Q: During a routine visit to the eye doctor, he noticed an eyelash on my bottom eyelid appeared to be poking my eye and said he’d remove it. When the bill came, it was listed as “surgery.” The ophthalmologist’s office billed my insurer for $335, and the doctor’s office said I owed them $200. Is this possible — what are my rights?
— Reese Morgenstern, 28, Los Angeles
A: As with buying a car, paying college tuition, and yes, health care, customers rarely pay the sticker price. The true price you end up paying becomes a game, and it’s up to you to figure it out. Will you have the endurance to make all the requisite calls? Will you relent and just pay what you’re told? Who will win? Capitalism!
In this case, Mr. Morgenstern wanted to understand how a regular eye checkup — albeit, one inside the behemoth University of California, Los Angeles health system — and a casual mention of a wayward eyelash could cost hundreds of dollars out of pocket. The office was in network. His co-payment was $30. Was there any way out of a charge within a health care system where dabs of skin glue cost more than $1,500 and high-tech bandages can reach millions?
Here’s how it happened: The doctor, kind and pleasant, noticed Mr. Morgenstern had a stray lash grazing his eye and said he’d remove it. “OK,” Mr. Morgenstern said.
Using what Mr. Morgenstern said looked like a pair of drugstore tweezers, the doctor plucked the lash. He left shortly after.
A few days later, his bill arrived: “Revise eyelashes, forceps,” it said. “Surgical.” $335.
“Maybe I should’ve told my family I was going into surgery that day,” Mr. Morgenstern mused.
The ophthalmologist had billed his insurance $1,085 for the office visit, and the insurer paid $545.20. (Mr. Morgenstern covered $30 of that through his co-pay.) But the pluck — that was extra. The doctor never mentioned it, and it hadn’t occurred to Mr. Morgenstern that he would be charged. “I cannot stress enough how casual the eyelash removal was,” he said.
Mr. Morgenstern filed grievances, both with the physician’s billing office and his insurer. Both were denied. “They each indicated, including when I called the billing office, that the doctor confirmed everything and it was billed correctly.”
Some time passed, and a new bill arrived, sans eyelash surgery. Mr. Morgenstern said he thought maybe someone had shown some mercy and cleared the charge. But roughly three months later, a $198.97 eyelash bill boomeranged back. He told his mother about it, and, feeling sorry for him, she took on the case.
So she called the physician billing department — immediately requesting a supervisor, as all good mothers do — and they told her the patient should know what’s covered. “Sure, physician billing, gaslight the patient,” Mr. Morgenstern thought to himself. “Maybe I should’ve known a random, nonchalant removal of an eyelash via tweezers — I mean, forceps — was a surgical procedure.”
Mr. Morgenstern’s mother thought that perhaps he might be protected by the No Surprises Act, a federal consumer law that took effect three years ago. But that generally applies to people who visit an in-network facility and, unbeknown to the patient, end up receiving care from an out-of-network doctor (like an anesthesiologist) who later hits them with a big surprise bill. It also applies to emergency care services. The law generally limits charges to what a patient would have paid in-network.
I called Kaye Pestaina, the director of the patient and consumer protection program at KFF, a health policy group, who helped me try to understand why, however ridiculous the charge, Mr. Morgenstern might be responsible for it.
She confirmed that insurers have negotiated rates with their in-network providers — and if you visit an in-network doctor, insurers should pay that rate. (Patients are usually not responsible for the difference between the provider’s full charge and the amount the insurer pays, something called balance billing.)
There are other potential complications, though. If a provider is owned by a hospital system, which is increasingly the case, the provider often charges a facility fee. “The consumer is on the hook for that, and there are limited protections at the moment,” Ms. Pestaina added.
Of course, if a deductible hasn’t been met, or if a policy carries coinsurance, those may also be due. “Most people don’t know the difference,” she added. “How would they know from the provider’s bill?”
As it turns out, those were the charges that surfaced for Mr. Morgenstern. His explanation of benefits provided some clues. He’s enrolled in a PPO, a type of insurance plan that usually generates lower out-of-pocket costs if you use providers within their network, which he did. The insurer agreed to pay $198 for the pluck, but since Mr. Morgenstern’s deductible had not been met, he owed that amount out of pocket. But Mr. Morgenstern was incensed that he was charged so much for his spontaneous “surgery.”
Do providers have any duties to disclose what they may charge extra for? Not usually, unfortunately. But there should be. (Hospitals are required to provide price information and make that available on their websites, Ms. Pestaina said).
But this story does have a happy ending, thanks to one mother’s moxie.
She prevailed, and the doctor’s office rescinded the charge.
Tara Siegel Bernard writes about personal finance for The Times, from saving for college to paying for retirement and everything in between.
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