Viewpoint: Business As Usual For Health System After Passage Of The No Surprises Act

"This is still business as usual for our broken healthcare system: overpriced, overcomplicated and impossible to navigate."

Self-pay/uninsured patients and people with high health insurance deductibles have a new tool called the No Surprises Act (NSA). As a top-down “solution” to a complex problem, it has its own complexities and imperfections, but it can still be helpful. There are also consumer protections in some state laws. 

I used this law recently to help get a written price estimate prior to a medical test at a hospital. I like to keep my health information private but am sharing this story because it nicely illustrates what people fear and routinely deal with regarding health care billing. My health is fine, thankfully. I had some symptoms in February 2022 which I shared with my direct primary care (DPC) physician. She referred me to a cardiologist, who recommended I have a stress echocardiogram (stress echo) to complete my evaluation. The results were normal, and the care I received was great. 

However, billing was terrible. My husband and I have been self-paying for medical care since 2016, and problems with billing are common. In contrast, we never have these problems with veterinarians’ bills or dentists’ bills – their cost estimates have been accurate, they have honored what they said and we pay at the time of service. My husband and I are self-pay by choice because our health insurance options are awful, largely due to the ACA (‘Obamacare’). We are self-employed/semi-retired. The ACA uses tax dollars to subsidize premiums for health insurance for some people, but not for us. I also hate the other changes to our health insurance options caused by the ACA, so we stopped carrying it and made other plans. 

I called our local hospital for a price on the stress echo and received an estimate of $3783.00 (as I found out later, 6.5 times what they get for the same test on a Medicare patient). The person I spoke to said that this hospital is “high”. I called the next closest hospital system (92 miles away) and got an estimate for almost the same price. Montana has a low population density, and accessing competitive alternatives often requires travel. The removal of the CON laws last year may eventually help, but for now we don’t have other local options for a stress echo test

I called back to the local hospital and requested a lower price, because my research confirmed that their price was high. I knew that the price for the exact same medical service can vary wildly for different people treated at the same facility, depending on their insurance. I then received a lower estimate of $1449.00, and the new written estimate had the same billing codes (CPT) as the first estimate. I asked for the fee for the same test for a Medicare beneficiary but got no answer. I agreed to the second estimate amount of $1449.00 and proceeded with the test on that basis. No additional services were provided. I offered to pay in full at check-in, but they did not have access to the estimate. Subsequently, I have been billed $2342.81 for the test – a full $893.81 over the second estimate. 

I eventually found out that the fee for the same test when done for a Medicare beneficiary is $581.63. My second estimate, which I agreed to, is still 2 ½ times that. I also found out that the fee for patients covered by the hospital’s highest paying healthcare insurer is $2830.92 (although the patient often pays some or all of that because of the deductible). The first estimate was almost $1000.00 more than even that. This is not the worst billing story, but it represents an all too common norm. People with health insurance rely on their insurer to keep prices in check for them, but they (and their employer and their insurance company) pay up to five times as much as a Medicare patient pays for this particular test. And, their insurance costs a fortune. 

The hospital did not correct it. They gave no logical reason for the higher charge, and they gave me the most amazing run-around. They “couldn’t find” the second estimate, so I brought a copy to them. Their solution after seeing the second estimate? They said that the higher-ups would probably add $400.00 to the $1449.00 amount. This is not the intent of the NSA, to allow them to add $400 to the estimate. The NSA provides for a dispute resolution process if the billed amount is more than $400 over the estimate, and the hospital would like to avoid that while still charging more than what they agreed to. If you don’t pay up, they send you to collections. However, an accepted estimate acts as an implied contract, and there are some rights that come with that. I am pursuing those rights. I will provide the rest of the story when it is over, which may help others navigate the hospital billing labyrinth. 

This is still business as usual for our broken healthcare system: overpriced, overcomplicated and impossible to navigate.  A system in which keeping prices hidden at all costs is one bound to cause issues. I do understand that Medicare often does not pay enough to cover costs. Medicare has been squeezing doctors and hospitals. The rest of us still deserve to know what Medicare is paying for comparison, and also deserve to receive a reasonable, reliable cost estimate for ourselves, and then have it honored.

Healthcare Viewpoints is a monthly series featuring original columns from Montana healthcare leaders focused on addressing the challenges presented by our broken healthcare system. The opinions of guest authors do not necessarily represent the policy positions of the Frontier Institute.