By Michelle Andrews, Kaiser Health News
Jose Mendoza’s snoring was bad – but the silence was even worse for his wife, Nancy, as he stopped breathing. Suddenly calm would wake her up and she was anxiously waiting for another breath. If ticked by several seconds, he pushed her hard so that she moved and started breathing again. This happened several times a week.
Mendoza was diagnosed with severe sleep apnea 1 year ago and was recommended a positive airway pressure (CPAP) device that helps her breathe. But the machine was noisy and uncomfortable. A month later, he stopped using it.
In late 2001, at 611, Mendoza went to an emergency department with an amazing head near the family’s Miami home. He thought it was related to his high blood pressure, a condition sometimes associated with obstructive sleep apnea. But after the test battery, doctors concluded that her obstructive sleep apnea itself may have caused her head and bone problems. He needed a new CPAP machine, they said.
But first, he had an anti-home sleep test. Mendoza’s pulmonologist said it was not detailed enough and ordered a one-night sleep laboratory visit to get detailed data.
Mendoza arrived at the sleeping center at around 8pm one night in early February and was shown in a room with a sofa, TV and bed. After he got into his pajamas, a Technician attached electrodes To track the activity of his brain, heart, lungs and muscles in his head and chest while he was sleeping. The technician fitted him a CPAP with two small cannulas for his nose. Despite the unfamiliar setting and awkward equipment, Mendoza slept that night.
After the study, Mendoza began to use the same, more intuitive CPAP model that he used during the study.
“I am not eating meat anymore. I feel very energetic. I am not as tired as before, ”he said.
The new CPAP was helping both Mendoza get a good night’s sleep – until Bill arrived
Sick: -1, through the construction company of Jose Mendoza, has a Humana HMO scheme where he works as a truck driver. It has a deductible of $ 5,000 and a maximum of in-of-pets, covered by 50,000 in-network providers for care. Once he is satisfied with the deductible, he is entitled to 100% of the other bill charges. (Nancy Mendoza, who works as a social worker, and her two teenage children under her employer scheme.)
Medical Services: A nighttime sleep study at the hospital’s sleep center to determine the type of mask and the appropriate level of airflow and oxygen to treat the severe obstructive sleep apnea needed in her Mendoza CPAP.
Total bills: , 10,322, for sleep study 5 ,, .853 outpatient charge and विशेषज्ञ 99 charge to sleep specialist explaining the outcome. Himana’s negotiation rate for the total was, 5,419. Mendoza’s bulk owed was: 7 ,, 177, से 2 and ded 2 in sixes. Including to satisfy his deductible. Humana has paid $ 222.
Service Provider: University of Miami Health System Sleep medicine facility At the Basque Palmer Eye Institute in Miami.
What gives: Sleep studies are somewhat controversial and flagged In the past as being overused. Not everyone who casts their eyes upon it, wants a go. But with Mendoza pause in breathing and high blood pressure, he probably did.
The president of the Lawn Institute, Dr. According to Vikas Saini, analyzing low-cost healthcare, think tank, sleep study falls into a gray area.
Truck driver Jose Mendoza has a humanitarian HMO scheme through his employer. It is Financial 5,000 deductible and 0% security, making him financially weak. (Brian Cerizo for KHN)
“They are incredibly useful and necessary in some clinical situations,” he said. “But it is known to be highly used.”
But how much does it cost to monitor it at home or in a hospital sleep laboratory? That is the question. Identified by the Office of the Inspector General of the Federal Department of Health and Human Services Billy problems Mendoza overpaid Medicare for the type of sleep study.
The total fee of the University of Miami Health System was higher by almost every measurement, but so was the allowance amount that the health system agreed to pay for the humanitarian study. And because Mendoza’s skimpy health plan is worth a 5,000 deduction, he’s almost on the hook of paying the most bills.
Mendoza’s Humana Yojana Hospital agreed to pay for the 4, 1 pay sleep study. Medicare often pays for the same service nationally – are 20 20 – for Medicare and Medicaid service centers.
Private insurers typically pay higher rates than Medicare for care, but that is much “much higher than what other insurance companies pay,” said Jordan Ventroub, vice president of the brothers Velarithms, which analyzes medical bills for self-funded companies and others. Customers
Facility charge, .85. Consider the deposit facility fee. The average charge for a similar type of sleep study in the United States is only more than half at 38 384, according to Fair health, A national independent non-profit organization that tracks insurance premiums.
Charges in the Miami area are at the upper end of the national range. The average bill for a similar hospital sleep study in Miami ranges from 64 2,64.6 to $ 1,334. Till, Ventroub said. So Mendoza’s bill is not the largest in the region, and so is Miami’s average.
“The billing fee is just completely fictitious,” Ventroub said. “There is no other real basis for them to charge.”
Telling more than what other Miami hospitals are charging for sleep studies means the University of Miami Health Systems reports that it actually costs the hospital to process. And that number averaged 1,144 in 2012R, according to Wellreths’ analysis of publicly available cost report data filed with CMS. That year, the hospital’s average charge for a Mendoza-type sleep study was .886, according to Welleritz.
Mendoza does not pay a premium for her health plan, but the cost of her “free” coverage. डलर कट 2,000 deductible and high security if he is found in search of family if he is financially supported by the sick financially. Nancy Mendoza’s plan is less deductible. $ 1,50 of 0, but her employer charges extra to cover spouses who have coverage available for their own work.
Obstructive sleep apnea is often diagnosed, sleep medical experts agree, and sleep studies can result in a diagnosis that leads to the necessary treatment to help prevent serious problems such as heart disease and diabetes.
“In that perspective, sleep tests have actually been observed,” said Dr. John Smith, medical director of Sleep Medicine at Atrium Health in Charlotte, North Carolina. Said Douglas Kirsch, who was a professional at the American Academy of Sleep Medicine.
After a steady increase in independent and in-hospital laboratory-based sleep centers over the years, there has recently been a shift to home-based sleep tests, said Charlie Whelan, vice president of research and consultation for Frost & Sullivan’s health services. Firm
“The entire sleep medicine sector is deeply concerned about the future where in-house testing is done because it means less money has to be spent for service providers at the center,” Whelan said.
After the sleep study, Jose Mendoza began to use the more comfortable CPAP model. “I “Feel very energetic,” she says, “I’m not as tired as before.” (Brian Cerezo for KHN)
Solution: When the bill came, Nancy Mendoza thought it must be a mistake. Hosea’s home sleep test didn’t cost him a penny, and no one mentioned his financial responsibility for the night test at the lab.
She called Billy’s office and asked for an itemized bill. There were no complications, no anesthesia, no doctors. Why is it so expensive? But what they got was no more knowledgeable than the summary bill.
She had the clear impression that if they did not pay, they would be sent to the collection. To avoid worsening their debt, they agreed to a two-year payment plan and in April received the first installment bill for first 214.87. Nancy’s overall charge seems too high: “It’s not fair [for] People who are in the lower end of the middle class. “
Lisa Worley, assistant vice president for media relations at the University of Miami Health Systems, said in a statement that Mendoza “does not qualify for financial assistance because he has health insurance.”
But the health system was posted Financial Assistance Policy It clearly states that “financial assistance is available to a vulnerable person with a balance of तेस्रो 1,000 or more remaining after third party liability, with a family income of up to 12 months or less than 100% of the federal poverty guidelines.”
Under the less detailed version of Hospital policy Included in one of their bills, Mendoza meets the income limit for “assistance provided on a sliding scale.”
In her statement, Worley referred to Mendoza’s sleep test as an “alternative service.” The Health Systems website says it provides financial support for emergency and other medically necessary (non-alternative) care. “
Mendoza’s sleep study was medically necessary. Emergency department staff evaluated him and determined that a new CPAP was needed to deal with serious health problems due to his obstructive sleep apnea. Her pulmonologist agreed, as did her insurer, who 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 set.”
Although Mendoza gave permission to discuss the matter, the insurer declined to comment specifically on Mendoza’s case.
Takeway: Mendoza followed the rules: he used a network provider and received prior authorization from his insurance company for testing.
Unfortunately, they fall into two financial traps of the U.S. healthcare system: high-deductible health plans, which are growing exponentially, and sky-high bills.
With a high-deductible plan, it is important to take the training to try to learn what you have to pay before you receive neurosurgery care. Ask for an estimate in writing; If you can’t get one, try shopping for a different provider that will give you an estimate.
Be aware that insurance plans that cover zero or low premium costs may not be your best option.
Once you’ve landed on a high bill that became a highly deductible hit, remember that you can still communicate with the hospital. Find out what the more practical charges are and ask them to adjust your bill. Also inquire about paid assistance from the hospital – most hospitals have to offer this option through law (although they often do not find it easy to apply).
If the doctor suggests a sleep study, ask if you can do one at home, or if it is really necessary. And remember: not every snoring sleep apnea.
Hosted by Dan Weissmann One arm and one leg The podcast contributed to the audio version of this story.
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