Inpatient Vs Outpatient Hospital Stay

My daughter had been suffering from sleep apnea (a very scary ordeal for a parent) for several months and it had gotten severe enough that we decided to have her tonsils and annoids removed several weeks ago. Lucky the surgery was a complete success and within hours of the operation my daughter was able to sleep very peacefully with no sleep apnea. It took a couple weeks for her to fully recover, but she is now 100%.

Since my daughter was so young (2years old), she had to stay at the hospital for a 24hr observation period after the surgery to ensure there were not any unidentified complications. We stayed in the hospital overnight and were released the next day.

I didn't give much thought to the costs of the surgery until all the paperwork started flowing in. The first unexpected surprise was before the surgery, during the registration process, we had to pay the hospital the estimated co-pay of ~$1,650. I was surprised both that we had to pay before the surgery and that the amount was so high. After the surgery I got hit with additional bills from the surgeon, anesthesiologist, pathology, etc. Here is the full list of line item charges from the surgery:

Tonsillectomy Surgery Costs Summary

Description

Charged

Ins. Discount

Ins. Paid

We Paid

Operating Room Services

$ 11,136.00

$ 5,189.38

$4,459.97

$ 1,486.65

Histology

$ 608.00

$ 283.33

$ 259.74

$ 64.93

Pharmacy

$ 80.70

$ 37.61

$ 32.32

$ 10.77

Anesthesia

$ 763.00

$ 355.56

$ 305.58

$ 101.86

Self Admin Drugs no coding

$ 114.30

$ 53.26

$ 45.78

$ 15.26

Recovery Room

$ 1,094.00

$ 509.80

$ 438.15

$ 146.05

Surgeon

$ 847.00

$ 387.36

$ 459.64

$ -

Anesthologist

$ 1,240.00

$ 248.00

$ 744.00

$ 248.00

Pathologist

$ 184.00

$ 27.60

$ 125.12

$ 31.28

Totals

$ 16,067.00

$ 7,091.90

$6,870.30

$ 2,104.80

What shocked me once I sat down with all this was how much my out of pocket costs were. My family is on the most restrictive, highest premium plan offered by my employer that generally has the most benefit coverage. I went back to verify our coverage and our insurance plan summary states that our co-pay for an inpatient hospital stay is $581 which didn't add up.

After a bit of research online it turns out that I missed an important classification: inpatient vs outpatient surgery. Even though my daughter was in the hospital for 24hours, she technically was considered outpatient and as a result our insurance coverage was for an outpatient surgery in which our co-pay is 25% of the cost. Yikes! I had assumed since she was admitted to the hospital overnight that was considered inpatient. Seems a bit backwards from a financial perspective - it looks like I have an incentive from an insurance perspective (higher coverage) to request inpatient hospital visits although I would think this is generally a more costly claim for the insurance company.

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Comments (5)


sickening ...

sounds about right --- you would have still been hit with the above charges, even if it ended up being an inpatient stay - except you would have added the cost of the inpatient stay to the outpatient procedure... they aren't bundled together...

isn't it crazy that it costs 8k for tonsils to be removed?

Wow, sorry to hear about all those costs 2million! What a bummer. But so glad to hear your daughter is doing much better and that's the most important thing.

I will have a baby next June and kind of frightened of all the medical bills, etc.

Another reason why IBM stinks.

I think even if you have requested the admission to be inpatient, if the criteria are not met for inpatient stay, insurance company has the right to deny the costs.

In the whole scenario, I am glad your daughter sleeps more peacefully now. Hope the Best.

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