonomous of eachother. i.e. Maternity/OBGYN has different billing system and costs than ER, which is billed differently than elective OR surgeries. You could always ask them. It's strange to me, but sometimes the billing dept at a hospital can alter charges and/or make financing deals to pay things off. It's better for them to get paid SOMETHING vs. nothing at all.

Competition for maternal services likely reduced those costs.

taxmantoo said:   It's sad when a major purpose of an insurance contract is to circumvent absurd prices on medical services.
  It's also sad when the cost of medical pricing is highly inflated in order to actually get reimbursed the actual cost from government payers.

For OP: The whole thing is a game. You are comparing apples and oranges, and even apples can vary in price by multiples from one hospital to another

Freakazoid said:    It's also sad when the cost of medical pricing is highly inflated in order to actually get reimbursed the actual cost from government payers.

  

Let's assume a c-section and four day stay billed at $12k gets the hospital $4k from Medicaid.
Are you saying that if they billed $5k, Medicaid would pay them less than $4k?
Or, worse yet, that if they billed $100k, Medicaid would pay more than $4k?

No Medicaid in your example pays the agreed upon rate. So if that was 4K then they get 4K. Doesn't matter what they want to charge.

C-section charges were likely in-network.  Hernia surgery charges might have been out of network.  In network charges the amount is pre-negotiated by your insurance company.  For out of network charges, they can charge whatever they want.

Both procedures were in network and we have the exact same insurance. Our final out of pocket was different because of copays, but I didn't provide those amounts since there are other variables there.

nic3456 said:   Both procedures were in network and we have the exact same insurance. Our final out of pocket was different because of copays,
 

  Does that not invalidate the notion that you have the exact same insurance?

State mandates for maternity care or some kind of state or private subsidy could also be involved.

Glitch99 said:   
nic3456 said:   Both procedures were in network and we have the exact same insurance. Our final out of pocket was different because of copays,
  Does that not invalidate the notion that you have the exact same insurance?

  Our copays were different because my wife had some other charges earlier in the year so she maxed some deductibles that I hadn't.  Overall with our plan we each have a max $2700 deductible and then a $3000 copay Max.

taxmantoo said:   
Freakazoid said:   It's also sad when the cost of medical pricing is highly inflated in order to actually get reimbursed the actual cost from government payers.

 

  

Let's assume a c-section and four day stay billed at $12k gets the hospital $4k from Medicaid.
Are you saying that if they billed $5k, Medicaid would pay them less than $4k?
Or, worse yet, that if they billed $100k, Medicaid would pay more than $4k?

  No but if everyone started charging $4k, ie what it actually costs,  then you don't think Medicare would drop the reimbursement to $3500?  It's just a cat and mouse game.  In the end the charges are really meaningless. Medicare pays $X depending on some ridiculously complicated formula. Insurance carriers pay $Y based upon their contract with the hospital (often based off Medicare reimbursement). If you are uninsured, you'll pay whatever they can get out of you.

But again, comparing 2 different procedures is apples and oranges. Completely different procedures, one performed inpatient while one what outpatient. One was a surgeon with scalpel which can be much cheaper than a surgeon with laparoscopy or even a surgeon with "robotic" assistance ($, $$, $$$). Implantable mesh? more $$  A number of differences.  And in the end you'll end up paying your out of pocket max anyway.

that's extremely cheap. my overnight appendectomy in SF billed my insurance 45k, which they paid. I paid $75.

nic3456 said:   We both went to the same hospital - her hospital charges were $12,200 & mine were $14,560! How is that even remotely defendable from the hospital? We either got a deal on the csection or screwed on the outpatient.

You're making the mistake of assuming that the hospital's "rack rate" has any basis in reality. It doesn't and nobody actually pays it, so it doesn't matter.

motuwallet said:   that's extremely cheap. my overnight appendectomy in SF billed my insurance 45k, which they paid. I paid $75.
  everything's more expensive in SF

rufflesinc said:   
motuwallet said:   that's extremely cheap. my overnight appendectomy in SF billed my insurance 45k, which they paid. I paid $75.
  everything's more expensive in SF

 "I left my appendix in San Francisco..."

Probably it was insurance mistake and you will get additional charges for c section.

This is why hospitals need to publish charges upfront which would allow for greater transparency and allow consumers to make financially sound choices for elective procedures.

Having had a couple of surgeries, both in- and out-patient, in the last couple of years, plus relatives who have had to have hospital stays and rehab center stays, it sounds to me like your wife got a bargain on her treatment and room, and that the charge for your treatment was not excessive.

I think you got a deal on the c-section. I had a vaginal birth in a hospital, left 14 hours after giving birth (so 1.5 days there total), and got a bill for $30k. What a racket. Then had another $5k charge from the birth center I was intending to give birth at before they transferred me (though that also includes all my pregnancy care). Best part is the midwife from the birth center managed my hospital birth. So that $30k didn't even include charges for a hospital doc to manage my birth.

For comparison - did not get transferred to a hospital for my first child, and just paid the $5k for the birth center. Much preferred giving birth in the birth center as opposed to the hospital as well.

nic3456 said:   Hers was $7900 and mine was $5500. I assumed the insurance adjustments would be based on certain charges that would be lower if the original bill was lower. Even with adjustments prices still seem mismatched.
  
Adding those together I get $13400 -- i would hazard a guess that your family max OOP is somewhere around there and you capped out during your hernia operation.

Plus, as Stano said, there is a LOT of competition for births.  People know WELL ahead of time that one is coming up and can shop.  Even if hospitals don't like to price anything, women talk...  especially about babies...  and it likely comes up.  It is predictable to the point of - and enough in advance that it affects insurance election options too.   How many co-workers do you have who picked the PLATINUM insurance option when the wife was pregnant?  (which to me is silly, because you are GOING to hit the max OOP either way with all the pre and post natal care as well as delivery)
 

Platinum insurance OOP+premiums are often lower than bronze OOP+premiums. For instance Kaiser CA HMO 1a has a $1500 a year out of pocket max for individual or $3000 for family and Aetna managed choice has a $4000 out of pocket max for individual or $12000! for family. And with Aetna the out of pocket max is doubled if it is out of network.

gnopgnip said:   Platinum insurance OOP+premiums are often lower than bronze OOP+premiums. For instance Kaiser CA HMO 1a has a $1500 a year out of pocket max for individual or $3000 for family and Aetna managed choice has a $4000 out of pocket max for individual or $12000! for family. And with Aetna the out of pocket max is doubled if it is out of network.
  
When I priced plans in TX the max OOP was always around $6K/person and 12K/Family plus premium regardless of tier.  Maybe it is different in other states, I haven't had "Platinum" as an option anywhere else.  (heck, last job I had Bronze was the UPGRADED plan - and they had a MV plan standard)  However if your expenses were in a particular range it might be cheaper to have Platinum since the co-pay percentages (90% and what is 100% are much  better).  However my friend in Florida ended up about 12k OOP for his newborn -- after capping Platinum.  I believe the main difference is what is considered "Essential" too.  

And lookie here:  

  • In 2016, your out-of-pocket maximum could be no more than $6,850 for an individual plan and $13,700 for a family plan before marketplace subsidies.

That is independent of the "metal level" of the plan.  The only reason I could see to get a higher "metal" plan is when you are on a federal subsidy and you aren't paying it.  Or you expect 10-20K in expenses so will recoup most of your premium in value but not come close to capping OOP.  If you will have enough to cap platinum then you are $13700 + high premiums, versus capping Bronze at $13700 + lower premiums. 

Texas isn't exactly the best place to have to buy health insurance though -- since Obamacare they have been doing their best to make the system fail so they can point to how much its failing and how expensive the programs are.  If they REALLY wanted to help they would tie max OOP higher but include premiums in the figure.  THAT will never happen.

RedWolfe01 said:   
nic3456 said:   Hers was $7900 and mine was $5500. I assumed the insurance adjustments would be based on certain charges that would be lower if the original bill was lower. Even with adjustments prices still seem mismatched.
  
Adding those together I get $13400 -- i would hazard a guess that your family max OOP is somewhere around there and you capped out during your hernia operation.
 

  
Those rates were the insurance negotiated rates, not OP's responsibility.

doveroftke said:   
RedWolfe01 said:   
nic3456 said:   Hers was $7900 and mine was $5500. I assumed the insurance adjustments would be based on certain charges that would be lower if the original bill was lower. Even with adjustments prices still seem mismatched.
  
Adding those together I get $13400 -- i would hazard a guess that your family max OOP is somewhere around there and you capped out during your hernia operation.

  
Those rates were the insurance negotiated rates, not OP's responsibility.

  
No, they were not -- these were the numbers AFTER the insurance adjustment:
nic3456 said: Hers was $7900 and mine was $5500. I assumed the insurance adjustments would be based on certain charges that would be lower if the original bill was lower. Even with adjustments prices still seem mismatched.


Original charges were:
nic3456 said: We both went to the same hospital - her hospital charges were $12,200 & mine were $14,560!

So add them together and they are REALLY close to the annual OOP max mandated under Obamacare.  Most likely there was another ambulance ride or something else that was already OOP that rounds that up to 13700..  which BY LAW they cannot exceed.
 

elvrovner said:   This is why hospitals need to publish charges upfront which would allow for greater transparency and allow consumers to make financially sound choices for elective procedures.
  
Why would consumers care about the prices? The bill just gets mailed to a third party... the insurance company. The consumer does not care about the costs which is precisely why health care is so broken.

rufflesinc said:   
nic3456 said:   Hers was $7900 and mine was $5500. I assumed the insurance adjustments would be based on certain charges that would be lower if the original bill was lower. Even with adjustments prices still seem mismatched.
well the overnight stays are basically just medical hotel rooom

  you ever had a C-section?
4 nights in a hospital after a C-section, including infant care, essentially means you're paying for 3x staff for the duration (nurse for mom, nurse for baby, and NP). That's not cheap.

imbatman said:   
rufflesinc said:   
nic3456 said:   Hers was $7900 and mine was $5500. I assumed the insurance adjustments would be based on certain charges that would be lower if the original bill was lower. Even with adjustments prices still seem mismatched.
well the overnight stays are basically just medical hotel rooom

  you ever had a C-section?
4 nights in a hospital after a C-section, including infant care, essentially means you're paying for 3x staff for the duration (nurse for mom, nurse for baby, and NP). That's not cheap.

  Have you ever had a C-section?

RedWolfe01 said:   
doveroftke said:   
RedWolfe01 said:   
nic3456 said:   Hers was $7900 and mine was $5500. I assumed the insurance adjustments would be based on certain charges that would be lower if the original bill was lower. Even with adjustments prices still seem mismatched.
  
Adding those together I get $13400 -- i would hazard a guess that your family max OOP is somewhere around there and you capped out during your hernia operation.

  
Those rates were the insurance negotiated rates, not OP's responsibility.
 

  
No, they were not -- these were the numbers AFTER the insurance adjustment:
nic3456 said: Hers was $7900 and mine was $5500. I assumed the insurance adjustments would be based on certain charges that would be lower if the original bill was lower. Even with adjustments prices still seem mismatched.


Original charges were:
nic3456 said: We both went to the same hospital - her hospital charges were $12,200 & mine were $14,560!

So add them together and they are REALLY close to the annual OOP max mandated under Obamacare.  Most likely there was another ambulance ride or something else that was already OOP that rounds that up to 13700..  which BY LAW they cannot exceed.

  
That's what I said, after the insurance adjustment. But the entire insurance negotiated rate, not just OP's portion of that amount. That is confirmed by his later post:
nic3456 said:   Our final out of pocket was different because of copays, but I didn't provide those amounts since there are other variables there.
 
ETA: Am I misunderstanding your point?

rufflesinc said:   
imbatman said:   
rufflesinc said:   
nic3456 said:   Hers was $7900 and mine was $5500. I assumed the insurance adjustments would be based on certain charges that would be lower if the original bill was lower. Even with adjustments prices still seem mismatched.
well the overnight stays are basically just medical hotel rooom

  you ever had a C-section?
4 nights in a hospital after a C-section, including infant care, essentially means you're paying for 3x staff for the duration (nurse for mom, nurse for baby, and NP). That's not cheap.

  Have you ever had a C-section?

  no, but I've paid for 2
 

doveroftke said:   
RedWolfe01 said:   
doveroftke said:   
RedWolfe01 said:   
nic3456 said:   Hers was $7900 and mine was $5500. I assumed the insurance adjustments would be based on certain charges that would be lower if the original bill was lower. Even with adjustments prices still seem mismatched.
  
Adding those together I get $13400 -- i would hazard a guess that your family max OOP is somewhere around there and you capped out during your hernia operation.

  
Those rates were the insurance negotiated rates, not OP's responsibility.

  
No, they were not -- these were the numbers AFTER the insurance adjustment:
nic3456 said: Hers was $7900 and mine was $5500. I assumed the insurance adjustments would be based on certain charges that would be lower if the original bill was lower. Even with adjustments prices still seem mismatched.


Original charges were:
nic3456 said: We both went to the same hospital - her hospital charges were $12,200 & mine were $14,560!

So add them together and they are REALLY close to the annual OOP max mandated under Obamacare.  Most likely there was another ambulance ride or something else that was already OOP that rounds that up to 13700..  which BY LAW they cannot exceed.

  
That's what I said, after the insurance adjustment. But the entire insurance negotiated rate, not just OP's portion of that amount. That is confirmed by his later post:
nic3456 said:   Our final out of pocket was different because of copays, but I didn't provide those amounts since there are other variables there.
 
ETA: Am I misunderstanding your point?

  
Maybe -- the OP was not specific on purpose, but even if that was the adjusted insurance portion the math still works out:

12200 - 7900 = 4300  hers
14560 - 5500 =  9060   his

Basically they paid 50% either way.  

so remainder is 13360.  It still gets to the cap and stops.  I would guess that they have the maternity portion more streamlined to be fully "in network" than a less-common major surgery event though.  As I said before..  women talk about babies.  Get one that had kids at two different facilities and price/performance/amenities get compared.  "oh #%#" off the cuff surgery not so much..  what are you gonna do, tell them to stick you back on the (expensive in itself) ambulance and take you to Parkland when you arrive at Baylor?

Its also possible I am misunderstanding how he is using the insurance adjustment term -- I assumed that was what HE had left on the bill after they paid their co-pay.  That was how I was always billed -- it showed what was due AFTER insurance.  Not that I have had any medical expenses under the AHA anyway.  (just acute care stuff before it was enacted)

RedWolfe01 said:   Its also possible I am misunderstanding how he is using the insurance adjustment term -- I assumed that was what HE had left on the bill after they paid their co-pay.  That was how I was always billed -- it showed what was due AFTER insurance.  Not that I have had any medical expenses under the AHA anyway.  (just acute care stuff before it was enacted)
 

  
I think your larger point about competitive pricing for maternity care is valid.

Just so we're on the same page, there are three type of medical bills/prices, "rack rate", "insurance adjusted" (i.e. rack rate minus insurance "discount"), and "patient responsibility" (i.e insurance adjusted minus insurance payment). OP posted the rack rate in the first post and the insurance adjusted rate shortly after, but declined to provide his portion because of differing benefits provided by the insurance company (helps compare apples-to-apples).



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