Bill Of The Month: Cost Of Hernia Repair Exceeds Estimates : Shots - Health News Patients are often told to be smart consumers and shop around for health care before they use it. But even when you do so, estimates from insurers, hospitals and doctors can be unreliable.

Bill Of The Month: Estimate For Cost Of Hernia Surgery Misses The Mark

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We're going to dig into another frustrating medical bill now. Each month, we dissect a bill to shed some light on the cost of health care in America. Dr. Elisabeth Rosenthal is the editor-in-chief of our partner Kaiser Health News, and she joins us in the studio.

Hey, Elisabeth.

ELISABETH ROSENTHAL: Hi. Great to be here.

CHANG: So who sent in their bill this month?

ROSENTHAL: This month we meet Wolfgang and Farren Balzer. When Wolfgang needed surgery, the couple planned ahead. They did all their homework, hoping to minimize their share of the medical expense.

CHANG: Which makes sense - I mean, they were just trying to be smart, responsible consumers. Right?

ROSENTHAL: Yeah. And they'd heard about out-of-pocket expenses, and they were scared. And especially - this wasn't an emergency, so they did all the right things. And yet, they were still shocked by the bill that came in the mail.

CHANG: Right. And we sent a reporter, Nicole Leonard, to visit the family in Connecticut. Let's take a listen.


NICOLE LEONARD, BYLINE: Wolfgang Balzer is lifting his 18-month-old son into the air. His wife Farren says, just a few months ago, before Wolfgang's hernia surgery, she would have been worried about him.

FARREN BALZER: I would not be happy with him doing that because I'd have been going - babe, you're going to hurt your hernia even worse.

LEONARD: After a successful surgery, Wolfgang is back to lifting a toddler, chasing a 4-year-old and playing host to a houseful of family visiting from Germany. You're having mac and cheese today.

F BALZER: (Speaking German). My daughter's favorite and it's a nice, quick InstantPot meal.

UNIDENTIFIED CHILD: (Speaking German).

LEONARD: Wolfgang knew for years that he'd need the surgery one day, but it wasn't an emergency. And the Balzers are planners, so they waited for the perfect time. They planned it for the same year their second child was born so that they would meet their high deductible. But Wolfgang grew up in Germany, so he wasn't used to this tactical way of making health care decisions.

WOLFGANG BALZER: To have to think about when and for what you go to the hospital, that's a foreign concept to me.

LEONARD: Before the surgery, they called the hospital, their insurer and the surgeon to get cost estimates for the procedure. They figured out it would be about $1,400 - not cheap but doable. The surgery went smoothly - no complications. And the hard part was over. Or so they thought.

W BALZER: When the bill came and we opened it, I knew it immediately from the numbers that this is off. And I showed it to Farren.

F BALZER: And I think I went, oh, hell no; we are not paying this.

LEONARD: Their bill was 50% higher than the quotes they got. Wolfgang picked up the phone to try and get some answers.

F BALZER: But how many times, in total, do you think you called Hartford Hospital?

W BALZER: I don't know. But I know that the more I called, the less hopeful I got because I knew that I didn't get anywhere with them.

F BALZER: Right.

W BALZER: And they just said a quote is a quote. You know? I'm sorry that you had a bad estimate.

LEONARD: The hospital's position was that the estimates were a guess. Those amounts were never a guarantee. That left the Balzers feeling like billing estimates don't mean anything. So why try to plan? Why bother?

F BALZER: We plan things to death. And when plans don't go according to plan (laughter), it becomes very frustrating.

LEONARD: Wolfgang is resigned that this is how health care works in America and this is what his young family growing up in Connecticut will be up against.

W BALZER: Do you pick this fight every time, trying to understand what you will owe and keep doing that? But it adds stress to something that should just be straightforward.

LEONARD: It may not have been straightforward, but it was perfectly legal. Unlike other industries, hospital estimates are under no legal obligation to be accurate.

CHANG: All right. That was Nicole Leonard of WNPR in Hartford, Conn. And we're back now with Elisabeth Rosenthal of Kaiser Health News. So Elisabeth, let me just get this straight. Health providers are not legally required to honor the estimates they give you. Like, consumers don't have a legal claim later to say, you misled me; you told me this was going to be cheaper.

ROSENTHAL: Yeah. I think it's a real outrage. You know, this was not a huge bill, but it's a huge problem that we all face. You know, we're told over and over again to be good consumers. And yet, you try and get an estimate for a hospitalization, an office visit. But they're often wildly off. And it may be tens of thousands of dollars off. And yet, you're expected to pay.

CHANG: And it's totally legal to make you pay for something that's wildly deviating from the estimate.

ROSENTHAL: Well, technically yes. It's kind of absurd, though 'cause think about it - you wouldn't put up with this in any other sector.


ROSENTHAL: I mean, if your contractor came in and gave you an estimate for a kitchen of $10,000 and then, without any notice, you just got a bill for 20,000, you would say, forget it; I'm not paying it. In some sectors, like mortgage lending, there are laws saying that estimates of origination fees have to be accurate. But in health care, it's a Wild West.

CHANG: That's incredible to me. I mean, it really speaks to how powerless people can feel when it comes to their health care.

ROSENTHAL: That's the thing here; the Balzers were perfect consumers. You know, they checked with the surgeon, the anesthesiologist. They did all of their homework, and yet they were stuck in the end.

CHANG: I imagine, like, there are a lot of people out there who would just assume - OK, I'm on the hook for this bill; I'm just going to pay it. But what happened to the Balzers?

ROSENTHAL: Well, I often tell people the first thing is, don't just write the check. Ask questions. Now, what happened with the Balzers is they submitted their bill to bill of the month. And when a reporter started calling, the hospital said - oh, sorry, we didn't communicate well with the patient. Now, my reaction to that is - what? - communicate that the estimate is going to be 50% off in the hospital's favor.

CHANG: Right.

ROSENTHAL: That's really not a good answer.

CHANG: How about for the majority of people, though, who will not have journalists pursuing, investigating their cases? I mean, should people just skip asking for quotes for medical procedures?

ROSENTHAL: No. But I think you have to be really specific about what you're asking for. You want an all-in quote that includes all the services. You want to know - you know, are you going to guarantee me that it's going to be within some range? And write down the estimates so you can fight the bill later.

CHANG: That's Dr. Elisabeth Rosenthal from Kaiser Health News.


ROSENTHAL: Thank you.

CHANG: And if you have a surprising medical bill you would like us to take a look at, go to NPR's Shots blog and tell us all about it.

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