out of pocket for procedure?

[sgull]

Hi. I having a hard time getting a straight answer to how much a colonoscopy will end up costing me out of pocket. The total cost for the colonoscopy is $3700 the hospital tells me. I have medical insurance through my job that has a $1500 annual deductible.
Already this year I've paid $640 out of pocket med expenses, toward deductible on the insurance. The insurance company says it pays 80% for a colonoscopy once the deductible is met.

So, my question is, according to the criteria above, how much is a colonoscopy going to end up costing me assuming I have no further medical expenses toward the deductible?

[Whitenack]

I assume the $3700 is the negotiated amount the insurance company can get you, and not a retail amount?

Deductible ($1500) minus past paid ($640) = $860 left to pay at 100%

So, $860 - $3700 = $2840 at 80% co insurance, meaning you pay 20%.

20% of 2840 = 568

568 + 860 = $1428

This is assuming you don't have a "Max out of pocket" limit less than $1428.

I would think you should be able to call someone in customer service and have them give you this information.

[marksr]

You might want to see if it can be done in a clinic instead of the hospital. I had a colonoscopy one year ago and my portion of the bill was about $300. I have medicare so I know it's a lower price than many pay with regular insurance but $3700 still seems kind of high. The thing that puzzles me is medicare sent me a card saying beginning in 2011, colonoscopy's would be free ...... but their web site says you have to pay 20% right under where they say it's free

[sgull]

Whitnack,
Thanks for the response. The $3700 is not any negotiated amount. It's the retail charge for the procedure; I called the hospital and asked specifically.

So my figuring is as follows:
Deductible ($1500) minus past paid ($640) = $860 left to pay at 100%

$3700 - $1500 = $2200

So insurance would pay 80% of $2200, which is $1760, and the 20% remainder of $2200 that I'd have to pay would be $440.

$860 + $440 = $1300, thus $1300 out of pocket cost for me.

I'm probably not figuring it right. The "co insurance" statement in your response is confusing to me, the $860 minus $3700. I called customer service both at my insurance company and the hospital. No straight answers from them. Hospital financial person seemed to indicate the cost to me after insurance would be around $400.

[Whitenack]

Ok, a couple of things...

You need to find out the negotiated rate that you will actually be charged. If $3700 is just the retail amount, that isn't actually what the bill will be. Your insurance company has negotiated amounts for every procedure. Consider it a "buying in bulk" benefit for having health insurance. For example, your health insurance company may say that the retail price is $3700 but we are only going to allow you to charge $X to our policyholders. Therefore, you need to find out the negotiated amount. I would imagine the hospital would give this to you if you tell them what insurance you have.

"Coinsurance" is an insurance term for the percentage split that you pay after the deductible has been met. You said you have a deductible of $1500 and then the insurance will pay 80% after that. What this means is you pay 100% of the first 1500 of expenses, then any expenses over 1500 is paid 80% by the company and 20% by you.

So...

You have $860 left to spend before you max your deductible. Once you max your deductible, you start the coinsurance portion of the payment.

(Negotiated Price of procedure) - ($860) = coinsurance portion.

(coinsurance portion) x 20% = your portion of the coinsurance

(your portion of coinsurance) + $860 = total amount out of pocket

The last part of the equation that might affect things is if you have a max out of pocket. Your max out of pocket is probably much higher than what we are talking about here, but for the sake of discussion, it is max you can pay for medical expenses in a policy year before the insurance company will pay 100% for the rest of the policy. Generally it is a few thousand dollars, but if for some reason it is, say, $2000, then that would be the most you would have to pay and the insurance company would pay 100% from that point forward.