Thanks!
I’m in the DMV area. Those rates are for a clinic, since hospitals would be pricier. I completely forgot about the radiology reading fee. I’ll probably get charged an office visit too.

I’ll update on what happens… don’t want to think it over too much amd stress out!

Sounds like a congratulations is in order! Good luck with everything.

Interesting, are you having it done in the hospital setting or at a clinic? I would lobby hard for that $150 rate if you can get it. You could try and meet them halfway at $300? Nice foresight keeping the calendar year-end in mind and the deductible re-set. Please let me know how it goes, could make a good case study. You will want to talk to their “revenue cycle director” or “patient financial services director” if possible.

You are getting a better deal than I am. My insurance has negotiated this service (76805) down to $740 in the hospital and it would all hit my deductible (New England market). There would be a “read” fee on top of that for the radiologist to read it. What regional market are you in?

Medicare wouldn’t pay for many of these since most of its beneficiaries aren’t child-rearing age, but their national payment rate is about $112 in the hospital. They would come in slightly higher in a high cost of living area. The radiologist read would come in at about $50. There is no reason for you to be paying over 4 times that.

Congrats! Max.

These are all estimates only but I can provide you the Medicare sources if you need it!

Max

It’s actually a 20 week sonogram cpt 76805 for my wife. Self pay without insurance is around 150 and the insurance negotiated rate is 665. So it’s a huge difference. And we are no where close to hitting the 3k insurance deductible by the end of the year, so getting the lower selfpay rate is a must!

Hi Abigail! Good questions about the pricing. There is a lot of cross-subsidizing going on (particularly in hospitals) where they are using on service to offset the cost for another service. Medicare usually pays at or a little under cost, so you are probably right that the true cost of the BMP is closer to $10. You should ask your provider the next time about your BMP and see what they think!

Max

I love this question. I used to think this was in the gray area, but now I definitely think it is fair game considering how broken the system is. Some hospitals or providers may say it is against their policy, but I would ask to see the policy. That said, you will want to know both rates (your insurance discount and uninsured discount). I am on a high deductible plan as well, and the hospital I will have the services at has an uninsured adjustment of 33% which will get this test down to $56.95 (this is $4.81 cheaper than my insurance negotiated rate that would hit my deductible). But it won’t always work to your advantage. Also, a few insurance plans (including mine) will cover the BMP as preventive with that Z00.00 code I referenced, so you would essentially be paying for a test you could get for free. Clear as mud?

I don’t think it would be out of line to ask for a referral without your insurance, but a lot of these billing systems talk to each other so it might not prevent them from seeing it. It may be easier to just negotiate them down to the self-pay rate but I would stay as professional as possible about it since that seems to work much better than the “angry red face” method.

Thanks – I will talk more about the uninsured discount soon. Are you having just the BMP or other tests as well?

Max