Question about cost of a biopsy

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Light Yagami

Light Yagami

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I recently had an EGD done with biopsy. The GI doc sent the biopsy specimen to an outside lab owned by a private group of pathologists.

I got the bill from the pathologist and it was for $2700. The insurance deducted/adjusted $500 of it and said I owe $2200. Was shocked when I received this bill as the entire cost of the office visits, actual EGD, and surgical center use to the GI doc was $1000. Owed the anesthesiologist $300. Pathologist bill was more than all others combined. Does anyone have an estimate what pathologists on average charge for this biopsy? Here is the line item what I was charged:

Level IV tissue exam: $2046 (- insurance adjustment $495). final owed: $1550
Tissue Stain I: $519 (no insurance adjustment)
Tissue Stain II: $121 (no insurance adjustment)

Thanks for any info on this.
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At the global 88305 CMS rate for 2017, that's 27 biopsies. I'm going to make the assumption that you didn't have 27 biopsies done. Perchance, do you live in the middle of nowhere and this is the only pathology group in the whole region?
 
I live in Orlando, FL and I assume there are lots of other pathologists in the region. I had one biopsy done. I didn't choose the pathologist. The GI doc selected the anesthesiologist and pathologist. I chose the GI doc that did the EGD.
 
Something's not right. Do you have your path report? Did they legitimately only do one biopsy of the esophagus, or did they biopsy duodenum, stomach, esophagus, etc? Either way there's NO way it should have come out to that amount. They're way overbilling, hoping to get less from insurance, and then expecting you to pick up the rest. Talk with your insurance and see what's going on, then you'll likely have to take it further from there. But don't pay that, or any of that. The amount they got from insurance sounds about right.
 
What ever the bill you should be able to settle it at near MC rates.
This could still be 250-750 depending on what they actually did.
 
They most likely did one biopsy each from proximal, mid, and distal esophagus. Then one each from Gastric antrum, body, and cardia. Performed upfront staining on all six(AB/PAS and H.Pylori immunostain). Made a diagnosis of mild reflux changes, and mild non specific chronic gartropathy(BS) to justify those stains. Then you get the bill you just mentioned. how do I know that!!
 
Yeah something's not right...don't pay it--$2046 charged for an 88305 is extortion, and if that's honestly what they charged for a solitary biopsy, I'd go ream out your GI doc for sending it to some yahoo that's charging $2k for an 88305. It's comical really.
 
Better report them to costhelper. Need more transparency websites out there, especially with people being on the hook for more and more nowadays.

How Much Does an EGD Cost? - CostHelper.com

Additional costs:
  • If it is necessary to take a biopsy, that would add a procedure cost and laboratory cost to the final bill. This could add as much as several thousand dollars to the cost. For example, at Good Samaritan Hospital in California, a biopsy adds $1,100-$4,800.
 
I will bet many of you posting don't have a clue on your own gross charges.
The interesting part to me is the insurance did not adjust or pay much.
 
AZpath said:
I will bet many of you posting don't have a clue on your own gross charges.
The interesting part to me is the insurance did not adjust or pay much.
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I know exactly how much we charge and how much CMS and BCBS/et al pay for our 88305s and it ain't nowhere near $2,046.
 
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These kind of bills are normal when GI groups have a TC-PC arrangement with big labs like Miraca, Quest etc or they hire a part time pathologist to read their slides.
 
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octopusprime said:
I know exactly how much we charge and how much CMS and BCBS/et al pay for our 88305s and it ain't nowhere near $2,046.
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I said charge not paid. We all pay to attention to net payment not the gross charges.
In this case most of the patient's cost did not get adjusted down very much by insurance.
Then it was moved to deductible/ patient responsibility.
 
The real problem in GI path is not what's charged vs what's paid, real problem is too many biopsies performed and almost every big lab or pod lab performing upfront staining on every specimen. Pretty soon everyone in great country of ours will have mild reflux changes, and mild chronic gastropathy.
 
You are correct. I had thought it was a solitary biopsy as I was only concerned about one and forgot the rest, but I dug up the path report and it turned out that it was those 6 biopsies you had mentioned. Is that a normal/justified bill for that amount or excessive? Regardless, I'm going to have to tell the office manager i'm a student and can't afford it and ask for the medicaid rate. If that doesn't work I'll have my dad, a retired IM doc, talk to the pathologist directly about the bill.

BTW, the one biopsy of concern was the one in the distal esophagus that he had diagnosed as Barrett's, which was shocking as I had been having esophageal pain from reflux for a few months when I was really stressed from CK studying. Never thought I could develop Barrett's. I gave my uncle, who has been a GI for 30+ years, the GI doc's procedure notes. My uncle said that it was basically worthless since it was not automated with a computer where the computer records the precise location of each biopsy sample, but rather a subjective assessment by the GI doc. My uncle said unscrupulous GI's can easily say that the z line was irregular and actually take a biopsy from the stomach and label it distal esophagus. Of course the path report will then say Barrett's and you've hooked a patient for EGD surveillance for life. A GI doc in his town had been doing that for many years whereby the state medical board and insurance regulators noticed that almost every patient in his practice had been eventually diagnosed with Barret's. The guy ended up losing his license permanently. My uncle said next year to get the repeat EGD done at a university affiliated hospital, where at least you know your getting an honest doctor.

Pathbusiness said:
They most likely did one biopsy each from proximal, mid, and distal esophagus. Then one each from Gastric antrum, body, and cardia. Performed upfront staining on all six(AB/PAS and H.Pylori immunostain). Made a diagnosis of mild reflux changes, and mild non specific chronic gartropathy(BS) to justify those stains. Then you get the bill you just mentioned. how do I know that!!
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Whenever we make a diagnosis of Barrett's we put a disclaimer note at the bottom that clinical correlation is needed regarded whether the biopsy was truly taken from the esophagus or the gastric cardia. There's no great way for us to tell histologically.
 
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Having been out of med school for >10 years now, I am increasingly wary of physician-owned facilities, which may include operating rooms, imaging, labs, etc. There are a lot of unethical doctors out there who think the world owes them a lavish lifestyle. And they will preserve their income at all costs.

Many of them are good, but many of them are not. How does a patient tell? It's hard enough for a doctor. A patient may go to one of these doctors and have a surgery recommended or a lot of imaging or testing, and just assume it's the right thing to do. They may not know or care about the physician's financial interest in doing that procedure.
 
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yaah said:
Having been out of med school for >10 years now, I am increasingly wary of physician-owned facilities, which may include operating rooms, imaging, labs, etc. There are a lot of unethical doctors out there who think the world owes them a lavish lifestyle. And they will preserve their income at all costs.

Many of them are good, but many of them are not. How does a patient tell? It's hard enough for a doctor. A patient may go to one of these doctors and have a surgery recommended or a lot of imaging or testing, and just assume it's the right thing to do. They may not know or care about the physician's financial interest in doing that procedure.
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Agreed. It's rampant. I know hospital administrators aren't exactly saints, but from my experience when you let doctors own all the means of production many take full advantage of it. The unfortunate side effect of fee-for-service - the more services you do, the more fees you collect. Not hard to see how human nature and greed would lead to over utilization of services. And unfortunately there isn't any good way for patients to have any idea about it, most just go and do what their doctor tells them to do, with no idea whether that doctor is ethical or not. Not sure why insurance companies don't have a better grasp of these things and can't spot patterns in over utilization. Maybe they'll figure it out at some point.
 
Tell the office manage that you are reporting this to CMS and make sure they are audited.
 
Light Yagami said:
I recently had an EGD done with biopsy. The GI doc sent the biopsy specimen to an outside lab owned by a private group of pathologists.

I got the bill from the pathologist and it was for $2700. The insurance deducted/adjusted $500 of it and said I owe $2200. Was shocked when I received this bill as the entire cost of the office visits, actual EGD, and surgical center use to the GI doc was $1000. Owed the anesthesiologist $300. Pathologist bill was more than all others combined. Does anyone have an estimate what pathologists on average charge for this biopsy? Here is the line item what I was charged:

Level IV tissue exam: $2046 (- insurance adjustment $495). final owed: $1550
Tissue Stain I: $519 (no insurance adjustment)
Tissue Stain II: $121 (no insurance adjustment)

Thanks for any info on this.
Click to expand...

You have two options: pay it or don't pay it :) If you don't pay it, the pathology group may send a collection agency after you; however, if you refuse to pay the bill, I highly doubt they will scar your credit history. It's a huge gamble, but it might work. If you do decide to pay the bill, I would call their billing company and try to negotiate for a lower rate but if your insurance has already paid out $495... I'd opt to not pay the bill.

It may be hard to tell if they are billing you for just the professional read or if they are billing you for the professional read + technical charges, but I will assume it's a global bill (professional plus technical). It's quite common for a billing company to send a bill for multiples of CMS rates (2.5 - 3X). These guys are charging you 20X CMS rates. If the pathology group gets paid that particular rate (2.5-3X CMS), then perhaps they are probably charging too little in their eyes and can charge a little more next time...

If one biopsy was performed (88305) and they happened to incorporate an Alcian blue/PAS (88313 or 88312 depending on if they provided a disclaimer that they were specifically looking for fungal organisms), the most I can theoretically see them billing is around $130-200 (CMS rates for 88305 x 1, 88312 x 1 and 88313 x1). What this looks like, to me, is that they did an Alcian blue/PAS stain but charged you both 88312 and 88313 because they probably commented on intestinal metaplasia (88313) AND "no fungal organisms identified" (88312). That's shady A F!

$2700 is EXCESSIVE and I would honestly tell them to go piss off. These guys could have seen the biopsy and noticed if there was Barrett's or not on H&E and stopped right there. Some labs do the special stains regardless and this been a HUGE topic on this forum and I'm sure all over the country. I hope I'm not opening up a can of worms here...
 
Six biopsies(three from esophagus and three from stomach), labeling them as separate biopsies. upfront AB/PAS and H.Pylori immunostain on all of them will get you a $2700 bill. You can thank big labs and their "GI experts" for it.
 
Pathbusiness said:
Six biopsies(three from esophagus and three from stomach), labeling them as separate biopsies. upfront AB/PAS and H.Pylori immunostain on all of them will get you a $2700 bill. You can thank big labs and their "GI experts" for it.
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The funny thing is that the original post just listed 88305 and 88312 and 88313 codes. Immunostains do not seem to be listed.

One thing to keep in mind is that for gastrics, I think doing a Giemsa stain is actually more profitable than doing IHC due to the lower overhead cost. Perhaps they did six biopsies as you say, but maybe the lab performed a bunch of Giemsa stains (88312) in place of HP immunostain.
 
Most race horses don't want to waste time on Giemsa. Time spent looking at a negative immunostain is much less than giemsa IMO.
 
CMS does not allow for upfront stains and it is overutilization to order them on every slide. In most cases H.Pylori, Barrett etc are easy to see on the H and E . Obviously having squamous and columnar mucosa in the biopsy it is easier to tell that it is compatible with GE junction. The professional component for interpreting special stains is minimal.... The technical component makes the lab money. Some labs setup(Alcian yellow etc) upfront in the autostainer and stain every slide but interpret only what is needed because its cheaper (tech time, going back to the block etc.). Most private insurance carriers allow for upfront stains but not CMS. Overutilization can occur when all slides are interpreted and billed out. This seems like a cat and mouse game with overutilization and exploitation followed by a hand slap and reconsideration of reimbursement( FISH, IHC, stains). Not sure what the ultimate solution is. When do you really need to do ancillary testing? The opinions vary and there are lots and lots of pigs/hogs at the trough. In some ways glass slapping pathologist are protected when nonpath (GI, derm, gastro, urology) make money off the technical (and part of the professional)component of the biopsy. Removing this possibility may cause increased reliance on upcoming technologies like mass spec, liquid biopsy etc. to make all therapeutic decisions and strip path even more. From my experience many docs (surgeons, onc, otolaryngology, ID,)would prefer to circumvent path in hospital settings (academic medical centers, private etc.) Justifying their clinical impression with a test that allows them to do the procedure or therapeutic option that their field is touting. Path services should ideally be the means of better stratification of therapeutic options and a brake/gatekeeper for crazy directions that are not evidence based. Just think of all the crazy stuff docs order based on a random differentials and crazy non Evidence based protocols.

Pathologist may need a vested interest from biopsy procuring practices (GI, urology, derm, gastro) to make money off the system. Without this, these services may move on to other technologies and leave morphology, IHC, and tissue requiring modalities as an afterthought. Many of the labs recently certified by the CAP are nonpath and include the aforementioned types of practices including derm labs, urology and GI groups and multi specialty practices. Maybe leaders at CAP see that it as necessary to allow for certification of gastro, urology, and derm labs as a bizarre means of protecting the field. If you truly wanted to move to a system that uses the most cost effective way to analyze a disease process, maybe the ancient art of histology and the 5 micron section will be replaced. We do have technologies that could highly decrease the number of biopsies but these advancements are held held at bay. Why is PSA rather than other test like a MASS SPEC looking at urine for signatures of definitive malignancy, or better options for looking at nevi etc more commonplace or better developed. Because there are lots of pigs/hogs at the biopsy trough. The big issue is how can pathologists be an integral part of this system and not get prostituted out by unscrupulous overutlizing practices. Ultimately pigs can get fat but hogs will get slaughtered.
 
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cmz said:
The funny thing is that the original post just listed 88305 and 88312 and 88313 codes. Immunostains do not seem to be listed.

One thing to keep in mind is that for gastrics, I think doing a Giemsa stain is actually more profitable than doing IHC due to the lower overhead cost. Perhaps they did six biopsies as you say, but maybe the lab performed a bunch of Giemsa stains (88312) in place of HP immunostain.
Click to expand...
This is why eventually the technical on this will be highly diminished
 
Thanks for all the helpful replies. I have United Health PPO. It was highly unusual that United Health did not adjust the rate for the Tissue Stain I and II. I've never seen an insurance company allow for 100% what the doctor billed (much less actually pay it). When I called them the person I spoke with said that that's the rate they contracted for with the doctor. I doubt this; thinking this is a case of United being lazy or incompetent. If I had met my $5k copay and United was on the hook for 70% of this bill I highly doubt that they would be saying this. Is there someone there I should be speaking with to argue my case? If the pathologist billing office is unwilling to reduce this, could threatening to report them to Medicare/Medicaid or the State Medical Board have any affect?
 
The Saga continues...today I received a new explanation of benefits (EOB) from United. This was from a company called CDX Diagnostics; haven't received the bill from them yet. I have no idea what this company was so I googled it and it is a pathology lab that is used in diagnosing biopsies. There were 4 claims of "Xray and Lab" on the EOB. The total billed by this company was $4,384. United repriced it to the Medicare allowed amount of $843, which includes a $281 penalty for using an out of network provider. I never agreed to use this company. The GI doc's office told me the pathologist would be in network. So, it also looks like I'm being double-billed here. The pathologist had billed me the $2700 earlier and now this CDX Diagnostics billed me $4,384. Total of $7,084. My father, a retired IM doc, called the GI doc's office today. He was friendly at first but the moment my dad said "my son received the pathologist's bill..." the doc quickly said "I'll get back to you" and hung up. I'm going to speak with United about this CDX Diagnostic bill and explain I never agreed to this out of network lab, and it is double billing and fraudulent. I will call the pathologist office and try to reason with them. If they don't budge I will report to CMS, the local newspaper, the local newschannel's investigative reporters, the state medical board of Florida and State Attorney General. This is beyond outrageous. I will also hire a lawyer if need be.
 
No need for a lawyer. Just spread the word and tell them you will try hard that this fraud reaches to appropriate authorities.
 
I would also call the clinician and tell him/her you are reporting them to the state medical board and also considering legal options for referring your tissue to such a fraudulant company
 
Light Yagami said:
The Saga continues...today I received a new explanation of benefits (EOB) from United. This was from a company called CDX Diagnostics; haven't received the bill from them yet. I have no idea what this company was so I googled it and it is a pathology lab that is used in diagnosing biopsies. There were 4 claims of "Xray and Lab" on the EOB. The total billed by this company was $4,384. United repriced it to the Medicare allowed amount of $843, which includes a $281 penalty for using an out of network provider. I never agreed to use this company. The GI doc's office told me the pathologist would be in network. So, it also looks like I'm being double-billed here. The pathologist had billed me the $2700 earlier and now this CDX Diagnostics billed me $4,384. Total of $7,084. My father, a retired IM doc, called the GI doc's office today. He was friendly at first but the moment my dad said "my son received the pathologist's bill..." the doc quickly said "I'll get back to you" and hung up. I'm going to speak with United about this CDX Diagnostic bill and explain I never agreed to this out of network lab, and it is double billing and fraudulent. I will call the pathologist office and try to reason with them. If they don't budge I will report to CMS, the local newspaper, the local newschannel's investigative reporters, the state medical board of Florida and State Attorney General. This is beyond outrageous. I will also hire a lawyer if need be.
Click to expand...

Yeah. Take those greedy bums down. That CDX crap is worthless.
 
Light Yagami said:
The Saga continues...today I received a new explanation of benefits (EOB) from United. This was from a company called CDX Diagnostics; haven't received the bill from them yet. I have no idea what this company was so I googled it and it is a pathology lab that is used in diagnosing biopsies. There were 4 claims of "Xray and Lab" on the EOB. The total billed by this company was $4,384. United repriced it to the Medicare allowed amount of $843, which includes a $281 penalty for using an out of network provider. I never agreed to use this company. The GI doc's office told me the pathologist would be in network. So, it also looks like I'm being double-billed here. The pathologist had billed me the $2700 earlier and now this CDX Diagnostics billed me $4,384. Total of $7,084. My father, a retired IM doc, called the GI doc's office today. He was friendly at first but the moment my dad said "my son received the pathologist's bill..." the doc quickly said "I'll get back to you" and hung up. I'm going to speak with United about this CDX Diagnostic bill and explain I never agreed to this out of network lab, and it is double billing and fraudulent. I will call the pathologist office and try to reason with them. If they don't budge I will report to CMS, the local newspaper, the local newschannel's investigative reporters, the state medical board of Florida and State Attorney General. This is beyond outrageous. I will also hire a lawyer if need be.
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You are right to be angry about this bill. It crosses the line. This is unmitigated greed and yaah's earlier post about money greedy entreprenuer-physicians is spot on.

I feel your options include:

File a formal, written complaint against the GI doc and the pathologist with the Florida Board of Medicine. Florida has an online complaint portal. Even if allegations are not pursued, they still go in a provider's file and the provider is notified.

United healthcare has an online portal for reporting suspected fraud. Go to google and type in "United health care and fraud" and it comes up. Hopefully, UHC will blackball the GI office and CDX labs.

File a complaint against both the pathology lab and CDX with the office of the inspector general (OIG). Even though you don't have medicare (you have United healthcare), the pathologist and CDX can be liable for the following:
Offering something of value (client billing, commerical billing, CDX testing) in exchange for medicare referrals, which is a violation of the false claims act (See US gov't versus Strata Dx 2015 decision)
Performing special stains up front on all GI biopsies, violation of the Palmetto and Noridian LCDs prohibiting this practice (See US gov't versus Piedmont Pathology 2017 Decision)

Write a complaint on the google website of the GI practice and give them one half of a star and tell your story.

The CDX test for detection of dysplasia in the esophagus is not FDA approved. No large insurance company covers non-FDA approved tests. Failure of the gastroenterologist to inform you of your costs is a violation of the AMA code of ethics, as is any fee splitting. Moreover, their assertion that the pathologist was in the UHC network was a flat-out lie.

Contact the clinic manager for the GI practice and indicate that each violation of the false claims act or anti-kickback statute carries triple damages plus up to a punitive 10K penalty (per violation) -- imply that you will be lawyering up and that 1/3 of all proceeds for a qui tam (whistleblower) suit go to the reporting individual.

I like your idea of contacting your TV station's investigative journalism team. The local newspaper could also have a desk for this. Look at the recent Seattle Times report on the rogue neurosurgeon at Swedish cherry hill. The CEO of swedish health resigned soon after that story came out.
 
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Thanks for the suggestions. I pulled up the pathologist's report and here are the CPT codes he listed that he said he performed:
88305x6, 88312x3, 88313x1, 3126Fx1

I spoke with insurance and it seems the GI doc sent my samples to CDX Diagnostics. So he sent them to the local pathologist, who billed me $2700, and also to CDX who billed me $4,384.

I was complaining of mild reflux and I have no PMH; it seems crazy that he did this much labwork.
 
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Somehow you need to get hold of the GI guy and the pathologist and talk to them personally. Plus do all other things people have suggested. Word spreads fast and anything which results in increased medical costs gets noticed these days. You are a physician. Your voice will carry weight.
There is a news tip option on the New York times home page. I would submit a complaint there.
 
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Light Yagami said:
Thanks for the suggestions. I pulled up the pathologist's report and here are the CPT codes he listed that he said he performed:
88305x6, 88312x3, 88313x1, 3126Fx1

I spoke with insurance and it seems the GI doc sent my samples to CDX Diagnostics. So he sent them to the local pathologist, who billed me $2700, and also to CDX who billed me $4,384.

I was complaining of mild reflux and I have no PMH; it seems crazy that he did this much labwork.
Click to expand...

Go after these sons of bitches with everything you have. They are nothing more than criminals guilty of fraud and theft/extortion.
 
Thrombus said:
Go after these sons of bitches with everything you have. They are nothing more than criminals guilty of fraud and theft/extortion.
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Agree I hope you go after all these crooks. I wonder how many patients they've done this to/screwed over.
 
There's alot of hungry mouths to feed...Jesus it reads like a Who's Who of a corrupt wall street corporation and the pictures are like caricatures of Despicable Me villains.

The CDx Executive Team

Founder & CEO, President & COO, VP of sales, executive VP of finance and admin, CFO, VP of finance and operations (Joseph Himy? Seriously did someone make these names up?), VP of Clinical affairs, Co-founder VP and Med Directore (a physician), Lab Director (physician), Director of Cytopathology (physician), Director of Squamous Pathology--whatever the eff that means (physician), VP of Engineering, Director of Imaging analytics, VP of global infrastructure, Director of marketing, Director of Informatics...then there's the Board of Directors...
 
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octopusprime said:
There's alot of hungry mouths to feed...Jesus it reads like a Who's Who of a corrupt wall street corporation and the pictures are like caricatures of Despicable Me villains.

The CDx Executive Team

Founder & CEO, President & COO, VP of sales, executive VP of finance and admin, CFO, VP of finance and operations (Joseph Himy? Seriously did someone make these names up?), VP of Clinical affairs, Co-founder VP and Med Directore (a physician), Lab Director (physician), Director of Cytopathology (physician), Director of Squamous Pathology--whatever the eff that means (physician), VP of Engineering, Director of Imaging analytics, VP of global infrastructure, Director of marketing, Director of Informatics...then there's the Board of Directors...
Click to expand...


LADoc00 said:
The Pathology Minion paradigm has always been a thing since the late 70s. I dont think its is worse or better now. Either you are a minion or you are Felonius Gru. You dont need someone to tell you what you are, you know it. And of course the lil yellow minions will be the prime group filling out such surveys, hence the response.
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I think we found our Felonius Grus.

I'd better go get a squamous fellowship.
 
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I think we should all write letters to the GI doc and this shady lab on "Light Yagami's" behalf. That should be enough for the matter to get noticed.
 
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Really appreciate the info this group has given me. I am first going to call the GI doc and tell him that he never told me he'd be sending my biopsy samples to two different pathology labs, including this money making CDX Diagnostics. I would never agree to use an out of network lab, and one that is based on speculative, non FDA approved science. Also, he should have informed me his Orlando lab would be charging me $2k+. He never received informed consent from me regarding CDX. I don't know if this forum allows names to be listed, but I have no trouble outing the GI doc and his local pathology group.
 
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Light Yagami said:
Really appreciate the info this group has given me. I am first going to call the GI doc and tell him that he never told me he'd be sending my biopsy samples to two different pathology labs, including this money making CDX Diagnostics. I would never agree to use an out of network lab, and one that is based on speculative, non FDA approved science. Also, he should have informed me his Orlando lab would be charging me $2k+. He never received informed consent from me regarding CDX. I don't know if this forum allows names to be listed, but I have no trouble outing the GI doc and his local pathology group.
Click to expand...

Out them all! Better yet, let this board help you write your letter to news media
 
Light Yagami said:
Is there any legitimate reason for the GI doc to have used CDX diagnostics when all I complained about was esophageal dysphagia? Is it fair to conclude he is being paid a referral fee by CDX Diagnostics, which is illegal? I want to make sure before I confront him. Thanks.
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For such a high and unexpected expense, I would ask him for high level evidence that what he did brings benefit to you. Then, I would ask him for high level evidence that this brings value to your health. The burden of proof is on THEM to provide evidence based care. Not you.
 
This is so basic but hasn't been really addressed yet. So, when a healthy young person with no PMH complaining only of dysphagia with no weight loss goes in for an EGD with biopsy, what is the normal, widely accepted reimbursement rate for the biopsy component in total (what insurance pays + what the patient pays)?
 
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