Impatient

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Your mammogram's hefty price tag, explained

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As part of #PriceCheck, we're trying to bring greater transparency to medical costs by asking you to tell us how much certain medical procedures cost. We received a number of responses to our request for mammogram prices.

We found that across the Los Angeles area, mammograms come with large price tags: Valley Breast Care and Women's Health Center in Van Nuys charges its privately insured patients $540 for a basic mammogram. At Cedars-Sinai Medical Center in Los Angeles, near Beverly Hills, the charged price is $519.

Charges 'don't make sense'

But Edward Prunchunas, the chief financial office at Cedars-Sinai, says these high sticker prices "really don’t make any sense." These charges are really just a starting point to negotiate discounts, he says.

"There's hardly anybody that gets anywhere near charges as payment from any insurer," says Prunchunas.

Dr. Thomas Lomis, medical director at Valley Breast Care, agrees.

"It's an unusual industry, where we don't get to charge what we think it's worth," he says.  "We have to accept what the payers want to pay."

Dylan Roby, with the UCLA Center for Health Policy Research, says that's where the difference between charges and prices comes into play.

"The price of the service is probably what a hospital is negotiating with each individual insurance company or payer," he says.

Roby says those negotiations between providers and private insurance companies are confidential.

Negotiating the price

Consider one medical bill submitted through our PriceCheck project: UCLA charged the woman's insurance company $630 for a basic mammogram. Her insurance company, Anthem Blue Cross, paid the hospital $318.

It's a bit of mystery how UCLA and Anthem agreed upon the price of $318. But officials at Cedars-Sinai described the variables they consider when negotiating a price with an insurer.

First of all, they tell us, the hospital needs to cover the cost of the staff who perform the mammogram, as well as the equipment they use.

The medical center also covers things that are totally unrelated to the mammogram, such as "all the techs and professionals you’re seeing during the scope of services," says Gretchen Case, a finance director at Cedars-Sinai. "You've got the bricks and mortar, the IT infrastructure, etc., the facilities. And then you have teaching and research that are also included in that."

Prunchunas, Cedars' CFO,  says there's yet another variable that factors into the hospital's final price: the need to offset the low-reimbursement rates it receives for its Medi-Cal and Medicare patients. And that's hard to itemize on a receipt.

"When we charge a commercial payer, 40 percent of what we charge... goes to cover those unpaid costs from other people," he says.

Valley Breast Care in Van Nuys uses a similar calculus, as about 80 percent of its patients are Medi-Cal, patients.

Price matters

Under the Affordable Care Act, most insurance companies are required to fully cover the cost of a mammogram.

So why do these high charges, and negotiated prices, matter?

They matter because the amount insurance companies pay for mammograms helps determine how much we all pay for insurance premiums, co-pays and deductibles. So while it might leave your head spinning, it’s nevertheless important to know how much mammograms – and other procedures – cost.

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