He and his wife both got cataract surgery. His bill was 20 times higher than hers

[The Rover]

https://www.npr.org/sections/health-...gher-than-hers

Danilo Manimtim's vision was cloudy and blurred — and it was growing worse.

The 73-year-old retired orthopedic surgeon in Fresno, Calif., knew it was time for cataract surgery. "It's like car tires wearing out because you drive on them so much," he said.

In December 2021, he went to the outpatient department of the local hospital to undergo the common procedure that usually replaces the natural eye lens with an artificial one and is designed to restore vision. The outpatient procedure went smoothly, and Manimtim healed over the next few weeks.

Manimtim, who has a job evaluating disability claims for the state of California, knows the health care system and keeps tabs on his health benefits. He knew he already had met his health insurance deductible for the year, so he expected a manageable out-of-pocket expense for the surgery. He calculated his coinsurance would be about $750.

Then the bills came.

[lovemachine97(Version 2)]

Not surprised.

So, two stories. One, my wife’s ACL surgery. We get balanced billed by the anesthesiologist for $1300. We have a friend who used to work for Aetna look at it and basically, kind of like this story, Aetna sets what is a customary or reasonable price for the anesthesia in an ACL repair. The intricate math they do? Twice what Medicare pays. Medicare pays $400, so they set the reasonable price at $800. The anesthesiologist billed $2100, insurance paid $800, and he balance billed us the rest. He could do that because he didn’t take our insurance even though the hospital did.

Turns out a coworker had had his ACL replaced recently. Anesthesia? $2100. So we asked my wife’s sister what she would charge for such a procedure. “I don’t know,” was her honest answer. In other words, the company she’s contracted with does the billing and she’s paid a rate. So we have 2 of the same surgeries with 2 different anesthesiologists that charge the same, but Aetna says they should charge $1300 less and none of the anesthesiologists actually know what their services cost.

Second story, my wife had these small cysts on her head. You’d never know they were there, and the only reason she wanted them removed was they hurt. So we went to a plastic surgeon. And we were all set up for surgery, but we started thinking about what if we got balance billed and all the possible costs associated with it. So she declined the procedure in the hospital. Now, my wife’s sister had the same cysts and had a doctor friend do the procedure on her dining room table. So we asked the plastic surgeon, “Why can’t it just be done in your office with local anesthesia?” He said, “Okay.”

Suddenly this procedure went from possibly thousands to a copay. Point being, we have a highly regulated, “free market” system with third party payer, and thus it has few, if any, of the benefits of a market-based system due to heavy regulation and few, if any, benefits of a system the government controls because they only partially control it.


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