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

Danilo Manimtim and his wife, Marilou, underwent identical cataract surgeries, but the charges were dramatically different — even though the couple from Fresno, Calif., were covered by the same health plan.

Heidi de Marco/KHN

Danilo Manimtim’s vision was hazy and blurry – and it was getting worse.

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

In December 2021, he visited the local hospital outpatient department to undergo the common procedure which usually replaces the natural eye lens with an artificial lens and is designed to restore vision. The outpatient procedure went well and Manimtim healed over the following weeks.

Manimtim, who has disability claims adjudication work for the state of California, knows the health care system and monitors its health benefits. He knew he had already reached his health insurance deductible for the year, so he expected a manageable expense for the surgery. He calculated that his coinsurance would be approximately $750.

Then the bills came.

Patient: Danilo Manimtim, 73, of Fresno, California. He is insured through his employer by Anthem Blue Cross of California for outpatient care and is covered by Health insurance for hospitalization.

Total bill: Overall, the charges were $9,084 for surgery, anesthesia, medical supplies, pharmacy, and clinical laboratory services. Anthem paid $5,027 and initially charged Manimtim $4,057.

Service providers: Saint Agnes Medical Center. It is part of Trinity Health, a nonprofit hospital system headquartered in Michigan with 88 hospitals and 125 urgent care centers Across the country. The hospital system provided nearly $20.2 billion income for most last exercise.

Medical service: Cataract surgery on an outpatient basis, involving anesthesia.

Which give: Manimtim’s big bill stems from a simple decision that turned out to be a trap in the country’s complex healthcare system: He scheduled his surgery at a nearby hospital – a hospital that charged about $7,000 more. for the procedure than her insurer would pay.

Manimtim has proof that it could have been different under his own roof: four months later, his wife, Marilou Manimtim, 66, underwent the exact same procedure at an outpatient surgical eye care center in Fresno called EYE-Q. It is half a mile from Saint Agnes Medical Center but is not affiliated with the hospital.

Both patients have the same insurance coverage through Anthem Blue Cross of California; they underwent identical cataract surgeries; and both providers were part of Anthem’s coverage network. Marilou owed $204, while Danilo was on the hook for a staggering $4,057.

“It’s ridiculous and it seems very unfair,” said Danilo Manimtim. “How can it be so much more expensive than the surgical center? It’s within walking distance, and if I had gone there, I would have saved a lot of money.”

Manimtim’s insurance plan, through his employer, the California Public Employees’ Retirement System, caps outpatient cataract surgery payment at $2,000, according to Anthem. CalPERS has instituted a “reference price” system in recent years, in which he determines a reasonable price for a high-quality procedure of this type in California. It then only reimburses up to that amount, encouraging patients to buy treatments at prices below the bar. For the cataract surgery itself, Manimtim plan patients are responsible for all costs over $2,000 .

Even for hospital care, Saint Agnes’ overall charges are high for cataract surgery, Dr. Ira Weintraubchief medical officer Well Rhythms, which analyzes health care prices for employers. “The hospital charged three to four times what this surgery typically costs, which is about $3,000.”

“Nobody gets $9,000 for cataract surgery,” he added.

If Manimtim had opted for Medicare Part B, the part of the Medicare program that covers outpatient care, it would likely only have been liable for around $565, a Medicare cost comparison tool shows. Medicare pays a fixed amount for the procedures, regardless of where they are performed.

But like many older Americans who are still working, Manimtim opted out of this coverage, opting instead for his employer’s plan because his monthly premium would be significantly cheaper.

Healthcare prices often have very little to do with the true costs of delivering care and its quality – and patients often face the “double whammy” of high prices and complex benefits, said Anthony Wright, executive director of Health Access California, a nonprofit organization. defense group. Too often, patients are left to figure out how to use their diet’s benefits on their own, he said.

“You wonder what the rationale is for any of the prices in our health care system,” Wright said.

Resolution: After investigation by KHN, Anthem contacted the hospital, Saint Agnes, asking for help for Manimtim. Although the doctor was instructed to seek an exemption from CalPERS’ $2,000 limit on payments for cataract surgery under Manimtim’s plan, this did not happen before his surgery. Anthem asked the hospital and doctor to review the claim after the surgery, Anthem spokesman Michael Bowman said.

Saint Agnes spokeswoman Kelley Sanchez told KHN that the hospital and provider then applied for the waiver that would allow the insurer to pay more than the $2,000 limit and that she eventually been approved by Anthem. That should leave Manimtim with a much smaller coinsurance bill, around $750 – and off the hook for being taken to collections by the hospital. The hospital will receive a higher payment from Anthem, which will cover much of the remaining bill of $4,057.

And this high payment, like all high payments, contributes to the increase in health insurance payments for all.

Sanchez said the hospital is not in the business of price gouging, but noted that hospitals generally have higher costs and tend to charge more than outpatient facilities.

“We never want to cause harm or create hardship for our patients, and that extends to our billing practices,” Sanchez said in a prepared statement.

She noted that Saint Agnes has financial assistance programs available and encourages patients to ask questions and understand potential costs before seeking care. “Every patient’s insurance plan is unique, so it’s their responsibility to understand the benefits of their plan,” she wrote. “It’s still complicated and we recognize that, and we will continue to work for greater price transparency.”

The takeaway: The bottom line for patients, experts say, is to make sure to read the fine print of insurance plans to understand all personal responsibilities, including premiums, deductibles, copayments and coinsurance. In addition, a small number of large employers who self-insure using the reference price, capping what they will pay for routine procedures. Shop around and ask about prices up front if possible.

“People often focus on premiums because they’re easy to compare, but premiums don’t tell the whole story, and this example illustrates the trade-offs,” said Tricia Neuman, a Medicare expert at KFF.

Anthem spokesperson Bowman urged patients to use the anthem online”care seekerto compare patient costs and find a cheaper option if available. If Manimtim had done this, he might have seen that having cataract surgery at an outpatient surgical center would have been much cheaper. Details of provider cost and insurance coverage can be idiosyncratic and often aren’t displayed in a patient-friendly way. Manimtim tried to explore its benefits before the procedure, he said, but didn’t did not get a clear answer from the insurer or the hospital.

Manimtim also had advice for consumers: if you get a medical bill and don’t understand the charges, don’t pay right away. Instead, call your provider and insurer to find out about the charges and if there are ways to lower your bill.

“People need to be better informed by insurance companies and hospitals about the options available to them, to avoid overcharging,” Manimtim said. “A lot of people don’t know it could happen to them.”

Stephanie O’Neill contributed to the audio portrait with this story.

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