When Cass Smith-Collins of Las Vegas arranged for an advanced procedure, she chose a surgeon touted as an early developer of the procedure, which she did not have insurance for. “I had a shot at getting natural breasts, and I wasn’t going to give that chance to someone who wasn’t an expert in the art,” he says.
Bridget Bennett for KFF Health News/Bridget Bennett for KFF Health News
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Bridget Bennett for KFF Health News/Bridget Bennett for KFF Health News
When Cass Smith-Collins of Las Vegas arranged for an advanced procedure, she chose a surgeon touted as an early developer of the procedure, which she did not have insurance for. “I had a shot at getting natural breasts, and I wasn’t going to give that chance to someone who wasn’t an expert in the art,” he says.
Bridget Bennett for KFF Health News/Bridget Bennett for KFF Health News
Cath Smith-Collins jumped through hoops to undergo surgery to reassign her breasts to her gender.
Now living in Las Vegas and turning 50, he finally feels safe enough to come out as transgender. He had the support of his wife and a doctor’s letter indicating a long history of gender dysphoria, the psychological distress felt when one’s gender identity does not match the sex assigned at birth.
“This Month’s Bill” is a crowdsourced survey. KFF Health News and NPR A detailed explanation of medical expenses. Do you have an interesting medical bill that you would like to share with us? please tell me about it!
Although in-network providers were available, Smith-Collins chose Florida-based surgeon Charles Garamone. Early developer of top female to male surgery and he says do not have insurance. Smith-Collins said he would pay more to go out of network.
“I had a shot at getting natural breasts, and I wasn’t going to give it to someone who wasn’t an expert in the art,” he said.
Smith-Collins planned to spend a week in Florida and contacted friends there who could help her recover from outpatient surgery.
Garamone’s practice required patients to agree to its financial policy, according to documents shared by Smith-Collins. One document stated that Garamone’s surgery costs had to be “paid in full” four weeks before the surgery, and that all payments to the clinic were “non-refundable.”
Smith-Collins said he and his wife poured into their retirement savings to cover the down payment of about $14,000. Since he had received prior approval from his insurance company that the procedure was “covered,” he believed that his insurance would reimburse him for anything he paid above the $6,900 out-of-network out-of-network treatment limit. was.
The day before the surgery, Mr. Smith-Collins signed another contract with the surgeon’s office outlining how he would bill outside of his insurance company’s network. The insurance money will be received by the doctor.
The procedure went well. Smith-Collins went home satisfied and relieved.
Then the bill came. Or in this case: No refund was issued.
The patient: Cass Smith-Collins, 52, has employer-based insurance through UnitedHealthcare.
Medical services: Double incision upper surgery with nipple implantation and clinical examination.
Service provider: According to Florida public records, the plastic surgery institute is owned by Garamone and does business as Garamone Center.
Total bill: The surgeon’s practice billed patients and insurance a total of $120,987 for his work. The company charged the patient approximately $14,000 upfront (including the $300 test fee and $1,000 appointment fee) and then billed the patient’s insurance company an additional $106,687.
The surgeon later informed the patient in writing that the upfront fee was for the “cosmetic” portion of the surgery and the insurance fee was for the “reconstructive” portion. Initially, the insurance company paid $2,193.54 on the surgeon’s bill, but the patient received no reimbursement.
After KFF Health News began reporting this story, the insurance company reprocessed the surgeon’s claim and increased the clinic’s payment to $97,738.46. Mr. Smith-Collins subsequently received a refund of $7,245 from Mr. Garamone.
What you get: Many patients are writing a letter on their bill this month every year We have unique questions about complex billing. In many cases, including this one, the simple answer is that the patient misunderstood the insurance coverage.
Smith-Collins was in a confusing situation. UnitedHealthcare said his out-of-network surgery would be “covered,” but later told Smith-Collins it was not obligated to pay him the compensation he had expected. He later received a refund after KFF Health News started reporting.
Adding to the confusion were clinic financial policies that set pre-surgery payment deadlines, gave doctors control over insurance payments, and put patients at risk of further charges (though fortunately In fact, the patient received nothing).
Agreeing to an out-of-network provider’s own financial policy typically protects its ability to get paid and creates a binding contract, although it may be littered with confusing insurance and legal jargon. Patients may be left with debt. In other words, they can put doctors in the driver’s seat and control the funds.
The agreement signed by Dr. Smith-Collins the day before the surgery states that the patient understands that he or she is receiving out-of-network care and that the out-of-network practice “requires no additional charges for any services provided.” may be held liable.”
Federal bill protection protects patients from high out-of-network bills, but not if patients knowingly choose out-of-network treatment. Smith-Collins may have been stuck with the difference in the cost of the procedure between an out-of-network doctor and her insurance company, which was nearly $102,000.
Emails show Smith-Collins took several weeks to review a version of the clinic’s out-of-network agreement before signing it. However, he said he likely did not read the entire document because he was focused on the surgery and was willing to agree to anything to get it.
“Surgery is an emotional experience for everyone, and it’s not an ideal time to sign complex legal agreements,” said Marianne Udow Phillips, a health policy lecturer at the University of Michigan School of Public Health. Ta.
Udo Phillips, who reviewed the agreement, said it contained complex terms that could confuse consumers.
Another clause in the contract states that the surgeon’s upfront fees are “separate and unrelated to the fees billed to insurance.”
Several months after the surgery, Smith-Collins said she contacted her surgeon after not receiving compensation. Mr. Garamone responded to him via email, explaining that while UnitedHealthcare paid for the “reconstructive aspects of the surgery,” the several thousand dollars advanced by Mr. Smith-Collins were paid for the “cosmetic portion.”
After filing an insurance claim, Garamone was initially paid, but Smith-Collins was not reimbursed.
Garamone did not respond to questions or repeated interview requests from KFF Health News for this article.
Smith Collins miscalculated the amount his insurance would pay out-of-network surgeons.
Before the surgery, Smith-Collins received a receipt from Garamone’s clinic marked “Final Payment” with a zero balance and that the surgery performed by Garamone was “covered,” the document says. It had also received prior approval from United Healthcare.
However, there is no limit to the amount that out-of-network providers can charge, and there is no minimum amount that insurance companies must pay.
An Explanation of Benefits (EOB) statement shows Mr. Garamone filed a claim with UnitedHealthcare for more than $106,000. Of this, UnitedHealthcare has determined the maximum amount it will pay, known as the “allowable amount,” is approximately $4,400. A UnitedHealthcare representative later told Smith-Collins in an email that the total amount was based on what Medicare would have paid for the procedure.
Smith Collins’ advance payment of about $14,000 was far more than the insurance company deemed fair, and UnitedHealthcare had no intention of paying the difference. According to UnitedHealthcare calculations, Mr. Smith-Collins’ share of the allowable amount is about $2,200, which is his out-of-pocket expense. This means, in the eyes of the insurance company, Ms. Smith-Collins has not yet reached the maximum amount for the year, which is $6,900, so she will not be reimbursed.
Neither UnitedHealthcare nor the surgeon provided billing codes to KFF Health News, making it difficult to compare the surgeon’s fees and the cost estimate for the procedure.
Garamone’s website says: Prices vary depending on the scale and difficulty of the procedure. The site said his prices reflected his experience, adding that “cheap can lead to very bad outcomes.”
Smith-Collins said she would never regret the surgery, although she spent more money than expected. He said he realized at an early age that his body did not match his identity, and that he lived with suicidal thoughts from a young age, fearing that he would be targeted by others because he was transgender. Ta.
“It was a life saver,” he said. “I jumped through all the hoops they tried to put me through to get the surgery and finally be able to be who I am.”
solution: Smith-Collins filed two appeals with her insurance company, asking UnitedHealthcare to reimburse her for the amount she spent above her out-of-pocket limit. The insurance company dismissed both appeals, determining that the payments were correct based on the terms of the insurance plan, and said his case was not eligible for a third external review.
However, after being contacted by KFF Health News, United Healthcare reprocessed Garamone’s nearly $106,000 claim and increased the provider’s payment to $97,738.46.
Maria Gordon-Sidlo, a spokeswoman for UnitedHealthcare, told KFF Health News that the company’s initial decision was correct, but that Smith-Collins would be “only” responsible for the $6,755 in patient costs. He said he had reprocessed the claim.
“We are disappointed that this uncontracted provider has chosen to charge higher fees to its members,” she said.
After that new payment, Mr. Garamone refunded Mr. Smith-Collins $7,245 in mid-April.
Key points: Udo Phillips, who worked in the health insurance industry for decades and led provider services at Blue Cross Blue Shield of Michigan, said he had never seen a provider agreement like the one signed by Smith-Collins.
He said patients should consult an attorney before signing an out-of-network contract and be sure to understand any pre-approval letter from their insurance company.
The pre-approval received by Smith-Collins “does not say it will cover the entire amount, nor does it say what percentage it will cover,” Udo-Phillips said, later adding: . [Smith-Collins] I thought the prior permission was for the cost of the surgery. ”
Patients can seek in-network care with greater confidence in what their insurance will cover and what their doctors will charge.
But for those who have a particular out-of-network doctor in mind, there are ways to try to avoid sticker shock, says Sabrina Corlett, a research professor at Georgetown University and co-director of the Center for Health Insurance Reform. he says.
- Patients should always ask their insurance company what it means to be “covered,” specifically, does it mean full payment, and what costs does it mean? And before paying upfront, patients should ask their insurance company how much of that total will be reimbursed.
- Patients can also ask their providers to agree in advance to accept insurance reimbursement as full payment, but they are not required to do so.
- Patients can then ask their insurance company for an accurate estimate of their out-of-pocket costs and whether they can get a refund if their insurance pays.
Emmarie Huetteman of KFF Health News edited the digital story and Taunya English of KFF Health News edited the audio story. NPR’s Will Stone edited the audio and digital story.
KFF Health NewsFormerly known as Kaiser Health News (KHN), we are a national newsroom producing in-depth journalism on health issues and one of our core operating programs on health issues. KFF — An independent source for health policy research, polling, and journalism.
