The same eye surgery cost husband thousands more than his wife : Shots - Health News Whether a simple operation is performed under the auspices of a hospital or at an independent surgery center can make a huge difference in cost.

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

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STEVE INSKEEP, HOST:

It's time for the Bill of the Month. On this program, we look at someone's real-life health care bill that was higher than it should have been and ask how you can avoid the same. Today's bill shows that where you get your health care can make a big difference in what you will eventually pay. Dr. Elisabeth Rosenthal is the editor-in-chief of our partner Kaiser Health News, and she's here once again. Dr. Rosenthal, welcome back.

ELISABETH ROSENTHAL: Thanks for having me again.

INSKEEP: Who got the bill?

ROSENTHAL: Today, we're going to meet the Manimtims of Fresno, Calif. Marilou is 66, and Danilo is 73. And they both needed cataract surgery, but they wound up with wildly different bills.

INSKEEP: OK. Well, let's hear their story from reporter Stephanie O'Neill.

STEPHANIE O’NEILL, BYLINE: Doctor Danilo Manimtim of Fresno, Calif., wears prescription glasses. So when his eyesight started getting a little blurry, the retired orthopedic surgeon figured it was time for a new pair.

DANILO MANIMTIM: I can't see sharp objects that far and also near. So I thought it was my glasses.

O’NEILL: After an eye exam, his ophthalmologist gave him a new prescription, but it didn't fix the problem.

MANIMTIM: So I came back to him and says, you know, what's going on? Is it the right prescription? He said, yeah, the right prescription. But I think it's because you have cataract. So - OK, so what do we do next? And they said, well, we need to consider surgery.

O’NEILL: Coincidentally, at about the same time, Danilo's 66-year-old wife, Marilou, learned she, too, needed the surgery. Husband and wife had different doctors, but had the same insurance - Anthem Blue Cross. And both of their doctors and their affiliated surgical facilities were in network. The only difference - Marilou's doctor worked with a stand-alone surgery center, while Danilo's worked with one at the local hospital. Marilou's out-of-pocket share was just over $200, and because Danilo had met his insurance deductible for 2021, they expected his would be somewhat similar.

MANIMTIM: And then I got the bill from St. Agnes.

O’NEILL: That's the local hospital where he had the surgery.

MANIMTIM: Holy moly. It was, like, $4,000. What happened here?

O’NEILL: A $4,000 bill versus Marilou's $200 bill - despite his 30 years dealing with health insurance as a private-practice surgeon and despite his new part-time gig helping the state assess disability insurance claims, Danilo was stumped. Their simple eye surgeries were virtually identical. Marilou suggested that maybe her husband got some sort of upgrade.

MANIMTIM: Maybe yours have special lenses. I said, no, I got - I'm a cheapskate. I got the cheapest one that they'll pay.

O’NEILL: So Danilo starts investigating.

MANIMTIM: I called the hospital, says, how come my bill is like this? And they said, well, your insurance allows only $2,000. OK. But you're in the network. How come you weren't accepting the insurance payment as payment in full since I'm in the network?

O’NEILL: He says he got no clear answers to his questions, but he did get a call from the hospital warning that he'd better pay them something or they'd send him to collections.

MANIMTIM: Long story short, I send them my credit card so I don't run into the collection stuff.

O’NEILL: After that, he says he sought outside help to find out why the hospital charged him so much. And while he still has no answers, he did just get a call from the hospital telling him to expect a refund of some sort on his credit card. Meanwhile, Dr. Danilo Manimtim recommends anyone facing a bigger-than-expected bill should ask questions and fight back. For NPR News, I'm Stephanie O'Neill.

INSKEEP: OK. Let's talk about how to ask those questions and how to fight back because Elisabeth Rosenthal is still with us. What happened here that one bill is 20 times larger than the other?

ROSENTHAL: Well, the big takeaway is that it makes a big difference in cost, not in quality, in what type of facility you go to for care. So Danilo went to a hospital. His wife went to a stand-alone, independently owned surgery center. Both are allowed to charge what's called a facility fee. And at hospitals, that tends to be a lot more.

INSKEEP: What is a facility fee?

MANIMTIM: Well, yeah, good question. It's a construct pretty much unique to American medicine. It's essentially a charge for using the room. And that charge, like a hotel charge, could vary a lot.

INSKEEP: Sure. You can have $1,000 room. You can have a $100 room. Does this mean it is always cheaper, as it was in this example, to go to the surgery center instead of the big hospital?

ROSENTHAL: Well, generally speaking, yes, but not always. So if your surgeon operates on some days at the hospital and on others at a surgery center, you're really better off scheduling your operation on the surgery center days.

INSKEEP: Was there anything else Danilo might have done that affected the cost here?

ROSENTHAL: Well, one is that Danilo happened to go to a hospital that charges way above average for cataract surgery. Another factor here is that Danilo's insurance comes from the California Public Employees' Retirement System, or CalPERS. That's a huge organization with a lot of clout in the California marketplace, but it uses a system called reference pricing for common procedures where it says we will pay only a certain amount for the procedure. It's $2,000 for cataracts. So employees will be on the hook for anything over that amount. It's designed to get patients to shop around for a good price.

INSKEEP: And Danilo didn't do that?

ROSENTHAL: Yes, he was unaware of that system. And the only way to override it is by getting approval in advance, which is not easy, since CalPERS sets a price it feels is reasonable for a high-quality operation. His hospital asks for and is getting about $9,000 for Danilo's surgery, when a fair price is between 2,000 and 3,000, according to many experts.

INSKEEP: Wow - they just - three or four times more and just ask for it, see if they can get it. So as the patient, what could he have done differently?

ROSENTHAL: Well, with something like cataract surgery, it's not an emergency. So call your insurer to understand the quirks of your policy. Ask your employer or your insurer to run your benefits and get in writing exactly what you can expect to pay after the procedure. Also, ask the provider about the facility fee where they operate in advance so you can compare a hospital's price versus a stand-alone surgery center's price because there isn't really a hard-and-fast rule to know which will be more.

INSKEEP: Dr. Rosenthal, thanks very much for the advice.

ROSENTHAL: Thank you. I hope it helps.

INSKEEP: And if you have a confusing or outrageous medical bill that you want us to take a look at, go to NPR's Shots blog and tell us all about it.

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