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An $18,000 biopsy? Paying cash might have been cheaper than using her insurance

Dani Yuengling of Conway, South Carolina, researched how much a needle biopsy of a lump in her breast might cost. The hospital website showed it would be about $1,400 for someone without insurance. She reasoned her bill with insurance would be less. Instead, the sticker price was close to $18,000, and she was on the hook for more than $5,000 — the balance of her deductible. (Gavin McIntyre for KHN)
Dani Yuengling of Conway, South Carolina, researched how much a needle biopsy of a lump in her breast might cost. The hospital website showed it would be about $1,400 for someone without insurance. She reasoned her bill with insurance would be less. Instead, the sticker price was close to $18,000, and she was on the hook for more than $5,000 — the balance of her deductible. (Gavin McIntyre for KHN)

When Dani Yuengling felt a lump in her right breast last summer, she tried to ignore it.

She was 35, the same age her mother had been when she received a breast cancer diagnosis in 1997. The disease eventually killed Yuengling's mom in 2017.

"It was the hardest experience, seeing her suffer," said Yuengling, who lives in Conway, South Carolina.

After a mammogram confirmed the lump needed further investigation, Yuengling scheduled a breast biopsy for Valentine's Day this year at Grand Strand Medical Center in Myrtle Beach.

Among many concerns she had ahead of that appointment — the first being a potential cancer diagnosis — Yuengling needed to know how much the biopsy would cost. She has a $6,000 annual deductible — the amount her health plan requires she pay before its contribution kicks in — and she wasn't close to hitting that. Whatever the procedure cost, Yuengling knew she'd be on the hook for most of it.

But the hospital wouldn't give her a price. She was told her providers wouldn't know what type of biopsy needle they needed until the procedure was underway and that would impact the price.

The hospital's online "Patient Payment Estimator" showed that an uninsured patient would owe about $1,400 for the procedure.

"That's fine. No big deal," she thought to herself, confident it would be cheaper for her because she did have insurance. A Google search indicated it could be closer to $3,000, but Yuengling thought that price seemed reasonable, too. She wasn't fretting too much about money as she underwent the procedure.

It soon brought the good news that she didn't have cancer.

Then the bill came.

The patient: Dani Yuengling, now 36, who is covered by Cigna through her employer, a human resources contractor for the Mayo Clinic.

Medical service: An ultrasound-guided breast biopsy.

Service provider: Grand Strand Medical Center, a 403-bed, for-profit hospital in Myrtle Beach, South Carolina. It is one of 182 hospitals owned by Nashville-based HCA Healthcare, which generated $58.7 billion in revenue last year.

Total bill: $17,979 for the procedure, including lab work, pharmacy charges, and sterile supplies. Cigna's in-network negotiated rate was $8,424.14, of which the insurance company paid the hospital $3,254.47. Yuengling was billed $5,169.67, the balance of her deductible.

What gives: It's not uncommon for uninsured patients — or any patient willing to pay a cash price — to be charged far less for a procedure than patients with health insurance. For the nearly 30% of American workers with high-deductible plans, like Yuengling, that means using insurance can lead to a far bigger expense than if they had been uninsured or just pulled out a credit card to pay in advance.

Ge Bai, an associate professor at Johns Hopkins Bloomberg School of Public Health, recently published research on this topic and said hospitals in the U.S. often set their cash prices lower than the prices they charge to treat commercially insured patients.

"We can very confidently say this is very common," said Bai, who advised that all patients, regardless of their insurance status, inquire about the cash price before undergoing a procedure. "It should be a norm."

Grand Strand charged Yuengling's insurance an extraordinarily high price for her procedure. By comparison, according to the federal government's website, Medicare patients who need an ultrasound-guided biopsy similar to the one Yuengling received would pay only about $300 — their required 20% coinsurance for outpatient care. Medicare would pay the hospital the remainder of the bill, about $1,200. The hospital expected more than five times the Medicare price from Yuengling and her insurer.

Patients in Conway with private health insurance who are treated at other hospitals also typically are charged less than what Yuengling paid for the same procedure — on average about $3,500, according to Fair Health Consumer, an organization that analyzes health insurance claims.

And uninsured patients who pay cash prices and need an ultrasound-guided breast biopsy at the nearby Conway Medical Center are likely to owe even less — about $2,100, according to Allyson Floyd, a spokesperson for the hospital.

Meanwhile, Grand Strand Medical Center spokesperson Caroline Preusser blamed "a glitch" involving the hospital's online calculator for the inaccurate information Yuengling received and said the correct estimate for the cash price for a breast biopsy at the hospital is between $8,000 and $11,500 "depending on the exact procedure and equipment used."

The hospital removed certain procedures from the payment estimator until they can be corrected, Preusser wrote. She did not say how long that would take.

Resolution: Yuengling tried disputing the charges with the hospital. She called the billing department and was offered a 36% discount, lowering the amount she needed to pay to $3,306.29. Grand Strand Medical Center allows patients to set up payment plans, but Yuengling decided to charge the full amount to a credit card because she wanted the whole thing to go away.

"I could not sleep. It was driving me crazy. I was having migraines. I was sick to my stomach," she said. "I hate having debt. I didn't want to think about it. Obviously, that didn't work because I'm still thinking about it."

She said she requested on multiple occasions to speak to the hospital's patient advocate and was eventually connected with an outside company, Parallon, which conducted an audit of her bill. She eventually received a letter dated May 26 from the hospital's Revenue Integrity Department. It stated: "After a review of the charges in question and your medical record, the following was identified; The charges on your account were appropriate."

"I don't know why I actually expected a different outcome," she said.

The hospital has requested that Yuengling return for a follow-up appointment related to the biopsy. She has refused.

Harlow Sumerford, a spokesperson for HCA Healthcare, told KHN in an email that the hospital system apologizes for any confusion caused by the payment estimator "and we are working to fix the issue."

The takeaway: With a family history of breast cancer, Yuengling was right to follow up with her doctor after feeling a lump. After failing to get a clear answer on her costs from Grand Strand Medical Center, she could have taken an additional step to explore what other hospitals in the area charge. Although her physician referred her to Grand Strand, she was not obligated to use that hospital. She could have saved a significant amount of money by opting to undergo the procedure elsewhere.

Furthermore, patients like Yuengling who have a high-deductible insurance plan should consider paying cash prices for certain procedures and not involving their insurance company at all.

Jacqueline Fox, a health care attorney and a professor at the University of South Carolina School of Law, said she isn't aware of any law that would prohibit a patient from doing that. After all, she pointed out, patients with health insurance pay cash prices for prescription medications all the time. It stands to reason they could do the same for medical procedures.

But some facilities make this difficult. Grand Strand Medical Center, for example, offers "self-pay" patients an "uninsured discount," but that discount is limited to people who have "no third party payer source of payment or do not qualify for Medicaid, Charity or any other discount program the facility offers," according to the hospital's website. Only patients confirmed to have no health insurance are offered information about the discount.

In some cases, paying a cash price for a procedure might not make financial sense in the long run because none of it would be applied toward the deductible. Patients might save money on one procedure but end up paying their full deductible if unexpected medical expenses mount later during the calendar year.

Insured patients should reach out to their health plan for a good-faith estimate before a procedure. Under the No Surprises Act, health plans are supposed to give members an idea of their total out-of-pocket costs upon request. Ask for an "Advanced Explanation of Benefits," said Sabrina Corlette, a research professor at the Georgetown University McCourt School of Public Policy, though she points out this part of the law isn't being enforced yet.

The No Surprises Act also allows patients to file complaints with the federal government regarding their medical bills — whether or not they carry health insurance.

Yuengling filed her complaint in June.

Stephanie O'Neill contributed the audio portrait with this article.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. It is an editorially independent major operating program of KFF (Kaiser Family Foundation).

Copyright 2022 Kaiser Health News. To see more, visit Kaiser Health News.

Transcript :


Time for the Bill of the Month. We look at real-life health care bills that somebody sent us and figure out what's going on. Today we hear about how using insurance can cost you more than just paying out of pocket. Dr. Elisabeth Rosenthal is here to explain. She's the editor-in-chief of our partner, Kaiser Health News. Welcome.

ELISABETH ROSENTHAL: Thanks for having me.

INSKEEP: OK. Who sent us the bill we're going to focus on here?

ROSENTHAL: Well, today's patient is Dani Yuengling. She's a young woman from Conway, S.C. And she tried really hard to find out what she would have to pay for a breast biopsy before she had the procedure. And despite her valiant efforts, she ended up with a bill that is the total opposite of a bargain.

INSKEEP: OK. Well, let's hear her story, which is told here by reporter Stephanie O'Neill.

STEPHANIE O'NEILL, BYLINE: For Dani Yuengling of South Carolina, finding a lump in her breast wasn't just worrisome - it was downright scary. Dani lost her mom to breast cancer.

DANI YUENGLING: I was around 11 or 12 at the time, and she went through chemo. And it wasn't too aggressive the first time that she had cancer. She went into remission for about 17 years.

O'NEILL: And then it came back, and it spread to her lungs, her spine, her brain.

YUENGLING: That was definitely the hardest thing I ever have and ever will go through, was seeing my mom have to suffer like that.

O'NEILL: It was an experience that left Dani extra diligent about her own breast health, causing her to take all precautions her doctors recommended, including regular self-exams, which last summer turned up the lump. Dani was 35, the same age as her mother when she was first diagnosed with breast cancer.

YUENGLING: I was just so nervous, just scared of, you know, what I might find out.

O'NEILL: But with urging and support from her husband and friends, Dani found the courage to make the doctor appointment.

YUENGLING: The doctors said that they did feel something. They couldn't tell if it was a tumor or a cyst, so they suggested getting a biopsy done.

O'NEILL: Before she went in, she researched the cost. Dani's health insurance comes with a $6,000 deductible, so she wanted to know what to expect financially. Her first call was to the hospital where her doctor had scheduled her biopsy, and they told her the cost would depend on which type of biopsy she needed.

YUENGLING: So I went home, and I actually did some research on my own. I looked at the hospital system's calculator.

O'NEILL: But the program kept rejecting her insurance information, so she finally tried it with no insurance. And to be on the safe side, she chose the more expensive of the two procedures. The estimated cost - about $1,400, which she was prepared to pay.

YUENGLING: So surely I thought that it wouldn't be any more than that.

O'NEILL: So last February she got the biopsy, which involves suctioning a tissue sample from the lump. It took about 10 minutes and ultimately showed no cancer present - a huge relief. But then came the bill - almost $18,000 - leaving her on the hook for more than five grand.

YUENGLING: I thought, this has got to be some type of error. They put it in, like, the wrong coding or something. I was like, there's no way it can be this much.

O'NEILL: Dani then requested an itemized bill, which helped her get the hospital to lower her bill by about $2,000. But that still left her on the hook for 3,300 bucks, which she paid with a credit card. Dani Yuengling is relieved it's now all behind her, but she says the experience has left her afraid to seek care in the future. For NPR News, I'm Stephanie O'Neill.

INSKEEP: With any other product that I would buy, I would ask the salesperson, what's the price, and they would just have to tell me. Why is that not the case here?

ROSENTHAL: Well - because nothing in American health care has a price. Medicare pays one thing. Medicaid pays another. And hospitals are always trying to get the highest price from people with private insurance. Now, the irony here is the cash prices that hospitals charge are often less than the insurance price because they're set at an actual real-life working person might be able to pay.

INSKEEP: So we're talking about the same vendor doing the same procedure, charging different prices for different people. What would Medicare pay if they were on the hook for this same procedure that Dani got?

ROSENTHAL: Well, Medicare's price in Dani's area is about $1,500. So Dani and her insurer were expected to pay around 8,000 - more than five times what Medicare would pay.

INSKEEP: So what is her recourse? Could she have done anything differently?

ROSENTHAL: Well, to me, it was a red flag when the hospital wouldn't give her an estimate. She could have gone to other hospitals and tried to price the procedure there and gone someplace cheaper. But as a number of people have written in to Bill of the Month have said, they did get estimates, and then the bill was twice as much as the estimate. And I always like to point out that in other countries, not only do patients get estimates, but they have to be binding estimates. So there's none of this kind of oh, well, that was just an estimate thing.

INSKEEP: Could you push back on the hospital and just say, thank you for the estimate, I will not pay one cent more than this, and that's what I'm signing right here?

ROSENTHAL: Well, you can try, but what they'll say is, oh, yeah, we didn't expect this or that to happen. And what we're doing is legal, which it is. But I feel like it shouldn't be. So, you know, you can do some things as she did. You can ask for an itemized bill and dispute some of the charges. And that - you know, the more you fight back, the more likely you are to get some kind of discount.

INSKEEP: If you are paying yourself, could you put the balance on a credit card and then dispute it that way?

ROSENTHAL: You could. It's best to dispute in advance. And the problem with putting things on a credit card is, of course, you have very high interest rates, and hospitals should be offering you instead a payment plan with no interest. So, you know, if you're going that route, go to the hospital, not a credit card.

INSKEEP: When we sort through all of that, are there situations when you should just pay cash and leave the insurance alone?

ROSENTHAL: Unfortunately, yes. But it just shows how incredibly broken our system is and how hard it is to navigate. So if you get a high estimate from a hospital or a pharmacy about your patient responsibility, ask about the cash price. It may be a much better deal, and you can just forgo using insurance and pay. Unfortunately, then it doesn't count against your deductible, so you're kind of dinged in that way. But you'll save money in the short term.

INSKEEP: They get you one way or another. Dr. Elisabeth Rosenthal of Kaiser Health News, thank you for helping many people to not get dinged quite as often.

ROSENTHAL: Yes, they'll get you one way or another - could be the motto for our Bill of the Month project.

INSKEEP: And if you have an outrageous or confusing medical bill, go to NPR's Shots blog and send it to us. Transcript provided by NPR, Copyright NPR.