r/HealthInsurance • u/JohnRoberts90 • Feb 06 '25
Claims/Providers I Cracked the Medical Billing Code and Saved ~$2,000 (90%) on My Kid’s X-Ray
I just went through a ridiculous medical billing experience, and wanted to share what I learned in case it helps someone else save thousands of dollars. Some of you guys may already know all this, but hopefully it helps someone out there who doesn't.
The Situation:
My infant son's pediatrician said he needed a hip X-ray to check for hip dysplasia. When I asked where to go, they said "Children's Hospital of Atlanta (CHOA)" was the only place "unfortunately". Note I'm in Atlanta, GA.
I called CHOA for pricing, and was quoted $2,200 for the hospital fee alone —and would not offer any discount. They also required me to pay 85% up front.
I then called some other hospitals, despite the pediatrician saying there was no alternative (hoping to find another that would do pediatric xrays), and was losing hope until I was fortunate enough to get in touch with Northside Hospital, who said they do offer pediatric imaging. Northside Hospital's self pay rate was $700. But when I asked if they had a self-pay discount, they said they offer a 75% discount upfront, bringing my cost down to $175 for the X-ray. Woohoo!!
However, what no one tells you is that there’s also a separate radiologist fee to read the X-ray. They don’t include this when they give you a price estimate, so you just get hit with another bill later. In my case, I’ll owe about $150 for the radiologist, bringing my total cost to ~$325. Still super stoked after almost losing hope and conceding >$2200 to CHOA.
What They Also Don’t Tell You: Even Getting a Price is a Nightmare
You’d think that by paying cash/self-pay rate, you'd be able to call and ask “How much will this cost?” would be simple. It’s not.
- I had to get transferred to a special pricing department just to get a cost estimate.
- I had to fill out a form and wait for them to process it before they would even give me an 'estimate'.
- Even after they gave me the estimate, they didn’t mention the radiologist fee.
- When I specifically asked, they didn’t even know if there was a radiologist fee.
- I had to get transferred again, track down a third-party radiology group, and repeat the entire process just to figure out that I’d owe an extra $150.
And that’s just because it was an X-ray. If it were another procedure, there could be even more hidden fees from doctors I wouldn't even know were involved.
What I Learned (The Hard Way):
- Hospitals never tell you about self-pay discounts unless you ask. If I had just accepted the price CHOA gave me, I would’ve paid >10x more.
- They also don’t tell you about radiologist fees. The price estimate never includes the doctor who actually interprets the X-ray, so you get an unexpected bill later.
- Even getting a price is a huge pain in the ass.
- You can’t just call and ask, they make you go through an entire process to get a quote.
- And even after all that, it’s probably not the full price.
- Insurance would have been more expensive than self-pay.
- Right now, I don’t have insurance (waiting for my Marketplace plan to kick in as my wife just quit her job to stay at home, and I'm self-employed).
- But even if I had insurance, I probably would’ve ended up paying more than the self-pay price.
- Hospitals bill insurance the full contracted rate, and if you have a high-deductible plan, you have to pay that full contract price out of pocket.
- The self-pay discount is way more than any insurance discount.
- High-deductible plans are a scam unless you have big medical expenses.
- If you have insurance and don’t hit your deductible, you’re still paying full price for almost everything.
- And hospitals usually won’t let insured patients access self-pay discounts because they have to charge the contracted insurance rate instead.
What You Should Do If You Need an X-ray (or Any Imaging):
✅ ALWAYS ask for the self-pay or cash discount. Don’t assume you have to pay full price.
✅ Call multiple hospitals and imaging centers. Prices can vary by thousands of dollars.
✅ Ask if the radiologist fee is included or separate (because it’s usually separate).
✅ If you have a high-deductible plan, compare the self-pay rate to your insurance’s contracted rate—self-pay is often cheaper.
✅ If they make you fill out a form to get pricing, expect that the number they give you is not the full price.
I can’t believe how many people must be overpaying just because the system is designed to make you think you don’t have a choice. If I had blindly followed my doctor’s advice, I would’ve paid ~$2,400 for a $325 xray at another reputable hospital.
Has anyone else had an experience like this?
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u/KeniLF Feb 06 '25
Thank you for this useful writeup.
One potential value of the high deductible plan is the ability to sock away $4,300 (individual)/$8,550 (family) per year into an HSA. The HSA contributions are tax deductible and can be invested in stocks/indexes.
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u/startingover_48 Feb 06 '25
100%. Keep throwing money in your HSA every year and when you retire you have a nice nest egg for med expenses when you’re 65.
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u/JessterJo Feb 06 '25
You can use HSA funds for things other than medical expenses after 65.
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u/shoeperson Feb 06 '25
But you will pay taxes if you use it for non medical stuff. It basically acts as another traditional IRA at that point.
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u/lol_fi Feb 06 '25
You can keep your receipts for past expenses and reimburse yourself at any time.
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u/JessterJo Feb 06 '25
I thought I heard it was tax free after 65? You pay taxes if you use it for non-medical expenses prior to that. I may be wrong.
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u/EqualSein Feb 06 '25
Prior to 65 you'll pay Taxes plus a 20% penalty for withdrawing for non-medical purposes. After 65 you'll pay ordinary income tax for withdrawing for non-medical purposes.
Withdrawing for medical purposes is tax-free.
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u/blakeh95 Feb 06 '25
It’s penalty free after 65.
So any age: medical expenses are tax free and penalty free.
Over age 65: nonmedical expenses are taxable, but no penalty.
Under age 65: nonmedical expenses are taxable and have a 20% penalty.
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u/Johnnyg150 Feb 06 '25
It's a great tax break for the upper middle class and rich, but problem is that with the lowest premium, they always fall into the hands of people who can't afford to save that.
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u/STEMpsych Feb 06 '25
Worse, a whole lot of people who sign up for HSA compatible HDHPs have no idea they're supposed to fund a HSA to go with it. If they did, they might have chosen another plan.
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u/Johnnyg150 Feb 06 '25
Yeah I'd definitely support requiring a mandatory video on the impact of an HDHP and how essential it is that you can contribute to an HSA, even possibly at the expense of a 401(k) contribution.
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u/KeniLF Feb 06 '25
Would you please clarify the final part of the sentence about something falling into people's hands because of a low premium? I don't understand it.
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u/Johnnyg150 Feb 06 '25
When you have lower income employees who barely make it paycheck to paycheck, and they get an option to choose how much will be deducted from their pay for health insurance, many will choose the lowest premium option (an HDHP), either not understanding the impact, or settling with it to keep money in their checks. Either way, they don't have money to contribute to an HSA, and if they did, it would have to be used on their healthcare expenses instead of trying to preserve the tax free funds.
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u/KeniLF Feb 06 '25
Got it - thank you for the clarification. For sure, investing it is not always possible, unfortunately.
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u/olily Feb 06 '25
Look at it this way. Someone who is struggling just to pay bills and buy food is trying to be responsible and buy insurance. A high-deductible plan costs $300 a month. The same high-deductible plan + an HSA costs $350. That $50 difference is huge to someone who has to scrape to get by. It can be used to buy food, help pay a utility bill, get your kid a new pair of sneakers from Walmart. The people that need that $50 every month just to survive aren't going to go with an HSA.
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u/KeniLF Feb 06 '25
Yes, the person to whom I posed the question responded an hour ago and I thanked them for the clarification.
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u/dboytim Feb 06 '25
It's also great though for low income who have expected medical expenses - people with upcoming surgery, or who take regular medication. Just run whatever you know you're going to spend anyway through the HSA and save the income tax on it.
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u/Toomanyredditors333 Feb 06 '25
HSA is a good idea, but the people on high deductible plans probably often or not on super high tax brackets where this even comes close to making up for the issues that high deductibles
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u/WRX_MOM Feb 07 '25
Yeah this is always suggested on Reddit as some kind of healthcare “hack” when it really only benefits people well off enough to put that much extra away. I used to see kids (as a therapist) and the wealthiest families always had HDHPs funded with HSA cards.
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u/Zealousideal_Food466 Feb 07 '25
Yeah- you can invest if you don’t have any actual medical expenses. Before you start investing you should have the plan max out of pocket saved- on family plans the average is $10,000. My son broke his arm playing football right on the growth plate above his elbow. Between emergency room, surgery, overnight hospitalization and physical therapy I hit his $5,000 out of pocket.
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u/alwyn Feb 07 '25
And it's only useful as long as you stay healthy
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u/KeniLF Feb 07 '25
Yes. If there are reasons not to use it, definitely don't use it. It's completely optional and not required in any way.
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u/Brilliant_Chance_874 Feb 07 '25
You can put money into your hsa & use it later to pay deductibles? Is that what you are saying?
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u/KeniLF Feb 07 '25
You can use it to later pay *any* qualified medical expense. The IRS defines what is considered to be a qualified medical expense. I don’t know enough about all (or many!) insurance plans to know if every insurance company’s deductible is solely for qualified medical expenses.
Below is a list directly from the IRS - even insurance premiums are included as qualified medical expenses. For the most part, in my opinion, there’s little downside to at least putting money in the HSA since it widens your options.
Definitely save all medical-related receipts. This may mean making photocopies or taking screenshots and tagging them very well. You can pull them all out decades later (at/older than 65) and use those receipts to withdraw money from the HSA tax-free.
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u/necrossis1 Feb 07 '25
To your last sentence, currently, I have an HDHP for my kids and me. Are you saying that I can save the receipts for whatever deductibles I pay now, and later when my kids leave (about 5 more years) I can switch to an HSA and submit these receipts for tax-free reimbursement?
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u/KeniLF Feb 08 '25
All of my comments are written specifically about the benefits of an HSA. I do not have knowledge about whether this is possible with only having an HDHP and no HSA. The IRS site has full details on what’s allowed if you want to understand if you can do this for this scenario.
Are you feeling some reticence about opening an HSA (since you already have an HDHP)? Please keep in mind that you have until April 15 2025 to fund your HSA for *last year* (assuming you had an HDHP).
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u/mardusfolm Feb 07 '25
You realise it's an investment...and gamble...there are no guarantees that it will go up in value....what if you need it when the market crashes etc??? Your Healthcare shouldn't be an investment on Wall Street...it should be guaranteed...just like your retirement but unfortunately we've conviently figured out a way to take all the money you have and put it in some sort of investment that offers no guarantee but yet will always earn money for someone else...
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u/Calm-Vegetable-2162 Feb 06 '25
Next time, look for a stand-alone medical imaging location (think MRI, CT, ultrasound, x-ray imaging). Those places are a fraction of the hospital self-pay price. Yes they do all ages. They also do insurance, just don't mention insurance before you ask for the self-pay price. Some offer payment plans. Some offer reduced price or free services bases upon your income. Some stand-alone medical imaging location include the radiologist fee in their price, some don't, call to confirm.
Some urgent care locations include any onsite lab work and x-rays (including radiologist fees) as part of their base charge for services. You'll need to call around to find out.
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u/Salty_Philosopher364 Feb 06 '25
Second this. Hospitals are almost always more expensive than stand-alone facilities, due to the fact that the hospital is trying to use their prices to cover other hospital costs, besides just the imagining.
The trick is that most hospital based physicians are encouraged by management to just send patients to the hospital's imaging center. This unfortunately gives patients the idea that the hospital's imaging center is the best / only place to have imaging done.
It is always worthwhile to search for independent stand-alone facilities to see if you can get a better price
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u/shwimshwim25 Feb 07 '25
How does one search for and recognize an independent imaging center? I've had knee pain for over a decade and have done PT three times and yet insurance still denies my request for an MRI. I've been quoted $3k for an MRI..curious to see the prices at an independent facility if it's would be cheaper to skip insurance there..
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u/Salty_Philosopher364 Feb 10 '25
The current best practice I know of is just using google to search for "independent imaging center". Then when clicking through the websites, you can usually see if they are affiliated with a health system in your area. You would then still need to call in to get an estimate though and do your comparisons.
Its a lot of legwork, but has the potential to save you a significant amount of money.
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u/fuzznugget20 Feb 07 '25
Problem is the quality of the radiologist can be hit or miss
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u/Calm-Vegetable-2162 Feb 07 '25
That's a human trait... It's difficult to ensure what you're going to get, until you get it. All you can somewhat depend on, is word of mouth. Posting to sites like this can get your real independent reviews.
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u/fuzznugget20 Feb 07 '25
Patients have no idea of the quality of the radiologist, so word of mouth is not very relevant. If performed in health system can get second opinion usually within the system. Otherwise would need a new scan. For simple xr not an issue to go to independent imaging center but patients with more complex imaging or history are well served by going to a good healthcare system.
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u/Calm-Vegetable-2162 Feb 11 '25
I disagree with your reply completely.
Word of mouth is VERY MUCH RELEVANT. If you have a long-term condition that requires ongoing monitoring (there are many of those conditions), you will quicky learn that word of mouth is everything. Your doctor (hopefully a specialist) is a wealth of information on steering you to the best imaging available. It won't always be in a hospital setting.
Not all hospitals have quality imaging equipment. Not all standalone imaging facilities have quality imaging equipment. Not all imaging is referred to the best radiologist. Both hospitals and standalone facilities have access to the same quality imaging equipment but do they take advantage of it. Even with the best equipment, you also need good technicians to regularly maintain the equipment, to operate the equipment, and capture great imaging.
You know, some hospitals farm out the imaging reading to a remote contract radiologist companies. Sometimes the same firm that standalone imaging companies do.
Most times the doctor will review the imaging themselves, before reading the radiologist narrative report, and form their own opinions, then read the narrative report see if the radiologist noticed the same things. Some things are obvious before the imaging, like if you have a broken bone sticking though the skin, it's obvious that you have at least a compound fracture. Many things are not that obvious that it takes a trained, experienced person to detect. Some things require reviewing prior imaging (like from a year ago) for comparison.
Sometimes your doctor will notice radiologist name on the narrative report and tell you that you got the best darn radiologist in the business, even if the imaging was done at a standalone facility.
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u/YIRS Feb 06 '25
First off, thank you for writing this all out.
My experience has been that the self-pay rate is higher than the contracted insurance rate (Cigna). However, that has been for office visits. Maybe there is a different trend for imaging and other procedures.
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u/JohnRoberts90 Feb 06 '25 edited Feb 06 '25
yeah, im sure big hospitals can be a lot more aggressive for discounts when paid upfront. FWIW I also just took my son in for his 4 month pediatrician office appt to get shots via self pay rate. the office visit and a bunch of shots all in was $200, I thought it was going to be a lot more candidly. It's a nice pediatrician office in an affluent area of atlanta
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u/justnana1 Feb 06 '25
For future immunizations, call your county health dept. Many do them for free for un-insured or underinsured.
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u/Soft_Plastic_1742 Feb 06 '25
I don’t understand why you’re self-paying for well baby exams. Those are free with any insurance.
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u/Many-Intern-4595 Feb 07 '25
OP currently doesn’t have insurance
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u/Soft_Plastic_1742 Feb 08 '25
They seem to be taking about selfpay versus insurance costs. Are we sure they don’t have insurance?
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u/Many-Intern-4595 Feb 09 '25
First bullet point under #4 in the main post (sorry can’t copy paste, I’m on mobile)
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u/Soft_Plastic_1742 Feb 09 '25
Ahh. I just read the billet but not any of the sub points. Because yes, vaccines are free for kiddos. (Well except maybe RSV 😕)
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u/nmdnyc Feb 06 '25
I would bet that was just the cost of the office visit. The vaccines were most likely covered by government programs — either VFC or Chip — both of which will likely be cancelled in the near future.
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u/rothc3 Feb 06 '25
This. I just wanted to add that different providers have different self-pay rates. Some are less than the insurance negotiated rate, some are not. I learned this the hard way through having TERRIBLE insurance that basically no provider accepted. It was BCBS but they did not take the plan. I negotiated with each of my providers between paying out of pocket for the self-pay rate or cash for the negotiated BCBS rate.
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u/threecolorable Feb 09 '25
Yeah, I think it depends a lot on the type of visit.
The insurance discount for a cardiology office visit was 25%, but my insurance discount for 2 weeks of heart monitoring was 95% (and it was fully covered by the insurance—I just noticed the discount because I’m nosy and read the claims documents even if they got approved)
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u/SteakNotCake Feb 06 '25 edited Feb 06 '25
Just a heads up too since you’re in Atl and have access to CHOA, their financial assistance rates are amazing!. They will discount the hospital costs (for ER visits) but you still have to pay a separate physicians bill that is billed through their physicians group.
https://www.choa.org/patients/bills-and-insurance There’s a “Financial Assistance Policy” that highlights the above image in my first link and an application you need to fill out and provide the documents that are required. It was super easy and we saved $1100 for an ER visit. Our family of 4 had a HHI of $70ish-K that year. To get 100% discount the HHI can be up to $124k for a fam of 4.
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u/mcmaddie Feb 06 '25
I think a lot of people tend to forget about financial assistance. A local hospital to me provides assistance for a single person that makes up to 80k.
Even if it's 25% off at the end (sliding scale based on income) that's still worth taking if it's something you qualify for.
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Feb 06 '25
"High-deductible plans are a scam unless you have big medical expenses."
This. I have insurance. It basically does nothing. I need monthly medication to live, WITH inaurance it cost $1,460 per month.
With the help of a very patient Cvs tech we figures out that running the bill through GoodRX and not using insurance at all makes it cost $50.
$50. Its all a scam.
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u/babecafe Feb 06 '25
With this kind of pricing, your HD plan is doing exactly what it supposedly was intended to do: get patients to shop around and obtain the lowest possible pricing for everything medical short of a catastrophic medical emergency. But yes, the downfall of these plans is that they somehow fail to negotiate better pricing. Drug pricing is particularly problematic, as insurers are getting rebate payments from drug manufacturers and managing to keep these rebates for themselves instead of using them to lower patient prices.
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u/vintageblackkatt Feb 06 '25
Pharm tech here, CVS is just expensive too. I used to work for a PBM (pharmacy benefit manager) and I had a patient who was willing to shell out 500$ for their medication even though they didn't have the money.
I said, "Hold on, lets shop around," so I put them into a few places and I still didnt like the price. Last resort, I used Mark Cuban Cost pharmacy. It came down to 20$ with their preferred NDC. I about fell out of my chair. CVS @ 500$ vs MCC @ 20$. Same exact medication just different manufacturer.
When in doubt get on the phone and ask insurance/pbm to shop around for you. If they say, "they don't do that" they are lying or you are talking to the wrong department. Request a supervisor. Never except the first price unless you are okay with it. (To clarify, your retail pharmacy level can't check what the price would be at a different chain. So you would have to call in to the PBM/insurance which is significantly easier than bringing a script around, waiting for it to be processed, only to be told it's even crazier.)
The one thing I will say when you use goodrx, (in the 1000$ a month for mediciaton case this is moot), it doesn't pay down your insurance deductible. When they run it through goodrx it doesn't mirror in the insurance. Even running with COB or Care of Benefits, which is when they run youf insurance with a manufacturer coupon, goodrx is singular in billing.
Also protip, google your medication with "manufactuerer coupon" this is a life saver. Especially for folks who are taking injectables like Dupixent, they have dupixent my way for patients to get it for free. So there are avenues but you the patient have to know them or get lucky and have someone willing to work this out with you.
Another protip I thought, double check your labels on your pharmacy med bags. If your medications are suddenly high there is a good chance it was ran as cash. So check your bags.
Hope this is helpful.
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u/KeniLF Feb 06 '25
This is very helpful!
You mention "insurance/PBM" to help shop around. Do you mean that most insurance plans (maybe all) have a department/area that is supposed to help shop around for medicine costs?
I do understand that you are indicating that major drug stores can check for different pricing within their chain.
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u/vintageblackkatt Feb 06 '25
Yes, technically they can. Whether your insurance uses a PBM is a variable for sure. Unfortunately every insurance has different moving parts. So no, not all will have a PBM, but it is important to find what tools you do have to use. Now if you called in and said I want to talk to the pricing department you wouldn't get anywhere.
Its best to either start in the pharmacy customer service or get to a patient customer service that will route you to a representative that can do something like that.
Now with all in mind, the huge caveat is your insurance. Knowing your tier and formulary is key. Weightloss meds for example can be completely exempt from the formulary. So even with a prior authorization the insurace WILL NOT cover it. (I use caps because patients often get confused.) You can request your formulary or ask if a medication is covered with your insurance/pbm. Technically...your doctor should do that when prescribing. Would save a lot of time for the patient in my opinion. Also save on a lot of prior auth paper work. (Grumblings of a pharmacy technician)
That is correct, CVS at the store level can only check pricing with in its own intranet. That doesnt mean they can't mess with NDC's (product numbers) or forms of billing like goodrx for example to get lower prices. But they can't tell you if Walgreens is cheaper at a store level.
I hope that clarifys a little more. If it doesn't let me know and I can try to reword it in a way that is easier to understand. I know when speaking of entities can be confusing when you don't understand the working parts.
Any good tech understands that if the therapy isn't affordable the patient won't take as directed. There will be huge gaps and the efficacy of the therapy will drop significantly. If the therapy is affordable, the patient has a higher percentage of taking the medication as directed and results in a healthy patient outcome. My goal is always trying to get as close to free as possible so the health patient outcome is satisified.
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u/TomBakerFTW Feb 06 '25
When in doubt get on the phone and ask insurance/pbm to shop around for you.
I haven't been able to talk to anyone at my insurance company since my plan started this year. I've never heard of a PBM, are they independent of my insurer, or is this a 3rd party I need to seek out?
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u/vintageblackkatt Feb 07 '25
They are 3rd party. But your insurer should have the information of the PBM too.
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u/JohnRoberts90 Feb 06 '25
holy f$*#. truly insane
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u/w_v Feb 06 '25
Why is this insane?
As someone already pointed out: The person with chronic illness that you’re responding to is not “getting out of a scam” or “going around the system.”
The whole point of HD plans is to encourage patients to do exactly what this person did.
Remember: the concept of insurance only works for unforeseen, unpreventable, rare catastrophic events.
Insurance as a concept falls apart if you’re trying to use that system for chronic, predictable events.
But Americans hate socialism. So High Deductible plans were designed precisely to encourage patients to shop around and stop trying to use their catastrophic coverage for chronic, everyday things.
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u/JohnRoberts90 Feb 06 '25
The issue isn’t high-deductible plans—it’s a broken system where insurance inflates costs while cash prices are cheaper. That’s not how insurance is supposed to work —that’s a scam.
Insurance should cover catastrophic events, sure—but why does a $50 GoodRX price become $1,460 with insurance? That’s price manipulation, not ‘patient incentives.
And HDHPs weren’t some free-market solution. Obamacare helped create this mess by forcing bloated plans while limiting real choices. This is a failure of government interference, not a reason for more of it
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u/K_act_cats1 Feb 06 '25
So while I 100% agree with your point that the system is a scam, you’re blaming the insurance company for getting charged a higher price by providers. The provider controls the price they charge. Blame the provider for not charging $100 to insurance and then getting $50 after the insurance’s 50% discount.
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u/w_v Feb 06 '25 edited Feb 06 '25
You think the insurance company “decides” to pay providers that much?
Do you go to the store and “decide” to pay 20$ for something that costs 1$?
No, the provider, the hospital, the doctor, the pharmacy company, they are the ones who decide how much to charge insurance pools. And some companies have certain deals that aren’t available to others. Kinda fucked up, right? Doesn’t seem very fair.
And every time insurance pools try to negotiate or strong-arm providers to lower their exorbitant prices, everyone freaks out.
Remember the Anthem/Blue Shield anesthesiologist fiasco last month?Patients defended the price gougers against the insurance companies who were trying to make things cheaper for patients! CLOWN WORLD.
Also, FYI, GoodRX offers coupons and lower prices for some drugs because they’re a tech company that sells ads and an app. But it’s no replacement for actual health coverage.
But cuz you get cheaper prescription you probably don’t care that you’re fueling an ad-selling, info-sharing, tech corp.
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u/K_act_cats1 Feb 06 '25
Which is crazy. Among the single payer discussion, people don’t seem to realize that unless the government would drastically lower what the provider charges, the cost for the vast majority of people will be exactly the same. And providers ALL say they can’t stay a float with Medicare/medicaid reimbursement and a ton are dropping the government programs.
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u/w_v Feb 06 '25
Yep. People need to get it in their heads that “pay every claim” is not a viable strategy for private AND public insurance.
It’s the reason why the “Death Panels” meme was so successful against single-payer. I guess it’s more palatable for an “evil private insurance” to deny a health claim than for a government worker to deny a health claim.
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u/barrnowl42 Feb 06 '25
The doctors are not the ones at fault here. It's the for - profit hospitals and other health care groups. I'm sure there are some exceptions, but generally doctors and others just want to get paid reasonably while the companies are looking for any way possible to increase revenue while decreasing costs.
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u/w_v Feb 06 '25
I used to believe in that and then I followed everything anesthesiologists and their association were saying about Anthem finally doing something about the rampant and fraudulent overcharging many of them do.
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u/hbk314 Feb 07 '25
It all comes down to how high the deductible is and how much you use it. HDHPs generally are best for people who know they're going to hit their max or are barely going to use it.
For me, my deductible and OOP max are both $2500, so I spend $2500 and I'm done. I'm able to max out my HSA (with $750 from my employer) and pay out of pocket for expenses so the HSA money stays invested. I have all the receipts uploaded to cash out at any point in the future.
I pay about $550 in premiums a year. If I had the normal HMO, I'd be paying around $1400 for a $1250 OOP max. I'm someone who's going to max out regardless, so it's easy math to do the HDHP, especially with the HSA invested.
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u/Ok-Lion-2789 Feb 06 '25
If you use your insurance, regardless of your plan type, it doesn’t make sense to self pay. I have a few health conditions and always hit my out of pocket, so it makes more sense for everything to count towards my insurance. I have a high deductible and it’s actually a better option for me than the other plan my company offers because of the HSA. Further my company contributes about 80% of the deductible.
Self pay may still be a good option for some people and if you only need healthcare once a year, then I completely agree with you. It’s really case by case though.
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u/LaRealiteInconnue Feb 06 '25
my company contributes about 80% of the deductible.
I feel like this is the biggest reason for your logic here
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u/Ok-Lion-2789 Feb 06 '25
Not really. I would hit my out of pocket max anyway. It would end up costing me more if I didn’t use my insurance.
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u/Ok-Lion-2789 Feb 06 '25
Why was this downvoted? I have way more health bills than I can count. If I did all self pay, I’d end up spending more than using my insurance. My prescriptions along would bankrupt me. I’m not saying this isn’t an approach for most people and if it is for you, consider yourself lucky to not need tons of healthcare. Some of aren’t so fortunate.
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u/JohnRoberts90 Feb 06 '25 edited Feb 06 '25
Yeah I should’ve clarified that I’m self employed. if you’re on an employer sponsored plan it may make more sense for you to run through insurance since the deductibles, out of pocket max, and HSA are more likely to be subsidized.
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u/STEMpsych Feb 06 '25
Self-employment doesn't change anything. I'm self-employed, and have even done the HDHP+HSA thing. I say this as someone who is keen on using self-pay to resolve gnarly situations myself: if you don't go through your insurance, it doesn't count towards your deductible. If you're not careful, you can effectively double your out-of-pocket expenses for a year.
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u/justdrowsin Feb 06 '25
Hmm.. I used to pay $2,550 per month for my family plan with a $20,000 out of pocket annual.
I'd happily pay cash.
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u/Aggravating-Wind6387 Feb 06 '25
Separate fees for radiologist interpretation of an x ray is nothing new. It's gone in for decades.
When you call a children's hospital, you are calling a specialty hospital with all the modifications of the facility, specialized staff training for pediatric patients and equipment. When you go to a standard hospital you get billed close to the standard rates for facilities. If you go to a walk in radiology facility. It's way cheaper. Walk in radiology has a smaller footprint, less staff, less costs dur not paying, linen, central supply, oxygen or supporting an emergency room or a incomprehensible amount of uncompensated care from insurance and patients.
Then one person takes the xray (technical component) they are educated on how to position fir the film, how much radiation is needed and so on. Next is professional done by a doctor whose training is to read the film which is anything from soft tissue to bone to foreign objects.
It's not cheap. The largest driver of cost is maintaining equipment so you don't get too much radiation, and there are horror stories out there on what happens. Then has to be the uncomprnsated care.
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u/Acrobatic-Water-157 Feb 06 '25
In November 2023 I got a colonoscopy and endoscopy in Central Texas. I had private insurance, but I realized that I would need to pay approximately $7000, once I met the deductible and paid 20% of the rest. The self-pay option was $1900. It was a wonderful experience because I knew exactly what I had to pay, I paid before the procedure, and then it was all done and I didn’t have to worry about phantom bills. So yes, looking into self-pay for procedures is worth it!
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Feb 06 '25
Seems we have reached the endgame for insurers. Take premiums but make the process so onerous that people don't use insurance.
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u/K_act_cats1 Feb 06 '25
Why is this on the insurer? The provider is charging insurance $10K while they could obviously take $1,900. It would even be reasonable to charge $2,500 due to needing to file with insurance and the extra work. But no, they need to charge 5x the cost.
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u/fezha Feb 06 '25
Every medical facility by federal law must have a cash/self pay price. Even surgeons office have it.
You can call and ask "What is the cash/self pay price for X?"
And yes, you can transfer your referral to any other provider/facility you want. It's called shopping around.
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Feb 06 '25
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u/JohnRoberts90 Feb 06 '25
Good points! I did consider that, but Northside is still a major hospital with a lot of experience in pediatric imaging. If the X-ray was positioned well and read by a board-certified radiologist, it should still be pretty accurate. I’d definitely follow up if the results were unclear, but from everything I’ve seen, there’s no real downside unless the scan itself was poor quality. Have you seen cases where a children’s hospital caught something a general hospital missed?
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u/JessterJo Feb 06 '25
If a provider is contracted with your insurance, they're obligated by the contract to bill the insurance for services. If they don't, they're in breach of contract and can end up losing it entirely.
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u/10MileHike Feb 06 '25
Where I live, in a not large town, at least one of the walk in clinics have x ray machines, as well as MRI and CT scanners. There are also 2 "independent" places that do xrays, mri and CT scans as welll, other than the 2 local hospitals.
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u/JohnRoberts90 Feb 06 '25
nice. yeah, this was a bit harder to hunt down even in a big city cause i was trying to get imaging for a 4 month old
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u/10MileHike Feb 06 '25
Yes, that is probably a lot harder and I see why you used the facilities you did. Glad you got it done and for reasonable, too. I'm sure your advice helped a lot of people.
Was just posting that for future reference in case anyone thought they had to use a hospital if they weren't infants.
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u/kirpants Feb 06 '25
Anything done at a hospital will have a bill for the facility use and the doctors charges. It isn't limited to xrays. It can be an office visit all the way up to surgery. I agree with everything else you mentioned but wanted to also include all other services. The hospital itself gets paid to perform the xray and then the doctor has to read it, thus the second bill.
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u/LivingTheBoringLife Feb 06 '25
Ya! Found this out myself here in Houston.
Major hospitals wanted several thousand for an ultrasound of my neck. Called independent places and paid $200.
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u/Designer-Contract852 Feb 06 '25
Yes, I was for a time without insurance. Anything I needed done at a hospital, I would tell them I was self pay and ask for a discount. My husband had to go to the er for chestpains . The bill was huge. He called and asked for a self pay discount and the bill was lowered to like $300. The price would be low and affordable. It usually doesn't work for normal doctors visits.
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Feb 06 '25
[deleted]
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u/BigTheme989 Feb 07 '25
Can you use your HSA from your employer to do self pay? I'm asking because I am going to go to a HDHP in < week.
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u/LegWorried4639 Feb 06 '25
For basic X-rays another good option is an Urgent Care center that is not affiliated with any doctor or hospital, such as Medac or ClearChoice. Two of my kids have had broken bones x-rayed for $25. They don’t treat the broken bones if casting is needed, but you can take the x-rays they give you to your ortho.
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u/upnorth77 Feb 06 '25 edited Feb 06 '25
If you have imaging done at a hospital, you'll get billed for the technical (equipment, technologist, etc) and professional (radiologist - typically a third party) components. If you are in a larger market, and have access to standalone imaging centers, their rates are typically all-inclusive. I do take issue with your point 12. If you have insurance and don't hit your deductible, you're still paying the contracted rate, not the full charge. 13 is a point many people don't realize, most hospitals have it built into their contracts with insurers that if the hospital knows the patient has insurance, they have to submit the bill to that insurance. If the hospital fails to do this, they are in breach of their contract with the insurer.
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u/STxFarmer Feb 06 '25
Did the same thing with a colonoscopy a few years back. Insurance deductible is high so I paid cash and got deep discounts. But it took some calling to find the right doctor and they gave me the name of the place to get the procedure at for the lowest cost.
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u/JustTheTrueFacts Feb 06 '25
Hospitals are required to publish their prices for standard procedures, but they don't necessarily have to make it easy to find. Search for "price transparency" to find it.
For example, for that hospital, use their online price estimating tool to quickly find the cost of a procedure.
The tools shows a $245 total cost for X-Ray of both hips, not sure why you were charged a different price. Maybe your procedure code was different?
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u/dboytim Feb 06 '25
Good summary. One caveat - high deductible aren't necessarily a scam. Let me explain...
At my last job, they had 3 plans available. I ran the numbers, made some graphs, and found that NO MATTER what you spend a year on medical, the HDHP was the cheapest option. If you spent absolutely nothing, you obviously saved since your premiums were lower. If you spent anything, that was still ok since the difference in premiums more than made up for the difference in deductible.
And then as a bonus, the smart play (which I told everyone to do) was to get the HDHP, and put the difference in premiums into an HSA.
(I did so much sharing my graphs and info with people throughout the company that HR called me in because they were worried about getting in trouble because I was giving insurance advice and none of us were licensed insurance brokers or advisors. I told them to pound sand; I was sharing facts and explaining things and people could choose whatever they wanted. The terrible HR people we had wouldn't even explain to anyone why they'd want any of the plans... I directly asked them why the middle plan existed at all and they said it was to meet some requirement for people planning to retire soon and change to medicare. I asked if they told literally anyone that and they said no. I want to rip their hair out because they were so terrible at their jobs....)
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u/JaySuds Feb 06 '25
It’s very likely that if you used your insurance, the contracted rate with the insurance company would have been under $200 for the x-ray and radiologist and this would have gone against your deductible.
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u/essxjay Feb 06 '25
Cash pay was just a fact of life for me pre ACA so got used to shopping around for imaging and lab services, applying to Rx assistance programs, utilizing very low cost community counseling through at a local university and attending first-come first-served mass health care/wellness events for immunizations and basic dentistry.
Five years ago when I got on my employer's sponsored PPO plan, my oop for anything other than PCP visits and one critical daily Rx was appalling. Co-insurance in particular is such bullshit. I learned the hard way not to talk about any concerns I had when booking preventive care appointments.
OP, you've done a great service to our community by spelling out how to push back on the medical insurance complex and beat it. 🙌
I've seen a few other threads describing how leverage chatgpt to successfully appeal denials. I'm thinking there's a good wiki project here.
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u/HealthLawyer123 Feb 06 '25
Have you looked into getting your kids on Medicaid if you don’t have insurance?
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u/JohnRoberts90 Feb 06 '25
I make too much. My marketplace plan kicks in March 1, wife just quit her w2 job to stay at home w the kid. I’m self employed.
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u/trikaren Feb 06 '25
Even if you get a self pay quote, they might try to charge you a different amount. That happened to me at Emory Midtown (Atlanta), and I had to insist that I would only pay the self pay quoted amount. This was for a CT Calcium score.
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u/katie_cat22 Feb 06 '25
Useful information, indeed! As someone who worked in registration for a long time, I’d like to point out that quite often people will say they are self pay and are given the discount. Only to magically produce insurance that the provider is contracted under many months later, which we are required to bill and by then it’s beyond filing and has to be written off and the members money refunded if they even paid in the first place.
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u/MissedAdventure92 Feb 06 '25
I had to do this exact same thing for a hip x-ray! I hope you got good results. My baby did not have hip dysplasia, and I was happy to get it checked out. But at the same time, I was pissed that I had to jump through so many hoops. The pediatrician recommended us to a hospital chain that I won't use under any circumstances. I knew we'd be charged $1,000+ with our high deductible plan because we had been to these facilities before hence why I'll never use them again. I shopped around and ended up getting the x-ray done for $170. The receptionist was really snippy when I asked them to send the referral to another place, but I literally did not give a shit. I'm not paying $1,000+ because a fax is inconvenient to you. I HATE the United States healthcare and insurance system.
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u/gxbcab Feb 06 '25
Have you looked into peachcare? Your kid might qualify since your wife isn’t working.
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u/JohnRoberts90 Feb 06 '25
Thanks, I earn too much though. Just waiting for my marketplace plan to kick in March 1 right now
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u/MrsSandler Feb 06 '25
Good job doing the legwork!
Never go to hospitals for xrays, scans, lab work, etc. if you can help it. Log into your insurance provider (ex. Myuhc.com)and look up the test. Then go to "change my provider" to see the cost for each provider in your area. I just got a CT for $322 at an imaging center that the hospital wanted $2k to do.
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u/Maleficent-Pie9287 Feb 06 '25
This all applies with pets too, although not quite as complicated. Experienced a similar situation with my dog recently. My vet quoted me $4500 and with a little research and calling around, I found a reputable animal hospital that charged $700 for the same procedure.
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u/Shadow1787 Feb 06 '25
My parents switched vets bc of this. My old beagle used to get hematomas all the time bc he had long basset hound ears. One place charged $1300 to drain his ear to look perfectly. When the next ear came up they took him to another vet who did it for $200 and his ear was just alittle bit wrinkly. It was a 9 flyer old beagle he ain’t in a beauty contest.
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u/SkyTrees5809 Feb 06 '25
An additional tip: if X-rays are being done for orthopedic reasons, they can often be done in the orthopedic surgeon's office and/or read by the surgeon. They all read X-rays. Check their pricing as well.
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u/charipepper Feb 06 '25
Thank you so much for sharing this valuable information. Health insurance’s nowadays are very outrageous with high deductibles combination.
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u/WorldlyLavishness Feb 06 '25
I found all this out the hard way. I have to get an mri every year and one year I got a huge bill bc I used my insurance instead of self pay. This year I had a baby in January so we hit our oop max already so yea... gonna run it through insurance this year lol but yes good tips. It's ridiculous the amount of work we have to go through to get healthcare.
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u/zesteroflimes Feb 06 '25
We should change "healthcare" in the USA to "healthobstacle" because having to do all of this for your newborn so that your payment is affordable is insane.
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u/TerribleTodd60 Feb 07 '25
What a great post!, My wife needed an MRI. Her doctor recommended the hospital and they wanted $1000 out of my pocket to do the MRI. Called around, found a non hospital affiliated imaging place that could do it for $312 out of my pocket. So much cheaper
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u/cynicpaige Feb 07 '25
You can shop around if you get an imaging order. You can take it anywhere. Had to get an MRI a few years ago and the hospital I was referred to by my podiatrist said it would be $1000. I looked around and learned if you have the order you can take it with you, you don't need to go to the place the prescriber referred you to. Went to an independent imaging center and paid $600. Not cheap, but $400 less.
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u/cballowe Feb 07 '25
Random question - did you call any specialist imaging centers or just hospitals? I've heard that the places that just do imaging can be much less expensive than hospitals. The fact that they're only handling diagnostic care can make things like their insurance and other overhead much less expensive - at least that's the theory. I've luckily never been in a position to find out.
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u/Upbeat-Reflection171 Feb 07 '25
If you apply for charity care and are accepted, you will pay zero.
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u/Hot_Issue_8777 Feb 07 '25
I got a $1200 PT bill for 8 sessions, with the “platinum” employer sponsored insurance plan. I called the PT office to negotiate and they said they could bring the bill down by AT LEAST half if I decided to self-pay instead.
On the other hand, I scheduled an MRI at an independent location and asked about self pay versus insurance. They quoted just over $1000 for self pay and $200 with insurance. 🤷🏻
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u/PharaohOfParrots Feb 07 '25
They have also financial assistance that could had potentially wiped your bill away if your family is below 600% of the FPL (which is generous).
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u/a-apl Feb 07 '25
Man, my kid got her hip ultrasound at CHOA and we were absolutely blindsided by the bill. Wish we knew this several years ago! If your kid ends up having hip dysplasia I’d be happy to chat if you want to know anything. I am a childhood hip dysplasia patient myself with a particularly bad case and experience while my daughter is a hip dysplasia patient with a particularly good case and experience!
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u/esptraces Feb 07 '25
This sounds similar to what I'm going thru for another procedure and calling several places as well as looking at online "transparent pricing" tools which are a joke.
Tons of bad information, including one billing lady telling me that if I said I was self pay but I have insurance id be committing insurance fraud and they don't do that. When I have an employer based insurance policy.
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u/thrilldigger Feb 07 '25
Please tell your doctor about the other hospital and how much you paid! Otherwise there's no feedback loop to correct your doctor's knowledge. Doctors can't easily find this info and rely on word of mouth to update their knowledge.
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u/DrMo-UC Feb 07 '25
The reason the cost of healthcare is expensive is because the real cost of care is not transparent. I'm glad that you found the cash pay option. I shared this with every one of my patients but I understand that it can be a tough scene to navigate.
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u/FigSpecific6210 Feb 08 '25
How many of these posts are you going to make? I knew I’d seen this before, and I just saw a similar story of a “guy cutting his chin skateboarding”. Found it: https://www.reddit.com/r/HospitalBills/s/mD8KrljBLr
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u/cernerburner2800 Feb 08 '25
Children’s hospitals are the absolutely most expensive place to obtain care. Source: Me, I worked in one and collaborated closely with the “revenue cycle” department. They have the leverage of being low in supply and high in demand. Most markets have only one children’s hospital.
Our local children’s hospital offers a 25% discount after your insurance pays if you pay your full balance. In this situation it can be helpful to use insurance. However, you have to call to get the offer. They do advertise that plainly on the bill, which is decent of them.
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u/VegetableKey1438 Feb 08 '25
As a cancer survivor who has saved thousands on treatment with this, ask if that have charity care. Because of the tobacco companies making cancer sticks they are obligated to donate to hospitals. If your bills are high they may be able to cut some of those fees/costs.
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u/ScaleNegative5697 Feb 08 '25
Thank you everyone for this valuable information!!!!!! I am most likely going to lose my insurance this year and I am 59 and am worried. I have 5 prescriptions and have had prostate cancer and had to have it removed in 2020. In 2023 I had to have 3 months proton therapy because my PSA detected it. Now PSA is 0. But for how many years? Just need more time. Getting older isn’t easier on the mind, for sure. Sorry to unload here, but feel a little better albeit temporarily.
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u/Lavaine170 Feb 09 '25
(hoping to find another that would do pediatric xrays)
I have never seen a hospital or private imaging clinic that didn't do pediatric xrays. Your pediatrician did you dirty (and likely gets a kickback from CHOA).
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u/Alexactly Feb 09 '25
Honestly, i kind of feel like we should stop going through insurance and start bullying hospitals into allowing us to pay by ourselves at the correct price. The only reason we have to pay so much is because insurance companies need to make money and hospitals know they can profit through insurance. It's all fraud and corrupt and until we start fighting it nothings going to change.
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u/JJ16v Feb 09 '25
That "free" in your countries uhh motto, does it mean free to fukking scam everybody? Or is it just free to scam the most neady?
Here you'll just go to a random hospital after having a referral from the GP and guess what you pay? 0 for kids under 18, max 385 for the whole year for yourself.
Sure I do pay a part of my salary to get and provide healthcare for me and others but at least no one here needs to go shopping for the "cheapest" price or even weigh whether they can pay this, making problems much worse or unfixable later.
Almost time to change that motto to "the land of the deluded"
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u/Low-Oven5189 Feb 12 '25
Thank you for this great writeup. I once stumbled on this when needing an MRI for my wife soon after we got married. I didn't have insurance, and my wife was visiting me from Canada. Hospital quoted a range of 5-7k. I called around and found a lab that would do it for $350. Insane.
A friend recently told me that the insurance company is actually paying the hospital/doctor that small fraction of the price, never the inflated price quoted. This is why the hospital is willing to offer you the discounted self-pay price, because THAT is the price insurance actually pays.
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u/randomusername1919 Feb 06 '25
Estimates are basically worthless. I had surgery a couple of years ago, estimate for my portion after insurance was $1600. Bill came, it was $4200. No explanation and they would never tell me what was included in the estimate. It was just over the phone, nothing written (except my notes). Ended up paying the $4200, but I have no idea why it was that much, even after an itemized bill. That bill had $1500 of anesthesia drugs listed, 2 or 3 dollars at a time. Just insane.
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u/moufette1 Feb 06 '25
I'm not sure I would use the word "scam" generally in relation to health insurance or health care in general. The problem is more that health care in general is probably not well suited to a pure capitalist approach in the purist classical (theoretical) sense. Insurance whether private or government will have distortions because health care is incredibly complex. I'm in favor of single payer just because it offers the most coverage at the least cost, but no plan is going to be perfect.
Health care providers of all kinds want to be paid and deserve to be paid. And because what they're doing is complex, takes years of training, and has literal life and death consequences of error paid a lot.
There are also costs that are beneficial, like research and development, that are hard to recover. They are also expensive because researchers may kiss many frogs before discovering the prince. And again, the consequences of failure are literally life and death. Google thalidomide and note how a lowly government bureaucrat saved lives in the US.
As consumers of health care, we really can't do an adequate job of deciding if Provider A or B is better or worse for cost/quality. Does Provider A have a higher death rate because they're bad or because they take sicker patients? Did Provider A cure your cancer because they're awesome or because they followed the science driven standard of care? In which case maybe cheaper Provider B would have been just fine.
In many cases you don't have time to research when you're having a stroke or bleeding out or having a heart attack minutes may count.
It's very complicated.
That said, I would trust non-profit, science driven (not profit driven) providers over others. I would trust a doctor more than an MBA.
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u/ruffznap Feb 06 '25 edited Feb 06 '25
They also required me to pay 85% up front.
This is the main kicker. Most places (at least in my experience) bill later. They definitely try really hard to get you to pay while there though, trying to get you to pay the full amount.
The big trick of paying lower medical bills is for the ones who don't require up-front payment. They'll ask you there to pay, decline. They'll send you a bill in the mail, ignore it. Same with the 2nd attempt in the mail. By the 3rd or sometimess 4th letter in the mail the bill will be notably reduced. AND you can also call and say you can only pay so much of it, and that can get you bill down even further.
I've always handled medical bills this way, and almost always pay half of what the original bill was at least (even before calling to ask for a reduced bill/that I can only pay so much).
The last time I did it, I got the reduced bill in the mail by the 4th attempt, then also called and said I could only pay half of it, and they accepted and the bill was payed. So that got an originally like $1k bill down to $600 by that 4th attempt, then down to $300 after asking for a reduced payment.
Edit: In case anyone's worried about credit being affected, I've done this a ton of times, and it's never gotten to the point of affecting credit at all. Eventually, sure, it will, but even if it's their 4th or 5th attempt mailing the bill and that 4th or 5th time are bills from a collection company instead, it still won't affect your credit if you pay soon-ish after the collection company asks you to pay (usually a much reduced bill at that point).
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u/BigTheme989 Feb 07 '25
Going into a HDHP in a few days, I'm appreciative of all of the tricks this thread is teaching me to screw them over.
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u/ruffznap Feb 07 '25
Happy to help, it’s sad how many people think they HAVE to pay right then when they give you a bill. They make so much money off of people falling for that
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u/peasuspendedinjello Feb 06 '25
I think healthcare providers have to offer a self-pay price, but it must be higher than the smallest contracted insurance fee. So if a doctor is contracted is UnitedHealthcare, and the contract price for an xray is $125, the smallest self-pay deal must be more than $125.
Hopefully an expert in this area will correct me here.
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u/sheik482 Feb 06 '25
Do you know if you can submit your self pay amount to insurance and have your deductible reduced by the amount you paid?
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Feb 06 '25
[deleted]
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u/sheik482 Feb 06 '25
Interesting, so when self paying, it's to your advantage to go to an out of network facility.
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u/dehydratedsilica Feb 07 '25
TX and TN have recent (within 2 years) laws that apparently allow this. I don't know anything about the details of how it works though.
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u/sirchadwick1 Mar 11 '25
CHOA has been a Godsend for us. Always always check their financial assistance options! Typically if your income is 4x the poverty level or less, they will cover your full bill. For a family of 4, if you bring in $120k or less, you can have your bills covered. Even a family that makes $180k+ a year can get 50% off their bills simply by applying.
Both of my children have a blood disease so we are constantly getting urgent care and ER visits and this has been a blessing and made life much more manageable. The process is fairly simple and each time I have been approved within 2 weeks.
I'm bringing this up because a lot of people I talk with don't know this and fight battles with their bills that are exhausting and the CHOA billing team doesn't typically advertise the financial aid process. Generally people think they make too much money and will never apply, but CHOA is generous when it comes to helping out, especially larger families. We don't go anywhere else at this point, straight to the ER for care. Best of luck to all of you and your little ones!
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