José Mendoza’s snoring was bad, but for his wife, Nancy, it was worse when he stopped breathing. The sudden silence woke her up, and if too many seconds passed, it shook him to start breathing again. This happened several times a week.
Diagnosed with severe sleep apnea 15 years ago, Mendoza had been prescribed a continuous positive airway pressure (CPAP) device to help him breathe better. But the machine was loud and uncomfortable. After a month, he stopped using it.
In late 2019, Mendoza, 61, went to an emergency near his Miami home with an excruciating headache. He thought it was from his hypertension, a condition sometimes linked to obstructive sleep apnea.
But after a series of tests, the doctors concluded that it was the apnea that was probably causing her a headache and heart problems. They told him he needed a new CPAP machine.
To have the accurate device, a home sleep test was first done. But Mendoza’s pulmonologist ordered a visit to a nocturnal sleep laboratory to obtain more data.
Mendoza arrived at the sleep center around 8 p.m. one night in early February and was shown to a spacious room with a sofa, a television, and a bed. After putting on his pajamas, a technician placed electrodes on his head and chest to track the activity of his brain, heart, lungs and muscles while he slept.
The technician placed a CPAP with two small cannulas for the nose. Despite the unfamiliar surroundings and uncomfortable equipment, Mendoza slept that night.
Mendoza began using the same model of CPAP, more comfortable, that he had used in the study.
“Now I don’t snore. I feel more energetic. I’m not as tired as before, ”he said.
The new CPAP was helping the Mendoza sleep better at night… until the bill came.
The patient: José Mendoza, 61, has a Humana HMO plan through the construction company where he works as a truck driver. You have a deductible of $ 5,000 and an out-of-pocket maximum of $ 6,500 for covered care from in-network providers. Once you meet your deductible, you have to pay 50% coinsurance for other billed charges. (Nancy Mendoza, who works as a social worker, and her two teenage children are covered by her employer’s plan.)
Medical service: a sleep study at a hospital’s specialized center to determine the type of mask and the proper levels of airflow and oxygen needed in Mendoza CPAP to treat your severe obstructive sleep apnea.
Total invoice: $ 10,322, including an outpatient charge of $ 9,853 for the sleep study and a charge of $ 469 for the sleep specialist who analyzed the results. Humana’s negotiated rate for the total was $ 5,419. Mendoza owed most of that: $ 5,157, including $ 262 in coinsurance and $ 4,895 to meet his deductible. Humana paid $ 262.
Service provider: the University of Miami Health System Center for Sleep Medicine at Bascom Palmer Eye Institute.
What was done to it: a sleep study, which are somewhat controversial and have been flagged in the past as overused.
According to Dr. Vikas Saini, president of the Lown Institute, a think tank that looks at low-value healthcare, sleep studies are in a gray area.
“They are incredibly useful and necessary in certain clinical circumstances,” he said. “But they are known to be overused.”
But how much should it cost to be monitored at home or in a hospital sleep lab? That is the question. The Office of the Inspector General of the federal Department of Health and Human Services has identified billing problems for the type of sleep study Mendoza conducted, which resulted in overpayments to Medicare.
The total charge for the University of Miami Health System was high in almost every respect, but so was the amount Humana agreed to pay the health system for the study. And because Mendoza’s limited health plan has a $ 5,000 deductible, you’re at risk of having to pay nearly all of that hefty bill.
Consider the total installation charge of $ 9,853. The average cost in the United States for a sleep study of the same type is just over half that amount at $ 5,384, according to Fair Health, a national independent nonprofit that tracks insurance charges.
Positions in the Miami area are at the higher end of the national range. Average charges billed for similar sleep studies at hospitals in Miami range from $ 2,646 to $ 19,334, Weintraub said. So Mendoza’s bill is not as high as the highest in the area and is slightly below the Miami average.
Humana de Mendoza’s plan agreed to pay the hospital 5,419 for the sleep study. That’s nearly six times what Medicare would pay for the same service nationally, $ 920, according to the Centers for Medicare & Medicaid Services (CMS).
Private insurers generally pay higher rates than Medicare for care, but that multiple is “much higher than what other insurers would pay,” said Jordan Weintraub, vice president of claims for WellRithms, a company that analyzes medical bills for self-funded companies and other clientele.
“The billed charges are completely fictitious,” Weintraub said. “There’s really no reason to charge it other than that they can.”
Somewhat revealing: The cost of this type of study to the University of Miami Health System averaged just $ 1,154 in 2019, based on WellRithms analysis of publicly available cost reporting data filed with CMS.
Mendoza does not pay premiums for his health plan, but his “free” coverage comes at a cost. The $ 5,000 deductible and high coinsurance leave you financially exposed if you need medical care, as the family discovered. Nancy Mendoza’s plan has a lower deductible of $ 1,350, but her employer charges more to cover spouses who have coverage available to them at their own jobs.
Obstructive sleep apnea is often undiagnosed, sleep medicine experts agree, and sleep studies can result in a diagnosis that leads to necessary treatment to help prevent serious problems like heart attacks and diabetes.
“From that perspective, sleep tests are actually under-prescribed,” said Dr. Douglas Kirsch, medical director of sleep medicine at Atrium Health in Charlotte, North Carolina, who was president of the American Academy of Sleep Medicine.
After strong growth in hospital-affiliated and independent laboratory-based sleep centers over several years, there has recently been a shift toward home sleep testing, said Charlie Whelan, vice president of healthcare consulting at Frost. & Sullivan, a research and consultancy. firm.
“The entire field of sleep medicine is deeply concerned about a future where more tests are done at home, as it means less money for testing providers at the center,” said Whelan.
Resolution: When the bill came in, Nancy Mendoza thought it must be a mistake. The sleep test at Jose’s home hadn’t cost them a penny, and no one had mentioned their financial responsibility for the nightly lab test.
He called the billing office and asked for an itemized bill. There were no complications, no anesthesia, not even a doctor present. Why was it so expensive? No one could answer him.
He had the clear impression that if they did not pay, they would be sent to collection. To avoid ruining their credit, they agreed to a two-year payment plan and received their first installment bill, for $ 214.87, in April.
Lisa Worley, associate vice president for media relations for the University of Miami Health System, said in a statement that Mendoza “does not qualify for financial assistance because she has health insurance.”
But the health system’s published financial assistance policy clearly states that financial assistance is available to “underinsured individuals with a remaining balance after third party liability of $ 1000 or more, whose household income for the preceding 12 months is equal to or less than 300% of the federal poverty guidelines ”.
According to a less detailed version of the hospital’s policy included in one of their bills, the Mendoza’s meet the income threshold for “care provided on a sliding scale.”
In his statement, Worley referred to Mendoza’s dream test as an “elective service.” The health system’s website says it “provides financial assistance for emergencies and other medically necessary (non-elective) care.”
Mendoza’s sleep study was medically necessary. The emergency department staff evaluated him and determined that he needed a new CPAP to treat the serious medical problems caused by his obstructive sleep apnea. His pulmonologist agreed, as did his insurer, who pre-authorized the sleep study.
In a statement, Humana wrote: “With sleep studies, there can be a wide range of costs, depending on the complexity of the case and the setting.”
The insurer declined to comment on Mendoza’s case specifically, even though the Mendoza’s had given permission to discuss it.
Conclution: The Mendoza’s followed the rules, used an in-network provider, and obtained prior authorization from their insurance company for the test.
Unfortunately, they were caught between two financial traps in the health care system: increasingly common, high-deductible health plans and sky-high billing.
With a high deductible plan, it is essential to try to know how much to pay before receiving non-emergency medical care. Request a written estimate; If you can’t get one, try looking for a different provider who will give you a quote.
And if you are stuck with a high bill, remember that you can still negotiate with the hospital. Find out what would be a more reasonable charge and request that your bill be adjusted. Also ask about hospital payment assistance; most hospitals are required by law to offer this option (although they often do not make it easy to apply).
If a doctor suggests a sleep study, ask if you can do it at home and if it’s really necessary. And remember: not all snoring is sleep apnea.
Dan Weissmann, podcast host An Arm and a Leg, contributed to the audio version of this story.
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