Troubleshooters: Tips on preventing pricey medical procedures

The Action News Troubleshooters receive many, many complaints about medical bills, and many of you tell us those bills are simply too high. We've discovered that asking the right question could save you hundreds, even thousands of dollars.

Bob Dolente works on his feet, so he can't afford to be in pain.

Dolente tells us, "Sciatica pain is very painful. You can't stand, and you can't put no pressure on your legs."

Dolente went to Fitzgerald Mercy Hospital for seven injections to relieve the pain. Each time he was charged a $400 insurance co-pay.

Dolente explains, "But I had no choice because I was in so much pain."

But he did have a choice. He could have gone to a surgery center where the same doctor provides the same treatment.

"And instead of paying $400, I can pay $150," Dolente said. And he did for his last injection, and saved nearly 63 percent.

David Shaffer wanted an adjustment for the hospital bill he got for his wife's MRA, an imaging scan. Shaffer has a high-deductible health plan, so he knew the cost would come out of his pocket.

To get a ballpark price, he used his insurance company's payment estimator in advance of the procedure. It showed his cost would be up to $2,367.

Shaffer tells us, "When we were hit for over $4,000, I thought that's completely crazy."

Shaffer says Abington Memorial Hospital charged his insurance company almost $8,000. And his portion of the bill was more than $4,300!

"Which would have completely wiped out our HSA account - just for one test," Shaffer said.

He says Abington refused to reduce the bill.

"My wife actually recommended, 'Why don't you contact Nydia Han,'" he said.

After the Troubleshooters stepped in, Shaffer got a call.

He explains the hospital told him, "Mr. Shaffer, we've adjusted your bill and it's now going to be $700."

That is a $3,600 savings!

"It was fantastic to have that wei ght lifted off my shoulders," he said.

Here's what you need to know: A procedure's price is based on the provider fee and the facility fee. The provider fee goes to your doctors. The facility fee goes to the venue for the room, the equipment, the lights, etc.

Shaffer says, "We've been told by our doctors that it's the facility fees that kill you."

Facility fees are typically much higher at a hospital outpatient facility versus a free-standing surgery center.

Robin Gelburd of FairHealth explains, "Oh, it can be dramatic. I mean it can be multiples of two or three times more."

For a colonoscopy in the Philadelphia area, the average charge by a surgery center is $1,492 - at a hospital it's $4,626!

For cataract removal and the insertion of a lens, the average charge by a surgery center is $3,274. Compare that to $10,488 at a hospital!

And remember, for his first seven pain injections Dolente could have paid just $1,050 at his nearby surgery center, but instead paid $2,800 to the hospital!

Dolente says, "It's way too high. It's just way too much money."

I contacted Dolente's insurance company, and Independence Blue Cross is now sending Dolente a full refund!

But to avoid overpaying in the first place, the question you must ask your doctor is: where else can I get this done?

As you ca n see, where you go can greatly affect the price you pay.

Shaffer says, "If you don't know that going in, you're going to be a shocked consumer as I was."

Steps to take and questions to ask to save money:

1. Ask your insurance company and doctor's office where else can I get this procedure done. Does my doctor do this procedure elsewhere?

2. Find out what kind of venue is this other option(s).

3. Check on http://www.FairHealth.org ^[1] to see if that venue is appropriate for the procedure AND find the average cost for that procedure in your zip code. Again, you can do both of those things on http://w ww.FairHealth.org ^[2]. But keep in mind, right now the numbers you see on FairHealth are ONLY the provider fees. They do NOT include the facility fees yet. FairHealth will add those as soon as it can.

4. To get the facility fees, you need to call your insurance company and/or the facility itself.

5. If you have insurance, call to see what your co-pay will be if you go to that venue. Also, check to see if the venue and ALL the doctors involved are within your network.

Don't forget - in many cases, there are a NUMBER of different doctors involved, including a pathologist and anesthesiologist. Again, make sure they are all within your network.

Also be advised - sometimes going to a surgery center is such a savings that it might make sense for you to go out-of-network. You need to do the math to find out!

And be aware - the Biparti san Budget Act of 2015 prevents health systems from charging facility fees at clinics they acquire in the future. But that does not apply to facilities they already own. So, ask for a breakdown on your bill of what you're paying as the facility fee. You have a right to ask for a reduction in that facility fee. Also, try to find a non-hospital owned clinic that may charge you less. But again, make sure it's in your network and all the doctors who will work on your procedure are, too.

Now, hospitals attribute their higher facility fees to having to defray the cost of more sophisticated and expensive technologies, having to operate 24-7, and provide emergency care as well as other services.

We have listed full statements from the hospitals mentioned in our story below:

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Mercy Fitzgerald Hospital statement:
Mercy Fitzgerald Hospital is committed to providing clear billing information, and our financial counselors are always available to he lp patients understand the costs they may incur from treatment at
our hospital. At the same time, an individual's co-pay rates are established by the benefit plan he or she has with their insurer, and it would be inappropriate to speculate as to how insurers determine their pricing.

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Independence Blue Cross Statement:
At Independence, our goal is to help members make the best use of their benefits to get the right care, in the right setting.

For our Medicare members we publish Update Magazine and offer a quick start reference guide with tips on optimizing our members' health care dollars. We also host educational meetings throughout the year to help our Medicare members understand and best use the benefits of their plan. For more information Medicare members can call 1-800-645-3965.

Here are a few tips for making the most of your health care dollars:

- Know the network. All insurance plans have networks of doctors and hospita ls, and selecting a doctor or hospital within that network can save you money. Some plan types require you to see an in-network provider. To be sure the hospital or doctor you choose is in your plan's network you can use our Provider Finder tool or call us at 1-800-ASK-BLUE (Medicare members call 1-800-645-3965). The tool allows you to do a smart search to narrow thousands of area doctors to ones near you who specialize in the care you need, but it also lets you know if a physician is a part of the Independence Blue Cross network. And, if you are planning to have surgery, make sure the hospital as well as all the doctors that will be in the operating room are also in your network.
- In a non-emergency, visit an in-network urgent care center. In a non-emergency you may save time and money by using an urgent care center instead of going to the ER. If it is not a true medical emergency, try to contact your primary care physician first. If your physician is not available, try an in- network urgent care center. This option will still have a lower co-payment or co-insurance, and helps you to avoid the longer wait times in the emergency room. In case of an emergency, go to the nearest emergency room. If you are unsure if you can get there on your own, call 911.
- Talk to your doctor. Members should speak with their doctors about where to schedule their upcoming procedure. In some cases an outpatient procedure can be performed in a non-hospital based setting like a freestanding ambulatory surgical center or a physician's office for a lower co-pay or co-insurance. It is an alternative to consider for certain services if your doctor believes it's the right option and your overall health allows it.
- Ask about generic drugs. Ask your doctor or pharmacist if generic drugs are right for you. Your doctor can prescribe the generic drug for you if appropriate. In many cases, your pharmacist can give you a generic drug, if available, when your doctor prescribes a br and drug as long as your doctor does not indicate "dispense as written." This may mean lower out of pocket costs for you. We also offer customers other ways to save money on prescriptions, including mail order services.

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Abington Memorial Hospital's statement:

How an insured patient's financial responsibility for services is determined

Contracts between individual insurance companies and hospitals determine each patient's financial responsibility for hospital services. A patient's individual insurance plan determines the patient's out of pocket costs related to co-pays and deductibles. The patient's out-of-pocket amount due is considered part of our contracted rate and the payer contract states that the hospital shall collect such amounts from the patient. At Abington, patients who have difficulty paying these balances are offered the option of a no-interest loan for up to two years through a service called the Care Payment Program.

Options for patients with high co-pays and deductibles

Increasingly, patients have high co-pays and deductibles set by their insurance plans. Patients who contact our Business Services office and express concern over out-of-pocket expenses have the option of participating in the Care Payment Program, which offers an interest-free loan that patients can use to pay off their balances up to two years. Many hospitals offer similar options.

Why hospitals need to negotiate higher rates with insurers than freestanding offices

Hospitals and their affiliated facilities provide access to critical hospital-based services that are not otherwise available in the community and treat higher-severity patients. In addition, hospital facilities have higher cost structures than other facilities due to the need to have emergency stand-by capacity and higher costs associated regulatory requirements imposed on them.

Hospital-based clinics provide services that are not otherwise av ailable in the community to vulnerable patient populations. The costs in these hospital-based clinics are higher due to more severely ill patient populations requiring greater use of resources, greater regulatory requirements, stand-by capacity costs related to offering emergency department and other services 24/7 and 365 days a year, and also the costs of unreimbursed "wrap-around" services.

Hospitals have more comprehensive licensing, accreditation and regulatory requirements. Hospital-affiliated facilities must comply with a much more comprehensive scope of licensing, accreditation and other regulatory requirements than do free-standing physician offices.