Part of the HospitalSoup.com Series on “ The Real Price You Pay for Healthcare”
Getting a price for a medical procedure is not like getting a quote for any other service or product.  Our healthcare system is  in such a chaotic state right now that it is difficult to know exactly what the price is for a service. 

When you go to your doctor or have any medical testing performed, most likely whatever diagnosis you have been given or testing you will have done is assigned to a CPT (Current Procedural Terminology) code. This code is also generally tied to a particular reimbursement amount, generally set by your insurance company if you have insurance. Now, many of you may never actually see the difference between what is charged and what is reimbursed by your insurer, but HospitalSoup.com has examined bills of several patients for the past few years and has found some interesting information.

patient-discounts In most cases what is being billed by either the provider or the testing facility and what is actually paid is very different. For example, one patient had laboratory testing performed and the charges came to $1272.00 that was billed by the laboratory company. The insurance company, however, allowed for a payment of $75.00 to the laboratory company as that was the amount that the insurance company said was “customary and reasonable” according to the procedural codes that were tied to the lab testing for the patient.

Now, if you are a cash paying patient or someone without insurance, and you had lab work performed, you would contact the billing office of the laboratory company and ask them for a cash discount or private pay discount since you are not using insurance. The shocking part about this story is that in most cases you as a private pay patient or one without insurance will most likely get  a 10 or 15% discount not off off the negotiated price or $75.00 price that your insurance company would have paid if you were insured by the company in our example, but you would get a 10 or 15% discount off of the $1272.00 basic or top dollar price. 

Let’s say the laboratory company was feeling generous and gave you a 15% discount off of the $1272.00 lab price. This gives you a $190.80 discount leaving you with a balance of $1081.20.  Quite a difference between this amount and the $75.00 that an insurer would pay for the exact same services. It’s no wonder that the average person in America who may have lost their job and or health insurance is struggling to pay their medical bills.  Cash paying patients are paying for services at the time they receive the service while often insurers may take months to actually pay the bills, yet the amounts charged and the terminology of “discount” can be deceptive. 

There is a lot of variability in pricing as well when it comes to certain tests and procedures. As a patient getting a diagnostic scan for example in your own city you may think that the cost of a procedure would be close to equal regardless of where you had a particular scan. Not so, the cost of a particular test can vary widely. As we reported in an earlier article the cost of a CAT Scan in Austin quoted to a patient we interviewed was between $250.00 and $1650.00 for the very same scan. That’s a huge different in price! But it’s even more important to monitor the actual bills that come in after you are quoted a price because when it comes time to pay, the bill you or your insurance company may receive may be much different from the amount quoted to you over the phone. Stay tuned for an upcoming article on what actually happened with one of the  patients we interviewed in terms of his billing for his CAT Scan in Austin, Texas.  By sharing his story the patient hopes he can help other patients avoid being overcharged for a medical procedure.