Diagnostic Tests

A few years ago, a patient of mine called my office because she was worried that she might have a urinary tract infection. She had recently lost her job and her health insurance, but she wanted to be sure about the infection because she didn’t want to take antibiotics unnecessarily. I called the lab at the local hospital and asked how much they charged for a urine analysis. They told me that it was 92 dollars! I couldn’t believe it. 92 dollars for a test that requires a plastic cup, a 25 cent dipstick and 2 minutes of a technician’s time! I called around to other local labs and the cheapest price I was quoted was 32 dollars. This was better than the first price but, compared to the four to five dollars they would get from most insurance companies, it was obscene.

This brings me to the subject of diagnostic tests and how much they should really cost. Most blood and urine tests are done with simple chemicals that cost anywhere from a few pennies to a couple of dollars. This means that it cost little more than that to run most of these tests. Add the lab time, and most tests still only cost a few dollars (labs are pretty efficient at running tests). There are a few expensive tests, such as genetic tests, but these are not frequently used in a routine screening or diagnostic work up.

The cost of radiology tests can be broken down in a similar fashion. There is the original cost of the X-ray machine, CT scanner or MRI which are usually bought and paid for by the hospital or diagnostic center. In addition, there are the costs of maintaining the machinery (which is usually a fixed annual fee), paying the staff, preparing certain patients for the tests and the radiologist’s fee for reading the X-ray.

In fact, here’s a site that offers reasonable cash prices for many medical tests and procedures in many parts of the US.

The insurance companies know all of these costs and try to reimburse the minimum amount that the institution running the test is likely to accept whenever they’re the ones purchasing the service. Routine blood work, for example, only gets paid a few dollars but a CT scan or MRI will bring in a few hundred dollars. A PET scan (which is relatively new technology) might cost a thousand to fifteen hundred dollars but, as with everything else in technology, the price of this test is dropping.

How much will they bill you if you try to pay for any of these tests yourself? Well, as you know by now, all tests, procedures, office visits and hospitalizations are billed for an amount that exceeds what they expect from any insurance company (often by a lot) in order to get the maximum amount possible from all of them. This means that anyone who doesn’t have insurance, or for whom the insurance claim is denied, will be billed five to ten times what any insurance company would likely pay.

This not only makes people 100% dependent on their insurance for even the most trivial medical cost but also means they will have to pay an enormous penalty any time anyone makes a mistake ordering or authorizing a test if coverage is denied. In addition, this policy results in millions of people being excluded from healthcare, not because they can’t afford it, but because they are not allowed to afford it. Most people could afford these services were they not priced at so many times their actual value.

Below is a list of commonly ordered medical tests along with a brief explanation of the test, typical billing charges and the reimbursement from Medicare and a sample PPO insurance negotiator. I obtained the billing charges by calling several different hospitals in the San Francisco Bay Area.

Here is a link to the chargemaster for every hospital in California if you wish to look up more hospital prices

Private labs and imaging centers that are not affiliated with hospitals charge less than hospitals, but some still charge well above what most insurance companies are likely to pay (they are getting much better though). It’s pretty clear, even from this short list of tests and procedures, that that the institutions providing them do not want you to pay for them yourself. The question is, why? Why would any organization go so far out of their way to discourage direct payment? This is especially strange when you consider what a nightmare it is to deal with insurance companies.

Also, consider how much the insurance companies have to pay for these tests. If that’s all you had to pay, how hard would that be? How do the prices of these tests compare to the price of a tank of gasoline, a bag of groceries or a tune up for your car? Even the most expensive tests listed wouldn’t cost you as much as a transmission overhaul so, why do we have to pay so much to have our insurance cover them?

PPO prices were taken from a sample fee schedule provided by Multiplan.

See Figure Here

Another Look:

Blood tests:

Comprehensive metabolic panel: A blood test that assesses liver and kidney function as well as electrolytes

Hospital charge: $179 Private insurance: $15 Medicare: $15

Lipid Panel: A blood test that checks total cholesterol and breaks it down to good and bad components.

Hospital charge: $68 Private insurance: $19 Medicare: $19

Complete Blood Count: A blood test that checks your hemoglobin, hematocrit, white blood counts.

Hospital charge: $51 Private insurance: $11 Medicare: $11

Urine Analysis: Looks for blood, signs of infection or protein in your urine.

Hospital charge: $92 Private insurance: $5 Medicare: $4

Hemoglobin A1C: A single blood test that checks your average blood sugar for the last 3 months.

Hospital charge: $61 Private insurance: $14 Medicare: $13

Thyroid Stimulating Hormone: A blood test that evaluates your thyroid function.

Hospital charge: $108 Private insurance: $24 Medicare: $23

Prothrombin Time: A blood test to check Coumadin level and your blood’s ability to clot

Hospital charge: $36 Private insurance: $6 Medicare: $6

PSA: A blood test that helps to check for prostate cancer.

Hospital charge: $117 Private insurance: $26 Medicare: $22

HIV: Tests for HIV (obviously).

Hospital charge: $92 Private insurance: $20 Medicare: $19

Cardiology:

EKG: A screening test for abnormal heart rhythms and other signs of heart disease.

Hospital charge: $367 Private insurance: $26 Medicare: $26

Echocardiogram: An ultrasound of the heart to look at valves and assess function.

Hospital charge: $4,361 Private insurance: $317 Medicare: $291

Exercise Stress Test: This test is good for evaluating chest pain to see if your heart is the cause.

Hospital charge: $1,182 Private insurance: $123 Medicare: $123

Radiology:

(Price includes fee for Radiologist)

Chest X-Ray: To check for lung disease and some forms of heart disease.

Hospital charge: $375 Private insurance: $42 Medicare: $41

Mammogram: Screening test for breast cancer

Hospital charge: $336 Private insurance: $191 Medicare: $146

Ultrasound of the Abdomen: Can assess Kidneys, Liver, Gall Bladder and other organs.

Hospital charge: $1,440 Private insurance: $184 Medicare: $181

Ultrasound of the Pelvis: Images the Uterus and Ovaries

Hospital charge: $1,106 Private insurance: $170 Medicare: $169

CT of Head: Often used to look for lesions in the Brain.

Hospital charge: $2,621 Private insurance: $344 Medicare: $269

CT of Chest with IV Contrast: Can accurately evaluate lung disease and other problem in the chest.

Hospital charge: $5,295 Private insurance: $431 Medicare: $426

CT of Abdomen with IV Contrast: Accurately images the abdomen for tumors or other disease.

Hospital charge: $5,680 Private insurance: $463 Medicare: $458

CT of Pelvis with IV Contrast: Often done at the same time as the abdominal CT.

Hospital charge: $5,030 Private insurance: $408 Medicare: $403

MRIs:

MRI of the Brain: A more accurate way to image the brain than a CT scan but it’s more expensive and can’t be done as quickly or easily.

Hospital charge: $3,422 Private insurance: $578 Medicare: $654

MRI of the Cervical Spine: Accurately images the neck

Hospital charge: $3,041 Private insurance: $584 Medicare: $587

MRI of the Thoracic Spine: Accurately images the upper back

Hospital charge: $3,422 Private insurance: $584 Medicare: $596

MRI of the Lumbar Spine: Accurately images the lower back.

Hospital charge: $3,535 Private insurance: $577 Medicare: $588

Procedures:

(Usually these procedures are done in an office not a hospital. The amount billed varies substantially for different medical groups but it usually ranges from $1,000 to $8,000 for each).

Colonoscopy, Diagnostic: A screening test for colon cancer where the entire colon is examined through a fiber optic tube.

Private insurance: $504 Medicare: $464

Colonoscopy with Biopsy: If a lesion is found on screening colonoscopy a biopsy is needed.

Private insurance: $603 Medicare: $555

Upper endoscopy with Biopsy: Evaluates problems in the esophagus and stomach, again through a fiber optic tube.

Private insurance: $447 Medicare: $410