His and her cataract surgeries, but his bill was 20 times

Danilo Manimtim’s vision was cloudy and blurry – and she was getting worse.

The 73-year-old retired orthopedic surgeon in Fresno, California, knew it was time for cataract surgery. “It’s like worn tires because you drive on them a lot,” he said.

In December 2021, he went to the outpatient department of the local hospital to undergo the combined procedure that usually replaces the eye’s natural lens with an artificial one, designed to restore vision. The outpatient operation went smoothly, and Mantimim recovered over the next few weeks.

Manimtim, who since his retirement has taken a job evaluating disability claims in California, knows the health care system and monitors its health benefits. He knew he had already met his health insurance deduction for the year, so he expected an out-of-pocket expense to have the surgery. He calculated that his co-insurance would be around $750.

Then the bills came.

patient: Danilo Manemtim, 73, of Fresno, California. He is insured through his employer by Anthem Blue Cross of California for outpatient care and coverage Medicare for hospital admission.

Total bill: Overall, the fees were $9,084 for surgery, anesthesia, medical supplies, pharmacy, and clinical laboratory services. Anthem paid $5,027 and initially billed Mantimim for $4,057.

Service Providers: St. Agnes Medical Center. It is part of Trinity Health, A nonprofit hospital system based in Michigan With 88 hospitals and 125 urgent care centers across the country. The hospital system brought nearly $20.2 billion In revenue for most last fiscal year.

Medical service: Cataract surgery on an outpatient basis, which involves sedation.

What gives: Manimtim’s huge bill stemmed from a simple decision that turned out to be a problem in the country’s complex healthcare system: He scheduled the surgery at a nearby hospital—one that happened to charge about $7,000 more for the procedure than his insurance company would pay.

Manimtim has proof that he could have been completely different under his roof: Four months later, his wife, Marilou Manimtim, 66, had the exact same procedure at an outpatient eye care surgical center in Fresno called EYE-Q. It is located half a mile from St. Agnes Medical Center but is not affiliated with the hospital.

Both patients have the same insurance coverage through Anthem Blue Cross of California; They had identical cataract surgeries; Both service providers were in Anthem’s coverage network. Marilou owed $204, while Danilo was on the hook for $4,057.

“This is ridiculous, and it feels unfair,” said Danilo Manetim. “How can it be so much more expensive than the surgical center? It is within walking distance, and if I were to go there, I would have saved myself a lot of money.”

According to Anthem, Manimtim’s insurance plan, via his employer, California Public Employees Retirement System, sets $2,000 for outpatient cataract surgery. CalPERS developed a Reference pricing system in recent yearsIt sets a reasonable price for a high-quality procedure of this type in California. Then it only reimburses up to that amount, encouraging patients to shop for treatment at a lower-than-minimum price. For the cataract surgery itself, patients on the Manimtim plan are stuck with any fee over $2,000.

Dr. said. Ira Weintraubchief medical officer of WellRithms, which analyzes health care prices for employers. “It cost the hospital three to four times what this surgery usually costs, which is roughly $3,000.”

“No one gets $9,000 for cataract surgery,” he added.

If Manimtim had chosen Medicare Part B, the part of Medicare that covers outpatient care, he would probably only be in trouble Approx. $565Medicare cost comparison tool, shows. Medicare pays a set amount for procedures no matter where they are performed.

But like many older Americans who still work, Manimtim chose not to opt out of that coverage, instead opting for his employer’s plan because his monthly premium would be much cheaper.

Anthony Wright, executive director of Health Access California, a nonprofit organization, said health care prices often have nothing to do with the actual costs and quality of care—and patients often face the “double whammy” of higher prices and complex benefits. Law firm. Often, patients are on their own to learn about the high prices and complex benefits, he said.

“You wonder what the rationale is for any of the prices in our healthcare system,” Wright said.

the decision: After inquiries from KHN, Anthem contacted Saint Agnes Hospital, asking for help with Manimtim. Although the physician is responsible for requesting an exemption from the maximum $2,000 CalPERS on cataract surgery payments under the Manimtim plan, this did not occur prior to surgery. Anthem has asked the hospital and doctor to consider a post-surgery request, Anthem spokesperson Michael Bowman said.

Kelly Sanchez, a spokeswoman for Saint Agnes, told KHN that the hospital and the service provider later requested the waiver that would allow the insurance company to pay more than the $2,000 maximum and that it was eventually approved by Anthem. That is expected to leave Mantimim with a much smaller co-insurance bill, around $750 – and get him out of the predicament of being taken to groups by the hospital. The hospital will get a higher payment from Anthem, which will cover a large portion of the remaining $4,057 bill.

This higher amount, like all higher payments, contributes to higher health insurance payments for everyone.

Danilo Manemtim and his wife Marilou underwent identical cataract surgery, but the charges were vastly different — even though the couple in Fresno, California, were covered by the same health plan.(Heidi DiMarco/KHN)

Sanchez said the hospital does not operate in price gouging, but noted that hospitals generally have higher costs and tend to charge more than outpatient facilities.

“We never want to cause harm or create hardship for our patients, and this extends to our billing practices,” Sanchez said in a prepared statement.

She noted that St. Agnes has financial assistance programs available and encourages patients to ask questions and understand potential costs before seeking care. “Each patient’s insurance plan is unique, so it is their responsibility to understand the benefits of their plan,” she wrote. “It’s still complicated and we’re aware of that, and we’ll continue to work toward more price transparency.”

Takeaway: The bottom line, experts say, for patients is to be sure to read the fine print of insurance coverage plans to understand all monetary responsibilities, including premiums, deductibles, co-costs, and coinsurance. Also, there are a small number of large employers who insure themselves Using reference pricingand setting limits on what they will pay for common procedures. Shop around, and ask for prices on the front end if possible.

“People often focus on premiums because they are easy to compare, but premiums don’t tell the whole story, and this example illustrates the trade-offs,” Tricia Newman said. Medicare expert at KFF.

Anthem spokesperson Bowman urged patients to use the internet anthem “care finderTo compare patient costs and find a cheaper option if available. If Mantimim had done so, he might have seen that having cataract surgery at an outpatient surgical center would have been much cheaper. But details of provider cost and insurance coverage can be confidential and often not presented in a patient-friendly manner. He said Mantimim had already tried to explore its benefits before the procedure, but had not gotten a clear answer from the insurance company or the hospital.

Manimtim has also given advice to consumers: If you receive a medical bill and don’t understand the charges, don’t pay right away. Instead, contact your service provider and insurance company to inquire about fees and if there are ways to lower your bill.

“People need to be more informed by insurance companies and hospitals about the options available to them, to prevent over-billing,” Mantimim said. “Many people don’t know this can happen to them.”

Stephanie O’Neill contributed the audio to this story.

Bill of the month is a collective investigation by KHN And the NPR Who explains and explains medical bills. Do you have an interesting medical bill and want to share it with us? Tell us about it!

This story is produced by KHN, which publishes California Healthlinewhich is an editorially independent service california health care institute.

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