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Excellent cancer care, byzantine billing

High-grade ductal carcinoma in situ was the diagnosis. To the rest of us that means breast cancer. Lucky for me it was found early through an annual mammogram, then an ultrasound, and finally a confirming biopsy.

One in eight American women will develop breast cancer in their lives. I beat the odds, though not in a good way.

That said, due to the consummate skills of general surgeon Dr. Ernest Rehnke and plastic surgeon Dr. Robert Rehnke, (yes, brothers) who worked in tandem performing a bilateral mastectomy with immediate reconstruction, I am healing and am intermittently back at work two weeks after the ordeal.

Robert Rehnke and his office staff treated me as if a member of their family was stricken. As Robert said, "The problem with medicine today is not a lack of technology or pharmacology but a lack of humanity." He and his office delivered compassionate care with the highest professionalism.

But not every part of this experience has been as smooth. America spends more than any other industrialized nation on its health care system, with often worse health outcomes. Coming through breast cancer from diagnosis to cure demonstrated quite clearly to me why this is.

First, trying to be an educated consumer of health services by understanding pricing schedules is like cracking Enigma code. Second, the way the medical establishment and private insurance system is organized ensures that Americans get impersonal, redundant medical care for the highest cost, a subject I will discuss in my next column.

Today, I'd just like to share with you some of my experiences with opaque medical billing and why there is no way to comparison shop.

After my biopsy I was told to obtain an MRI to see if the cancer had spread. I obtained the names of two local MRI centers in my Cigna health network and called each for pricing information.

The woman who answered the phone at Saint Pete MRI told me the cost would be $625. The woman answering the phone at the second option had no idea. Eventually I was told they would bill a total of more than $3,000. I went to Saint Pete MRI.

I later discovered that Saint Pete MRI actually bills insurers $2,450 for an MRI, but it charges self-paying customers $625. Under Saint Pete MRI's contract with Cigna it would receive $650 for my MRI — except that Cigna has contracted with MedSolutions Inc. as a third-party payor. MedSolutions would be paying Saint Pete MRI and then seeking reimbursement from Cigna (and me). But I was told by Cigna that information about pricing between Cigna and MedSolutions is proprietary.

When I received the "Explanation of benefits" (the greatest misnomer in the English language) from Cigna on my MRI, it said the amount billed by MedSolutions was $1,500, of which Cigna paid zero. So I owed $1,500 to MedSolutuions. I called Saint Pete MRI to see what MedSolutions had paid it for the procedure and was told it had received only $450, or $200 less than the contracted price and $1,050 less than what I apparently owed.

Now this claim is being "reprocessed." But so far I have been unable to get a straight story on the initial billing, despite hours of effort.

Now let's turn to the gargantuan charges for medical services.

The biopsy I had performed at Bayfront Medical Center involved a radiologist extracting tissue from two concerning areas of one breast. It took maybe a couple of hours, and there was one technician in the room assisting.

Here's what Bayfront billed for the procedure: $12,016.58. It claims this is less than what others charge. But that's not even the end of the bills for that day. This sum didn't include the services of the radiologist who did the extractions, the pathologist or the laboratory. Add those bills together and the total is more than $16,700.

A substantial percentage of this was discounted due to the contract between Cigna and these providers. But why is the same procedure thousands of dollars costlier for those paying out of pocket?

Seeking a justification for the charges, I asked Bayfront for an itemized bill. I received a single page with descriptions such as these: "MA Mammotome Assist Biop" $3,244.26, "MA Breast Surgical Speci" $1,221.33. You get the idea. Or if you're like me, you have no idea what this could possibly mean.

Further attempts to get a breakdown of detailed costs for each item proved fruitless beyond being told that bills reflect the cost of hospital resources, including equipment, overhead, personnel, supplies, etc. At one point I was told that if I wanted more information on pricing policies I should contact the hospital's president.

This is why it is laughable to think that by shifting more of the financial burden for health care onto individuals they will make more economical choices. I tried. It can't be done.

Excellent cancer care, byzantine billing 10/29/11 [Last modified: Saturday, October 29, 2011 5:31am]

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