Same surgery cost nearly 20 times more in HOPD than ASC in California

A retired orthopedic surgeon in Fresno, Calif., was charged nearly $4,000 more for a cataract surgery at a hospital outpatient department than his wife who received the same procedure at an ASC, Kaiser Health News reported June 27. 

In December 2021, 73-year-old Danilo Manimtim, insured by Anthem Blue Cross of California, went to the HOPD of Saint Agnes Medical Center to receive the cataract surgery. Overall charges ended up being $9,084 for surgery, anesthesia, medical supplies, pharmacy and clinical laboratory services. Anthem paid $5,027 and initially billed Mr. Manimtim $4,057.

Four months later, his 66-year-old wife, Marilou Manimtim, had the same procedure at Fresno-based Eye-Q. Both patients had the same insurance coverage and both providers were in network, but Ms. Marilou ended up owing only $204. 

"This is ridiculous, and it feels very unfair," Mr. Manimtim told Kaiser Health News. "How can it be so much more expensive than the surgical center? It’s walking distance away, and if I would have gone there, I would have saved myself a lot of money."

Mr. Manimtim’s insurance plan, the California Public Employees’ Retirement System, caps payment for outpatient cataract surgery at $2,000. After being contacted by Kaiser Health Network, Anthem reached out to the hospital seeking help for Mr. Manimtim. 

Under Mr. Manimtim’s insurance plan, the physician is responsible for requesting an exemption from the $2,000 limit, which didn’t happen before the surgery. Anthem then asked the hospital and physician to consider the request after the surgery. 

Saint Agnes spokesperson Kelley Sanchez told Kaiser Health News that the hospital later requested the exemption and that it was approved by Anthem. 

The update would leave Mr. Manimtim with a $750 coinsurance bill, with Anthem covering a large portion of the remaining $4,057 bill.

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