I am retired military and have Tricare Prime. My surgery bill came to $45K and Tricare "allowed" $5,362 and that was on one single line item listed as "Medical".
Certainly medical care is inflated, but to only pay 11% of a bill seems absurd.
How does this work?

45K for Shoulder surgery sounds more than inflated.

I had subacromial recision surgery and a partially torn cuff repair a couple of years ago and the entire bill was 13K.

Might want to challenge the bill as well as the coverage amount.

My shoulder surgery was $30K. I don’t remember how much I had to pay.

I broke my shoulder in October, my surgery was 42k

quote:

I am retired military and have Tricare Prime. My surgery bill came to $45K and Tricare "allowed" $5,362 and that was on one single line item listed as "Medical".
Certainly medical care is inflated, but to only pay 11% of a bill seems absurd.
How does this work?

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It is complicated. Insurance companies negotiate rates with hospitals and doctors. If they are participating the doctor and hospital agree to discounted rates, which is generally the allowed rate. You are responsible for a portion of the allowed amount. Many doctors will not accept Tricare because their rates are low and tied to the Medicare rate. There should be a notation on the bill as to your financial responsibilty. If you feel that is unreasonable you can ask for an itemized bill.

$60. I’m certainly happy about that.

OR rental.
Dr.
OR nurses
Anesthesiologist
X-ray guy
Building charge...
Etc...

Trust me a bean count er can turn a five minutes visit into a few grand pretty quick...45K sounds about right

That’s what the poor bastard would owe if he didn’t have ins.

quote:

Originally posted by Graniteguy:
45K for Shoulder surgery sounds more than inflated.

I had subacromial recision surgery and a partially torn cuff repair a couple of years ago and the entire bill was 13K.

Might want to challenge the bill as well as the coverage amount.

I had a complete shoulder replacement many years ago due to a traumatic injury and it was way more than that.

I have a company do my billing, so I am not an expert but.....If you bill 10k and the insurance company will only pay 1k then fine you negotiate the in network fee and move on, BUT if they will pay 10k and you only bill 1k then you only get 1k. It is an effort to capture as much of the insurance as possible.

The "allowed amount" on your EOB is the amount that insurance agrees to pay and that amount often is drastically lower than the "billed" amount. Then you pay whatever your benefit agreement shows. In our case that is ten percent copay so what you see is not unusual at all assuming yearly deducible has been met. Prices on surgery vary a lot depending on what surgery is done, how much staff are involved, and how long it takes. Wife had foot surgery and got a separate bill from the doctor that did the surgery and another from the anesthesiologist. Then the hospital sent another bill for outpatient surgery that was quite a bit more than included use of operating room, recovery room, drugs, supplies, etc.

NO experience with Tricare, however the process may be similar enough to restate what others are saying.

Get detailed billing, and then ask Ins for detailed explanation. You may have in network / or out of network %, you may have limitations and deductibles. If the covered part is 15K and you have a 10K deductible it will suck but it is the beginning of the explanation. You may also have things from hospital coded incorrectly ect excluding coverage by mistake. Not everything will make sense, but nothing will make sense till you see details from both sides.

Edit added. I have had providers show me a statement of my portion of expected bill. Did you see and sign this?

I recently had a 8mm kidney stone try to pass, emergency room visit followed by surgery to break it up. $30K bill about blew my mind! PTL, I am on Medicare, our share is 8% of the total inflated heart attack in a envelope.

Wife had surgery lately and just received statements from medicare. About 60 pages of bills including some time in rehab and ambulance charges. What a nightmare.

quote:

Originally posted by TRshootem:
I recently had a 8mm kidney stone try to pass, emergency room visit followed by surgery to break it up. $30K bill about blew my mind! PTL, I am on Medicare, our share is 8% of the total inflated heart attack in a envelope.

Wow! Thanks for the reminder to drink more water!

This past November some power-swimming resulted in severe limitation of movement in my right shoulder and I feared the worse. Total out-of-pocket is $8,000 but that is for "covered services". So in an emergency, a non-covered part of a hospital team could administer to me and bill separately. Thanks for the wake-up call. It's high time I figured out exactly what my plan is.

quote:

Originally posted by Graniteguy:
45K for Shoulder surgery sounds more than inflated.

Although a little high, not so much.

Consider this, the average knee replacement runs about 50K. The shoulder is a much more complex joint. All depends on what they found in there, what they had to do, and how long it took.

I'm not surprised at all to see a bill that high.

For comparison, the total bill for my ankle replacement was $104,000.

My first shoulder surgery went well over 100k. This last one was about 45k as well. I really think that it really depends on what work is actually done and the time it took to do it. Insurance rates vary, but I'd imagine most are fairly similar.

While each situation is different, in my discussions with Tricare related to my late wife's medical expenses, Tricare stated that they negotiate rates with hospitals which the hospital must honor. This sounds like "balance billing" which may not be allowed under the terms of the hospital's contract with Tricare. Recommend contacting Tricare, if you have not already done so, to discuss your situation; Tricare may be in your corner.