Kathleen DeRosa, an 80-year-old South Philadelphia bowling queen, was mid-season with the Guys & Dolls League and her throwing shoulder was killing her.
In the past, her primary-care doctor had treated knee pain from a bowling injury with a $10 cortisone shot, and he recommended the same for her shoulder.
But this time, the doctor wanted DeRosa to have an ultrasound of her shoulder first. So she went to a Jefferson Medicine outpatient center for the scan last October and, immediately after, was offered the cortisone shot.
She wouldn’t have agreed to it had she’d known the injection would cost her $256.
“Who would volunteer to pay $250 when they could pay $10?” she said.
After The Inquirer asked about DeRosa’s case, her insurer, Independence Blue Cross, eliminated the bill — and promised to reach out to the debt collector who had been calling DeRosa weekly after Jefferson sent her bill to collections. But her experience still serves as a cautionary tale about the unexpected places high bills can arise.
Prices for even common services vary wildly, depending on the provider, insurer and even the specific plan you have. As out-of-pocket costs continue to rise, exposing patients to potentially crippling bills, it’s important for patients to be able to anticipate what price they’ll be expected to pay, though that’s not always so easy.
Patients who question bills are commonly told they should have read their plan more carefully, should have called their provider or insurer to get a price estimate. But the rates that hospitals and insurers negotiate are considered proprietary and patients often find they’re unable to get the information they need.
President Donald Trump in June issued an executive order calling for hospitals to disclose the prices they negotiate with private insurers. The move is intended to improve transparency and help patients make more cost-effective decisions about their care, but some economists question whether it will work. Medicare already publishes prices for services, yet patients, including DeRosa, still get stuck with bills they weren’t expecting.
“Our larger patchwork system of health care in our country puts a lot of onus on the individual to navigate the system,” said David Lipschutz, associate director for the Center for Medicare Advocacy, which represents patients. “Accessing health care is not like shopping for a toaster, but unfortunately it’s often treated as the same thing. [There’s] an assumption that people will research and gravitate to the highest-quality, lowest-cost providers, but often that’s not the reality.”
‘Getting it over with’
DeRosa, who worked as a law office bookkeeper for three decades and has served as her bowling league’s treasurer for 15 years, prides herself as being on the ball when it comes to personal finance. She’s so punctilious, Gov. Tom Wolf inducted her into the Pennsylvania Voter Hall of Fame for casting a ballot in every presidential election for the past 50 years.
But it never occurred to her that something as simple as a cortisone shot would cost so much more if given by another provider.
“I just thought I was getting it over with. I was still bowling, I needed my arm. I thought the sooner I get the shot the sooner I can throw the ball again,” DeRosa said.
The league’s season ended in May with a banquet on DeRosa’s 80th birthday. There was an Elvis impersonator and a cake shaped like her prized blue bowling ball in her honor.
She started bowling as a girl, throwing a few rounds with her friends on Friday nights at a Center City alley where teenage boys reset pins in the days before automated lanes.
“We’d throw the balls while they were setting up so they’d have to come out and we’d meet them,” DeRosa recalled.
She picked up the hobby again 40 years ago and accepts that the occasional cortisone shot is part of the game as she ages. But such drastically different prices seemed unfair — especially because no one warned her.
So she appealed the bill to her insurance plan, Keystone 65 HMO, a Medicare Advantage plan by Independence Blue Cross. Independence denied the appeal, arguing that DeRosa’s plan has a $350 co-pay for outpatient centers, meaning she is responsible for up to $350 in charges for the appointment.
The $256 charge was for an “ultrasound-assisted cortisone shot,” which bundles together the cost of the ultrasound, administration of the shot, and the medication, according to Independence, which reviewed DeRosa’s case at The Inquirer’s request.
“In this case, the injection cost was higher because it was given in a hospital and combined with another higher-cost procedure,” Richard Snyder, Independence’s chief medical officer, said in a statement.
Jefferson University Hospital billed her insurance a total of $1,170 for the visit, including $467 for administering the shot. DeRosa’s plan allowed a charge of $256, which it passed on to DeRosa because it was below her $350 co-pay for an outpatient hospital center.
The doctor’s practice, Jefferson Radiology Associates, billed DeRosa’s plan an additional $606, which Independence reduced to $97 and paid in full, without passing on any of the cost to DeRosa.
The insurer later said that after reviewing “new information” in DeRosa’s case, the plan would accept as full payment the $40 co-pay from her visit as a “one-time exception in this special circumstance.”
Procedures done at a hospital facility usually cost more than a physician’s office “due to the complexity and expense associated with the services that hospitals provide,” said Brandon Lausch, a spokesperson for Jefferson, in an email.
“The best way for patients to understand costs for a specific hospital service is to talk with their insurer and our patient financial services staff,” Lausch wrote.
Snyder, a physician, encouraged patients to use the plan’s online price tool or call the number on the back of their card for help estimating their out-of-pocket costs.
“We want our members to know the estimated cost before they get a procedure so they can avoid surprises,” he said.
The need for that level of research may not be apparent to everyone, especially seniors who enjoyed more generous health plans in the past, but it’s an increasingly necessary step.
Patients today are taking on a greater share of health-care costs through high deductibles, “coinsurance” cost-sharing rules that require patients to pay a portion of the bill even after meeting their deductible, and narrow provider networks that limit which doctors patients can go to for the plan’s negotiated rate.
Still, there’s a limit to how much patients can do to protect themselves, Lipschutz said.
DeRosa went to a doctor she knew was in-network and didn’t know she would be offered the cortisone shot at her ultrasound appointment. Should she have taken a time out in the middle of her appointment to call her insurer to inquire about the price of the shot she was about to receive?
“Most people do what their providers tell them to do. They don’t question the wisdom of their providers’ suggestions,” Lipschutz said. “But again, the system assumes you’re going to be a rational actor at all times and will plan for every contingency and insulate yourself from any surprises — which is completely and utterly unrealistic.”
‘No way to stay on top of it’
Even patients who take all the recommended precautions can stumble.
A study by research and consulting firm Altarum found that a third of Pennsylvania residents with private health insurance received a bill that was unexpected, larger than they anticipated, or from an out-of-network doctor who treated them at an in-network facility.
Billing errors are common, but understanding what constitutes a mistake can be challenging.
“Unless it’s egregious — just a huge, obvious mistake — there’s really no way to stay on top of it,” Stephen Ferich, a health care consultant for Cotiviti Healthcare, a firm that advises health insurers on billing error issues.
Three-quarters of people who received such a bill took action, such as calling their insurer or provider, according to the Altarum study. Yet more than half ultimately paid the bill in full.
Many people may be unaware of their right to appeal a coverage decision to their private insurer or Medicare, said Lynn Quincy, a director at Altarum.
In Pennsylvania, the insurance department investigates consumer complaints related to insurance coverage and the attorney general’s office investigates consumer health issues involving providers.
After DeRosa’s insurer rejected her appeal, she made another appeal, to the federal Department of Health and Human Services, which oversees Medicare. That appeal was also denied.
DeRosa had already submitted her next appeal, to the Medicare Appeals Council, and told her story to The Inquirer when she got a call from Independence, saying her debt had been cleared.
“I’m so glad I fought it, because otherwise I would be paying that bill $10 or $20 a month until it was gone," she said.