By Consumers For Quality Care, on September 11, 2019
Wolfgang Balzer did what experts recommend for effectively shopping for health care services. Balzer, who works as an engineer in Connecticut, had known for a number of years that he would need surgery to repair a hernia. In February 2018, his wife, Farren, gave birth to their second child. With the family having met their insurance deductibles early in the year, Balzer decided it was the right time to have the non-emergency surgery, Kaiser Health News reports.
Before scheduling the surgery, Balzer called the hospital, surgeon and anesthesiologist to find out how much he should expect the procedure to cost. He says he tried his best to weigh the costs and the timing of the procedure.
The hospital told him that the normal billed rate was $10,333.16 but that Cigna, his insurer, had negotiated a discount to $6,995.56, meaning his 20% patient share would be $1,399.11. The surgeon’s office quoted a normal rate of $1,675, but the Cigna discounted rate was just $469, meaning his copayment would be about $94. (Although the Balzers made four calls to the anesthesiologist’s office to get a quote, leaving voicemail, no one returned their calls.)
The Balzers used this information to budget and save for their portion of the costs. In November 2018, Balzer had his bilateral inguinal hernia repaired. When the bill for the surgery arrived on Christmas Eve, it was anything but a joyous surprise.
Even with Cigna’s discounted rate, the hospital charged $10,552 for Balzer’s surgery, more than 51 percent higher than the original estimate of roughly $6,996. The reduced rate for the surgeon was $968, also more than a 50 percent increase from the estimate. With their deductible already met, the Blazers were responsible for paying $2,304.51 out of pocket.
“This is ending up costing us $800 more,” said Farren, 36. “For two working people with two children and full-time day care, that’s a huge hit.”
The Balzers began calling Hartford Hospital, where the surgery was performed, to try and understand why the bill was so much more expensive than the estimate. They said they were bounced around between departments and then were told that the quote they had been given did not take any complications into account.
Confused because the surgery had gone according to plan and frustrated by the lack of clarity, the Balzers appealed the charges to Cigna. They waited to hear back, but collection notices begin arriving. Wolfgang says that he wanted to pay the bill and move on, but Farren would not let that happen.
“I’ve been tackling this since December,” Wolfgang said. “I’ve lost two or three days in terms of time.”
After reporters made inquiries to the hospital about the discrepancy between the quoted price and the billed price, Hartford Health told the couple that the charges would be written off as an “administrative write-off.”
Cynthia Pugliese, vice president of revenue cycle at Hartford HealthCare, told Kaiser Health News that the estimate that the Balzers received was an average produced by a computer program that looks at what other consumers have paid for services under the same procedure code as Balzer’s.
“Because it was new, perhaps the system doesn’t have enough cases to provide an accurate estimate,” Pugliese said. “We did not communicate effectively to him related to his estimate. It’s not our norm. We look at this experience and this event to learn from this.”
While Pugliese pointed to the newness of the system for the error, other mechanisms make it so that consumers can receive wildly off-base estimates. Unlike estimates in other industries, hospitals have no legal requirement that their estimates are accurate or even in good faith.