Why It’s Hard to Trust—Part 2, My Personal Healthcare Shopper

As the lady in billing said, "You're paying your insurance company to do the shopping." But when I asked for price breakdowns from various vendors, my Aetna representative declined to do the research and recommended that I go to the Aetna Navigator website in order to see “a rough estimate for the cost of this procedure.” She said that, “Navigator calculates the cost based on historical claims information adjusted to take into account health care cost inflation,”

So what kind of numbers did Aetna Navigator come up with for me? It estimates that for a colonoscopy I will pay:
In Network: $1384. That is my 20%, meaning that they pay the remaining 80%, $5536, for a grand total of $6920. Out-of-Network the total cost is estimated to be even higher, assumedly for lack of their negotiating skills, at $7205.

Aetna says, seven thousand dollars for a colonoscopy…Bob, let’s see what our vendors had to say about that when I called and quizzed them:

Digestive Disease Clinic (Out of Network): Doctor, $831 + Facility (everything included), $970 = Total Cost, $1801. (I pay $720, they pay $1081.)

G.I. Associates (In negotiations to be in Network) Doctor, $550 + Facility, $860 = Total Cost, $1410. (My cost either $282 or $564, theirs $1128 or $846.)

Gastroenterology Associates Sarasota (In Network): Doctor, $600+ Facility, $1300-$2400+Anethesiologist, $455-$585 + Total Cost = $2355-$3585. (My cost $417-$717, theirs $1884-$2868)

So, while I am personally happy that I’m not paying over a thousand dollars for a $7000 procedure, I have a feeling we must all be paying for these kinds of gross inaccuracies in ways I don’t fully understand. There is a chance that Aetna’s estimates are a true accounting of the costs of doing a procedure at the hospital but NO ONE, either service provider or insurance provider volunteered the price differences until I explicitly asked. So not only is no-one looking out for my (the individual’s) pocket-book, no one seems to be bargain hunting at the insurance company either.

If a quote of $7000 is really coming from historical charges, that means my Aetna has paid at least this much in the past. To whom? And if a for-profit company is coming up with these numbers, what about government’s numbers?. Where are they getting them? Hopefully not from the insurance companies that don’t know their procedure codes or their negotiated rates.

I don’t have enough information to have a stance on things like universal healthcare, but I wonder if the people who make the decisions do either. All I know is that if Aetna gave me $7205 for one colonoscopy today, I could shop around and use the same funds to provide 5 people with the same service at $1410, or 4 at $1801, or even 2 at $3585.

Hello, Personal Healthcare Shopper? I’ve got my eye on you!