Smart Medicine

Information to help you make good decisions when it comes to healthcare

Add a comment

In addition to our annual Top Doctors list, we’ve also gathered tips on how to spend your healthcare dollars wisely—because nobody wants to overpay, even for the best medicine.

Buyer Beware: Hospital Prices Vary Widely

If you have chest pain, a trip to the hospital can cost nearly $35,000 at one metro Atlanta facility and closer to $11,000 at another. The price swing is even greater for hip or knee replacement. This spring, such price comparisons became public for the first time as part of the greater transparency demanded by the Affordable Care Act, aka Obamacare.

Hospitals’ “retail” prices are now available online, as are the average amounts paid by Medicare (which also differ depending on related services offered by various hospitals). Hospitals rarely enforce those full prices, says Kevin Bloye, spokesman for the Georgia Hospital Association. Still, that’s where insurance companies start when they negotiate “reasonable and customary” charges. And with today’s high deductibles, nearly all patients have a vested interest in the final bill. Most importantly, the “retail” price is what hospitals charge patients who are uninsured or out of network. Many consumers don’t realize that hospitals are open to bargaining.

You can access the data at data.cms.gov (Inpatient Prospective Payment System Provider Summary). Click on the filter tab to sort hospitals by diagnostic code and city or state. Download an Excel version at cms.gov (Research, Statistics, Data & Systems > Medicare Provider Charge Data).

Hip/knee replacement
Atlanta Medical Center South: $109,073 (Medicare paid $15,100)
Saint Joseph’s Hospital: $28,319 (Medicare paid $11,174)

Kidney and urinary tract infections
Atlanta Medical Center: $31,197 ($6,138)
DeKalb Medical at North Decatur: $13,021 ($5,146)

Chest pain
North Fulton Hospital: $34,757 ($3,304)
Emory Johns Creek Hospital: $10,977 ($2,994)

Pneumonia
North Fulton Hospital: $39,501 ($4,220)
Emory University Hospital Midtown: $7,865 ($4,947)

Heart attack
North Fulton Hospital: $35,160 ($4,625)
DeKalb Medical at North Decatur: $14,684 ($6,165)

NOTE: These costs are for conditions that do not involve complications or other related medical conditions. The hip/knee replacement may also include other major joints or reattachment of a lower extremity. Pneumonia can include pleurisy, which is inflammation of the outer lining of the lungs. Average prices do not reflect the costs paid by insurance companies, which negotiate individually with hospitals.

There’s An App For That!

FH Healthcare Cost Estimator: Check low, high, and “fair” prices for medical and dental procedures based on your zip code. Use the app or visit fairhealthconsumer.org. FREE

Healthcare Blue Book: A fair price for medical services based on your zip code, plus advice about negotiating a discount. Also at healthcarebluebook.com. FREE

GoodRx: Find the cheapest place near you to fill your prescription. The app (or goodrx.com) provides discount coupons, information on generics, and alternate choices to discuss with your doctor. FREE

Family Drug Guide: Cost comparisons from Consumer Reports’ Best Buy Drugs guide, plus info on medication safety and effectiveness. $4.99 (familydrugguide.com requires membership fee)

Out-of-Network Gotchas

Even if your medical treatment is “covered” by insurance, a loophole could cost you hundreds or even thousands of dollars. Here’s what to watch out for:

Out-of-network providers chosen by your in-network doctor. You need surgery, so you carefully choose a hospital and surgeon who are in your insurance network. As you recover, you are slapped with a bill from your out-of-network anesthesiologist. Or radiologist. Ask your insurance company in advance if all your providers will be considered in network.

Out-of-network pricing. If you choose a doctor or hospital that is out of network, your insurance company will pay only a percentage of the fees, based on what it considers to be “reasonable and customary.” You will pay the remainder. So if a hospital charges $20,000, and your insurance company considers the “reasonable” charge to be $15,000, you’ll owe your percentage of the $15,000 (up to your deductible) and the other $5,000.

Grading Hospitals

It’s a customer’s world. We seek online reviews for almost every decision we make—restaurants, hotels, home repairs. Increasingly, you can find similar ratings for healthcare. Hospital Compare (medicare.gov/hospitalcompare) gives side-by-side comparisons of institutions in your area. Find out how patients rate their stays, how long people wait in the emergency room, and whether the hospital’s infection rate is better, the same, or worse than the national average. Popular national rankings, such as U.S. News & World Report’s Best Hospitals and Consumer Reports’ hospital safety ratings, are based at least partly on this data, which comes from Medicare reports and surveys.

For example, here’s how four local hospitals rated on “patients who reported yes, they would definitely recommend the hospital.”

Emory University Hospital, Atlanta: 84 percent

Northside Hospital, Atlanta: 82 percent

WellStar Cobb Hospital, Austell: 70 percent

DeKalb Medical, Decatur: 65 percent

Cost-Saving Questions

Fair Health, a nonprofit consumer advocacy organization, recommends always asking these key questions:

  • Is this doctor in my insurance company’s network?
  • Will all my additional providers and tests be in my insurance network?
  • Is a generic version of this medication available?
  • Is that test necessary? Does my insurance company require pre-authorization for the test or procedure?
  • May I have a copy of the itemized bill?

Medical Doublespeak

Hospital bills are often padded with charges that should be included in the room rate, are inflated, or don’t belong on a bill at all, patient advocates say. Don’t be fooled by professional-sounding jargon. Some charges that have actually appeared on medical bills:

Mucus recovery system = box of tissues
Oral administration fee = handing pills to patients
Cough support device = a teddy bear to hold to your chest to ease the pain of coughing after surgery
Fog reduction/elimination device (FRED) = a piece of gauze used to wipe moisture off an optical lens or other device

Get Help Fighting Your Bill

As an insurance agent and medical-bill advocate based in Woodstock, Cindy Holtzman is an expert at the sort of financial wrangling that most find excruciating. She fought for a Georgia State University professor whose wife got sick in India to get coverage for a 2 million rupee bill (about $10,000). And she helped negotiate a 75 percent discount for a woman with cancer facing charges of more than $200,000. Advocates like Holtzman can be an antidote to healthcare sticker shock. Find one to help you sort out complicated medical bills:

  • Medical Billing Advocates of America (billadvocates.com), Alliance of Claims Assistance Professionals (claims.org), and HealthCare Advocates (healthcareadvocates.com) are national networks of healthcare billing experts.
  • Expect to pay about $100 an hour. Some advocates may request a set-up fee of $100 to $500. They may agree to take 30 percent of the money saved.
  • Ask for references.
  • The Patient Advocate Foundation (patientadvocate.org) provides free help with insurance, payment, or employment issues for people with chronic, debilitating, or life-threatening illnesses.

Cover Your Rear

Insurance typically covers the cost of a preventive colonoscopy with just a copay. But if your doctor finds and removes a polyp, you’ll pay up to your deductible—polyp removal is considered treatment rather than prevention. Ask about your insurance company’s policy before the procedure. The Affordable Care Act (aka Obamacare) requires insurers to cover polyp removal as preventive care, but that rule doesn’t apply to many existing plans.

Shop Around

No one worries about cost as they’re being wheeled from an ambulance into an emergency room. But for many healthcare encounters, it makes sense to shop around.

Need an MRI? Tests and scans are usually cheaper at freestanding centers than hospitals. Scheduling surgery? It may cost less at a nonprofit hospital than a for-profit one. With high deductibles becoming more common, even your percentage of “covered” procedures starts to mount up.

Hospitals are becoming more accustomed to answering questions about estimated costs, says Kevin Bloye, spokesman for the Georgia Hospital Association. He suggests calling ahead and asking for the hospital’s billing department. Your insurance company may also provide an online estimator that will compare your share of the costs at different facilities.

If you are not part of a healthcare network and you get hit with sticker shock, you may be able to negotiate the bill by using information about average costs from Fair Health (fairhealthconsumer.org) or Healthcare Blue Book (healthcarebluebook.com). They also provide dental cost information.

Related Content