An Inguinal Hernia Repair – Stupidity of the Status Quo

• This is the story of an inguinal hernia repair executed at Sutter Health’s California Pacific Medical Center (CPMC), San Francisco on 3/6/07.

• The following slides document the financial experience of a patient in a Blue Cross of California (BCC), now Anthem (WellPoint) HSA-compatible small-group plan.

• Slides have notes below: read them, too!• Information current as of 3/26/08

An Inguinal Hernia Repair – The Surgeon

• Patient was diagnosed with an inguinal hernia. Surgeon recommended California Pacific Medical Center. Surgeon was in BCC network and communicated his fee to patient

• Strangely, patient never received claim from surgeon nor EOB from BCC.

• Therefore, surgery was (surprisingly) free.

An Inguinal Hernia Repair – The Hospital

• Before the op, patient called CPMC and learned that day case-rate, including supplies, for self-pay (uninsured) patient was $1,497.50 (slide 9).

• When patient informed hospital he was insured by BCC, price “disappeared” and CPMC refused to state the contracted rate.

• BCC also refused to state.

An Inguinal Hernia Repair – The Hospital

• After the op, BCC EOB & CPMC claim (slides 10 & 11) showed:

Billed rate $13,552.80

Disallowed $3,523.73

BCC paid $5,167.07

Co-pay $700.00

Applied to Deductible $4,162.00

An Inguinal Hernia Repair – The Hospital

• The sum of what BCC paid, and what CPMC expected the patient to pay, was 670% of the self-pay case rate!

• Patient wrote a letter to CPMC querying the claim (slide 12) on 5/23/07, and never received a reply, and therefore never paid.

An Inguinal Hernia Repair – The Anesthesiologist

• Patient wrote a letter to anesthesiologist (slide 13) on 5/23/07 querying the anesthesiologist's original claim (not shown)

• Subsequent claim (slides 14 &15, dated 6/6/07) caused patient to write another letter (slides 16 & 17 dated 7/5/07) and partial payment of claim.

• Slide 16 shows yet another follow up claim for balance (7/17/07).

An Inguinal Hernia Repair – The Anesthesiologist

• Slides 19 & 20 show referral for collection (9/19/07) which patient paid on 11/18/07.

• This was 8 months after the procedure, at a large cost to the anesthesiologist because of the cut the collection agency no doubt took.

An Inguinal Hernia Repair – Conclusion

• Lack of price transparency profited the hospital (but not by as much as it expected) and cost the anesthesiologist dollar-income and time-value of money.

• Patient has no idea whether or how the surgeon ever got paid.

• To the reader: Either laugh or cry and feel free to forward to whomever is interested in making consumer-directed health care happen.