Top Doctors: My Daughter’s $29,000 Appendectomy

When the bills and insurance forms for my five-year-old’s surgery started rolling in, I was the one who needed a doctor. So I set out on a quest to understand them — and learned just how screwed up our health-care system really is

Given the difficulty I was having understanding one simple, successful appendectomy, I can’t imagine what it must be like for those families whose stays at CHOP are measured in months, not days, and whose bills climb into the hundreds of thousands of dollars and beyond.

And what happens if you have no insurance at all? Families that can afford to pay cash get a 20 percent discount. If you can’t afford to pay anything, CHOP offers a variety of options, including a charity-care program. While a portion of every bill goes toward subsidizing those cases, Madeline said there was no way for her to say what the exact percentage was. (Philanthropy also helps cover the cost of charity care.)

“This is how things have evolved over time,” Madeline said of the system in general. “Nothing will drastically change unless we have a different person in office and blow up the entire system of health care and have universal health care. Then, things will change.”

In the meantime, CHOP is playing by the current rules. A few minutes after I got off the phone with Madeline, a woman from CHOP’s public relations department called me and — in a move that says everything you need to know about what a business health care is — told me there was some concern Madeline might have said too much about how CHOP figures out its rates with insurance companies. Please don’t print how much the hospital gets paid for specific services, she implored. It could hurt CHOP in its negotiations with other insurance companies.

GIVEN THE AMOUNT of health care Americans consume — in 2007, we spent $2.3 trillion on it — I’ve come to realize that Sarah’s successful surgery wasn’t the only miracle that happened last fall. The simple fact that her bills were processed — and processed without any denials or complications, other than the fact that I thought my head was going to explode — was astonishing.

“We handle 300 million claims per year,” said Daryl Richard, a vice president at United Healthcare, when I called for some insurance-industry perspective on both Sarah’s bills and the entire Gordian knot of a system.

One of the ways United avoids being overwhelmed by that kind of volume is by removing human beings from the process as much as it can. The charges Sarah rang up at CHOP, for example, were sent electronically to United Healthcare, where a computer determined whether the charges seemed valid and signed off on how much to pay. Daryl told me that 82 percent of the company’s claims are “auto-adjudicated” — meaning no person has to get involved. It’s simply one computer talking to another.

Given that, I asked how United knew that all of Sarah’s charges — all 95 line items, $29,000 worth — were legitimate. I had no reason to suspect they weren’t, and frankly, I wasn’t going to fight CHOP even if something was fishy, but I wondered how much of a leap of faith United is willing to take.

“One of the roles we play, for the employers and consumers we serve,” he explained, “is to make sure we administer your benefits correctly — so that you’re not overcharged, or undercharged, and that your plan is covering what should be covered.

“And I think you highlight such an important issue, because — and I’m quite impressed with how much you dug into this — because I wish there were more consumers who were taking the time to understand their benefits and claims. Health care is going to continue to be a fairly complex system. But part of the way we can simplify it is if our consumers become more educated about how these processes and systems work.”

This “empowering the consumer” is something United is really big on. Daryl told me, for example, that the company’s website has a calculator that tells you how much a particular service or procedure should cost in your particular area of the country. He also said that starting this year, the company has come up with new claims statements designed to be much simpler for patients and their families to understand.