Hernias and High-Deductibles: Unclear EOBs and Unknown Providers

March 19, 2012

Three weeks after surgery, the costs are clearer with two "bills": one from my surgeon, the other from a provider I've never heard of or even seen before.

Today, as I write this, I am post-operative day number 21.

An unusual challenge came upon the artificial mesh in my gut, as I’ve come down with something that strikes me as the flu. Or rather, "The Flu." Not the simple cough, cough, runny nose, move-on-with-your-day flu. But the all over aches, immobility, and deep-angry-frequent-cough flu.

I can’t feel the bulges in my groin that were there pre-operatively, so I think things are holding up. I go to the surgeon tomorrow for a routine post-op check-up. I expect that my visit tomorrow will be "free," as part of the global fee for laparoscopic hernia repairs.

I have received my bill from the surgeon. And, from someone else (to be explained). What is strange is the hesitation I feel in writing about it on a public forum. I wonder if there is some sort of ethical, or even legal, issue. We’re told on our hospitalist listserv that we are not, under any circumstance, to discuss pricing or reimbursement, for fear of being in violation of the Sherman Act.

It is this hesitation that represents the challenges we are trying to overcome, as a society, to stifle the issue of transparency in pricing.

In this situation, I am a patient. I have read through all the paperwork - though not with a magnifying glass - and I don’t think there’s anything that prevents me from explaining what I was charged, and what I ultimately paid.

Let me start this process by noting that I have not yet received a bill from the hospital. Maybe by the next blog?

I first received a bill from the surgeon, charging the amount of $297. With my high-deductible plan in place, contractually I pay the amount that my insurance company has negotiated with the provider / surgeon. In this case, that amount was $294. Yes, folks, I received a 1 percent discount.

What arrived in the mailbox next, that I have in my possession, are two claim recaps from the insurance company. As I expected, they are not straightforward. Nor are they actually considered "bills" but rather the Explanation of Benefits (EOBs).

The first is the surgeon’s fee. In this case, the surgeon’s name is listed - not conspicuously, but quietly on the side - as the "Provider." The charge listed is for "Surgery-Abdominal" and there is nothing that hints that this was a hernia repair. Nowhere on the EOB. Just a generic term for abdominal surgery. And, this charge is listed twice, I’m assuming because I had a bilateral hernia repair.

The charge is for $1,717, per "Surgery-Abdominal" - a total of $3,434 - and the negotiated discount brings this down to a $740.63. An 80 percent discount, and a seemingly fair price. Probably even too fair, for a person with the fine motor skills and intense training to do laparoscopic surgery?

The second claim recap, or EOB, has me more confused. Initially, I thought it was from the anesthesia team, but the amounts seem too low and the coded procedure is the same. The listed "Provider" is a name I’ve never seen or heard (I don’t think).

The codes are there again, twice, for "Surgery-Abdominal." Also, the charges are the same - a total of $3,434. But in this case, on this EOB, the amount due to a different provider whose name I’ve never seen or heard is only $118.

Perhaps a surgical assistant? I think he used one.

Mine was a very straight-forward, elective surgery. These things that I’m pointing out to you now are things I had seen before and that I expected: unclear EOB with overly generic terms; unclear provider; unclear cost sharing. The idea that the insurance company can’t provide more consumer-friendly information on these forms is odd. Should be an easy fix.

I suppose the next step is that I wait for the bills from the actual offices, as EOBs do very plainly state "This Is Not a Bill." My job then will be to match the EOBs up with the office bills, a step that seems innocuous but could wind up a huge annoyance in someone with multiple bills, from multiple providers, for complex or unexpected issues.

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