So… I just need to vent for a minute. This gets long and ramble-y (sorry), but I just needed to get it out there.
There are are many things in this world that I don’t understand, but one of the most frustrating for me is the US healthcare system. Here’s a recent example from my life:
I have had two separate HSGs done in the past few months, first with an OB-GYN and then with an RE (Reproductive Endocrinologist). Even though I was repeating the same test, these were two vastly different experiences, both in the outcome and in the way they were billed. Despite not covering infertility treatments, my insurance does provide coverage for diagnostics, so I had been told by each doctor’s office that the HSGs should be fully covered.
For my second HSG, the one with my RE, this turned out to be true. My insurance company was charged $1,138 for the entire procedure, and they paid every penny, except for the $40 copay that I have with each appointment. Maybe it’s a testament to the fact that the billing office at the fertility clinic truly knows what they are doing in this area or the fact that they work hard to help their patients navigate the finances of infertility, but this was a relatively painless procedure, physically as well as financially.
The first HSG was a completely different story. Not only was the test a failure, but trying to work out the billing has been ridiculous. The initial bill was higher than the one from my RE, which I suppose was to be expected because this HSG took place in a hospital, so I had bills from the OB-GYN, the radiologist, and the hospital itself. The total sent to my insurance company was $1,959. I still haven’t figured out all of the details with how this HSG was coded, but somehow it was submitted in a way that resulted in the insurance company considering it a surgery to treat infertility, and therefore they only gave me partial coverage.
Between the three different bills for this first HSG, I ended up being held responsible for $1,088, while insurance covered the rest. Now, I know this is just a drop in the bucket in the world of infertility treatments, but it seemed like a pretty big drop to me. It all adds up so quickly, and I was not happy to receive these bills after being told by my insurance and my doctors that it would be completely covered. From what I’ve seen online about how much to expect an HSG to cost, my bills seemed pretty high anyway. (Also, how was the RE able to code everything so that it was completely accepted by my insurance, while the OB-GYN’s office wasn’t? I am still trying to wrap my head around the fact that my repeat test at the fertility clinic, the one I worried my insurance would think was non-essential, was completely covered, while the first one wasn’t. They were the exact same procedure!)
Anyway, I had a bill from the OB-GYN for $750. This charge was apparently for the catheter and the dye insertion, which is a big chunk of what my insurance refused to pay for. When I called the billing office to see if there was any way the codes could be changed so that the insurance company would accept it, I was cheerfully told that it should have been covered 100% – they had even checked this with my insurance beforehand – and that the insurance company must have made a mistake.
And thus began a 2-month long roller-coaster of negotiations that I have (hopefully) just ended.
When I called my insurance company, they informed me that based on the codes put in by my billing office, there was nothing they could do. They hadn’t made a mistake at all; my plan simply didn’t cover the procedure. Of course, they couldn’t tell me why it was considered a plan exclusion, because they weren’t allowed to discuss what was in my file; I would have to check with the doctor’s office for more details about how it was coded.
When I called the billing office again, they told me that an HSG wouldn’t have been covered anyway, because it was more than a simple x-ray. Clearly, it’s more of a surgery than a radiology test. (Even though this was the opposite of what they had told me before! Even though my second HSG was covered! And does anyone want to explain to me how an HSG is a surgery? That makes no sense to me, either.) They said that they would send a message to the insurance company and see if there was anything that could be done. This would take 4-6 weeks, so I’d have to wait patiently to see what happened.
I felt like everyone was giving me the run-around, and no one was actually trying to figure out if there was anything that they could do to help me. Then, sometime last week, I got a new version of the bill in the mail. Apparently the OB-GYN’s office hadn’t gotten anywhere with the insurance company, but they had decided to give me the discounted rate that the insurance company would have paid if they did cover the procedure. (This also makes no sense to me – if the insurance doesn’t cover it, why do they have a set price for a discounted rate? This is a private health plan, so I don’t think they have other versions that would include infertility. But, who knows, maybe they do?) So, now instead of being billed for $750, I was being asked to pay about $530. Better, I guess, but still a bit pricey.
I finally got up the courage today to call the billing office back. I was starting to think that I would probably just have to pay up, but I wanted to ask one more time why it had been coded the way it was and why I had been told that it would be covered if it wasn’t. After getting nowhere with the first person I talked to, I finally got through to the billing manager. She gave me the same speech, telling me that this was how they always coded HSGs and that the insurance just didn’t cover it. I finally said that I understood that there was nothing they could do for me, but I was confused why I had been told, when I first called all the way back in November, that it should have been covered and that the insurance had made a mistake. Why was I hearing different things every time I called?
She changed her tune at that point and said that there actually was something she could do. She said that my insurance company must have tacked on a lot of extra costs for overhead because the HSG took place at a hospital. She was actually surprised to see how high my bill was, since most other insurance companies apparently have a site-of-service differential that would have been used to reduce the cost to about $100 dollars, but mine doesn’t. (Or just didn’t use it? I’m not sure.) So, she said that she could reduce my bill so that I would only be paying $100, the same as what they would normally charge to a different insurance company.
So. On the one hand, I am VERY grateful that the charge has been reduced. On the other hand – I don’t get it! Why is the amount that my doctor bills me set by my insurance company, if my insurance has already refused to pay for the procedure? Why were hospital overhead charges tacked on to my bill if the bill was not for the hospital at all, but for the regular OB-GYN office? (I have completely separate bills for the hospital and radiologist.) Why do uninsured patients automatically get higher rates than insurance companies? And if the billing office really did have the ability to reduce my $750 bill to $100, why didn’t they do this in the first place???
Here’s another example of frustrating heath care costs – my husband’s first semen analysis, which was ordered through a different OB-GYN and conducted at a local andrology lab, was billed to us at a price of $630. We were able to get it covered by insurance eventually, after a lot of back and forth with the insurance company, but we still paid $240 with the deductible and copay. This is a ridiculous cost for a simple lab test! After switching to an RE, we found out that the self-pay price at our fertility clinic is only $25.
It seems like such a mess to me. I know there’s a lot I don’t know about insurance and health care, and I also know that all these people I’ve interacted with are probably trying to do their best in their jobs, but the cynical part of me feels like they are just arbitrarily making up numbers to charge me, hoping that I don’t notice and call to challenge them. I don’t understand why the prices are so different from one provider to the next – or from one insurer to the next – and how insurance companies can accept or deny the same procedure based on how it’s presented to them. I know that good healthcare is expensive and worth paying for, but so many prices we have been given seem so outrageously inflated.
I’m deeply grateful that I have health insurance coverage at all, but it is always, always a frustrating experience to have to deal with billing issues. Infertility – or any health issue, for that matter – is difficult enough without also having to face a crippling financial burden and having to be your own advocate in the face of impenetrable medical companies that seem to be watching out only for their own bottom line. I don’t know what the answers are, but I can’t help but feel that there has to be a better way.