How Your Medical Bill Can End Up Being a Lot Bigger Than You Expect

  • Experts say medical bills are many times much higher than original estimates for surgery, treatments, and other procedures.
  • A new law that took effect Jan. 1 requires healthcare providers to be transparent on their prices.
  • However, experts say there are large loopholes in the law, and the rules are sometimes difficult to enforce.

Jobbie Spillane took her 17-year-old son to a Kaiser medical facility in Northern California in 2018 for a procedure he underwent every 4 months.

Only this time, there was an unwelcome twist.

“I showed up only to be told that there was a $300 copay for the procedure,” she said. “I had driven all the way to Oakland from Petaluma at 6 a.m. for a necessary procedure that had never cost us anything in the past. I was stunned, and I paid for it, but had some scathing words for the doctor and the administration.”

Spillane had been told for years her son’s treatment was a medical necessity. He received Botox for his salivary glands due to a breathing condition that elevated his risk for pneumonia and other issues.

On this day, her son’s treatment was coded as “cosmetic surgery.”

“They never reimbursed me. But moving forward, we have not paid for the procedure again,” Spillane said.

Understanding how medical billing procedures work can seem like winning the lottery, spotting Bigfoot, or winning an Oscar. It rarely seems to happen to normal people.

“No one ever said, ‘I understand this medical bill,’ not a single person,” said Ed Scott, CEO of New Jersey–based ElectrifAI, an artificial intelligence developer that helps providers catch billing mistakes.

“You go to a restaurant and you can see a hamburger is $12… why can I not see how much it is to take care of my health and my body?” he said.

These surprise medical bills aren’t uncommon. They can happen during office visits as well as after surgery or medical treatments.

What’s the law?

Healthcare has become one of the hot-button issues early in the 2020 election. Price transparency is at the forefront of the debate.

In July, President Trump proposed that hospitals be required to post prices they’ve negotiated with insurers online. A month earlier, he signed an executive order aimed at giving Americans more information about their healthcare costs.

The argument goes that consumers will make more informed choices, which will lower costs. Health providers and insurance companies say revealing prices will stifle competition.

Kaiser officials say they support providing consumers with detailed information.

“Kaiser Permanente supports price transparency and is in compliance with the CMS hospital price transparency rule. Additionally, Kaiser Permanente provides a convenient cost estimator tool to our members that helps them manage their health expenses by providing a general estimate of out-of-pocket costs for many of the most common medical exams, tests and procedures,” Sara Vinson, a Kaiser spokeswoman, said in a statement emailed to Healthline.

The CMS (Centers for Medicare and Medicaid Services) hospital transparency rule is a new federal mandate that went into effect Jan. 1, requiring providers to post price lists online.

The providers must update those prices at least once a year. Hospitals can choose the data’s format, but it must be machine-readable and must include all items and services provided by the facility.

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