Help – How to handle a high medical bill (insurance covers only part of it) – NY – PPO Plan
Hello!
I had an appendicitis earlier this year and went to an in-network hospital in NYC. Arrived in the morning, had surgery in the evening and was released the next day (so entire stay around 26h) – no complications.
Approx. four weeks after the surgery I got two notes (cover denial letter and final adverse determination) from my insurance company that they won't cover part of the bill (code C1889 and Inpatient Care). For context, I am not a US-citizen and here with a student visa, so navigating through the healthcare maze is new to me. I have a PPO plan.
Since I am a complete newbie to the system, my question is:
Can I appeal to the insurance decision? Is this recommended/complicated? How do I negotiate with the hospital? I read online that people negotiated in the past by using average charges as reference, but how do I know what charges are overpriced or unnecessary? Isn't 108k for an uncomplicated appendectomy insane?? – I don't really want to be stuck with almost 50% of it. All parts that are not covered (C1889 and inpatient care) are things I can not control as a patient anyway – i can't control what devices the doctors use nor if I have to stay at the hospital or not? I don't understand why this should be not covered.
Any advice/help/pointers/health system rants are appreciated.
—
This is the original hospital estimate: $108,783.55 (not billed yet)
Here is the itemized bill: (bold is the amount my insurance told me they won't cover)
Ambulatory Surgery (total $16,287.60):
HC Operating Room Flat Fee $4,564.35
HC Operating Room per Minute – quantity: 77 $11,723.25
Anesthesia (total $937.49):
HC Anesthesia per Minute – quantity: 77 $390.39
HC Anesthesia Base Fee $547.10
CT Scan (total $8,251.96):
HC CT Abd & Pel W/Cont – 74177 (CPT®) $8,251.96
Emergency Room (total $5,904.10):
HC Emergency Dept Visit Lvl 5 – 99285 (CPT®) $5,904.10
IV Therapy (total $2,588.52):
HC Non Chemo IV Push 0-15 Minutes, Initial – 96374 (CPT®) $1,221.12
HC Non Chemo IV Push 0-15 Minutes, Seq – quantity: 3 – 96375 (CPT®) $1,367.40
Laboratory (total $3,352.76):
HC Metabolic Panel Total Ca – 80048 (CPT®) $178.89
HC Hepatic Function Panel – 80076 (CPT®) $148.34
HC Assay of Lipase – 83690 (CPT®) $256.12
HC Complete Cbc W/Auto Diff Wbc – 85025 (CPT®) $138.61
HC Chorionic Gonadotropin Assay – 84703 (CPT®) $234.31
HC Urinalysis Auto W/ Microscopy – 81001 (CPT®) $60.86
HC Prothrombin Time – 85610 (CPT®) $172.43
HC Thromboplastin Tm Prtl Plsm/Whl Bld – 85730 (CPT®) $124.45
HC Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq – 87635 (HCPCS) $205.40
HC RBC Antibody Screen – 86850 (CPT®) $395.39
HC Blood Typing, Abo – 86900 (CPT®) $294.21
HC Blood Typing, Rh (D) – 86901 (CPT®) $294.21
HC Blood Typing, Abo – 86900 (CPT®) $294.21
HC Blood Typing, Rh (D) – 86901 (CPT®) $294.21
HC Urine Culture/Colony Count – 87086 (CPT®) $261.12
Laboratory Pathological (total $1,428.87):
HC Level III-Surg Path Gross&Microscopic Xm – 88304 (CPT®) $1,428.87
Medical/Surgical Supplies and Devices (total $27,834.20):
Tip Scissors Endocut L19.3 Mm Disposable – C1889 (HCPCS) $535.28
Suction Irrigator 2 W/Disp Tip – C1889 (HCPCS) $1,482.44
Clip Endo Applier III 5mm – C1889 (HCPCS) $2,329.70
Tote Nyu No 016 Mini Laparotomy $1,477.71
Trocar Kii Balloon Blunt Tip Sys 12x100mm – C1889 (HCPCS) $1,620.00
Stapler Handle Endo Gia Ultra Stnd – C1889 (HCPCS) $1,480.41
Manifold 4 Port Neptune Disposable – quantity: 2 $1,144.26
Dermabond Advanced Skin Adh $515.03
System Visualization Clearify W/Anti Fogging Solution $977.54
Electrode Laparoscopic Wire L-Hook 36cm – C1889 (HCPCS) $620.19
Trocar Versaone Optical W/Fxtn Cann Std 5mm – C1889 (HCPCS) $417.42
Bag Specimen Retrieval Endos 10 Mm – C1889 (HCPCS) $1,435.86
Cannula Bladeless Opt Fxtn Std 5mm Trocar – C1889 (HCPCS) $162.68
Sealer Divider Ligasure Maryland Jaw 37cm W Nano Coating – C1889 (HCPCS) $10,985.76
Garment Calf Vasopress MD (Scd) $142.43
Reload Stapler Artic MD Thk 45 – C1889 (HCPCS) $2,507.49
Pharmacy (total $2,328.87):
Diatrizoate Meglumine-Sodium 66-10 % Soln (0270-0445-35) – quantity: 30 – Q9963 (HCPCS) $74.47
Iopamidol 300 Mg Iodine /Ml (61 %) Soln (0270-1315-35) – quantity: 75 – Q9967 (HCPCS) $109.62
Ondansetron 4 Mg/2 Ml Soln (60505-6130-0) – quantity: 4 – J2405 (HCPCS) $2.75
Morphine 4 Mg/Ml Soln (72572-440-01) – J2270 (HCPCS) $25.58
Sodium Chloride 0.9 % IV Bolus Solp (0264-7800-09) – quantity: 4 – J7050 (HCPCS) $63.00
Ceftriaxone 1 Gram Solr 1 Each Vial (0409-7332-11) – quantity: 4 – J0696 (HCPCS) $30.19
Sodium Chloride 0.9 % (Pf) Soln 10 Ml Vial (0409-4888-01) – A4216 (HCPCS) $63.00
Metronidazole in Iso-Osmotic Nacl 500 Mg/100 Ml Pgbk (0409-0152-01) – J3490 (HCPCS) $25.20
Phenylephrine 10 Mg/Ml Soln (0641-6142-01) – J2370 (HCPCS) $34.65
Fentanyl 50 Mcg/Ml Soln (0409-9094-22) – quantity: 2 – J3010 (HCPCS) $24.90
Heparin (Porcine) 1,000 Unit/Ml Soln (63323-540-11) – quantity: 5 – J1644 (HCPCS) $63.00
Sugammadex 100 Mg/Ml Soln (0006-5423-02) – quantity: 2 – J3490 (HCPCS) $1,197.25
Metronidazole in Iso-Osmotic Nacl 500 Mg/100 Ml Pgbk (0409-0152-01) – J3490 (HCPCS) $25.20
Lactated Ringers Solp (0338-0117-04) – J7120 (HCPCS) $63.00
Lactated Ringers Solp (0338-0117-04) – J7120 (HCPCS) $63.00
Heparin (Porcine) 5,000 Unit/Ml Soln (0409-2723-30) – quantity: 5 – J1644 (HCPCS) $63.00
Lactated Ringers Solp (0264-7750-00) – J7120 (HCPCS) $63.00
Bupivacaine (Pf) 0.25 % 0.25 % (2.5 Mg/Ml) Soln (0409-1159-02) – quantity: 30 – J3490 (HCPCS) $18.90
Propofol 10 Mg/Ml Injection Emul (63323-269-29) – quantity: 20 – J2704 (HCPCS) $26.21
Succinylcholine 20 Mg/Ml Soln (0409-6629-02) – quantity: 5 – J0330 (HCPCS) $103.95
Lactated Ringers Solp (0264-7750-00) – quantity: 2 – J7120 (HCPCS) $63.00
Heparin (Porcine) 5,000 Unit/Ml Soln (0409-2723-30) – quantity: 5 – J1644 (HCPCS) $63.00
Lactated Ringers Solp (0264-7750-00) – J7120 (HCPCS) $63.00
Recovery Room (total $25,209.18)
HC Recovery Room 15 Min Optime – quantity: 4 $1,976.16
HC Recovery Room > 12 Hrs $23,233.02
Treatment or Observation Room $14,660.00
HC Hospital Observation per Hr – G0378 (HCPCS) $8,000.00
HC Hospital Observation per Hr – quantity: 11 – G0378 (HCPCS) $6,660.00
submitted by /u/CryptographerHead959
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