José Mendoza may be sleeping better but he’s stuck with an outrageous medical bill.
Truck driver José Mendoza, 61, of Miami, has a Humana HMO plan through his place of employment that has a $5,000 deductible and 50% coinsurance. It covers the bare minimum, and the high deductible means that Mendoza is required to pay a chunk out of pocket. However, previously diagnosed with severe sleep apnea, he decided it was time to return for another check-up and undergo a sleep study.
There were some points in the middle of the night that Mendoza would stop breathing, according to his wife, Nancy, who told him the silence would wake her and make her extremely anxious. Sometimes, he would stop for so long she would have to nudge him to make sure his breathing started again. This happened several times a week.
Mendoza was prescribed a continuous positive airway pressure (CPAP) device after he was initially diagnosed fifteen years ago, but he stopped using the machine after a month because it was noisy and uncomfortable. Something more, the couple determined, had to be done.
In 2019, Mendoza went to an emergency department with an unmanageably painful headache. After testing, the medical staff concluded his obstructive sleep apnea was causing the headache as well as some cardiac problems. The attending physician told Mendoza he needed a new CPAP machine. However, he would first need to complete an at-home sleep test.
After this, Mendoza’s pulmonologist reviewed the results and determined the at-home data was insufficient, so he ordered a sleep center test with a specialist. Mendoza visited the University of Miami Health System’s sleep medicine facility at Bascom Palmer Eye Institute. This allowed him to obtain a more comfortable CPAP model – the same one he used during the center’s study.
“Now I’m not snoring. I feel more energetic. I’m not as tired as I was before,” he said.
However, the bill for the testing and machine was outrageous. Mendoza was hit with a $10,322 tab, including a $9,853 outpatient charge for the sleep study and a $469 charge for the sleep specialist to review the results. Humana’s negotiated rate was $5,419 of which Mendoza was responsible for $262 in coinsurance and $4,895 to satisfy his deductible.
According to Dr. Vikas Saini, president of the Lown Institute, sleep studies “are incredibly useful and necessary in certain clinical circumstances. But it’s known to be one that can be overused.” In other words, while sometimes medical necessary, that’s not always the case. The Office of Inspector General at the federal Department of Health and Human Services has actually identified billing issues for the type of study Mendoza received, leading to Medicare overpayments.
Humana negotiated rate of $5,419 was almost six times what Medicare would pay for the same service nationally, $920, according to data from the Centers for Medicare & Medicaid Services. And, medical service charges in the Miami area are on the high end of the national range.
“Private insurers typically pay higher rates than Medicare for care, but that…is much higher than what other insurers would pay,” explained Jordan Weintraub, vice president of claims at WellRithms. After looking at Mendoza’s bill, he added, “Billed charges are just completely fictitious. There’s really no grounds for charging it other than that they can.”
And because of changes to the field of sleep medication overall, there may has been a stronger push towards in-center testing. Charlie Whelan, vice president of consulting for health care at Frost & Sullivan, a research and consulting firm, explained, “After strong growth by independent and hospital-affiliated lab-based sleep centers over several years, there’s been a shift toward home-based sleep tests recently. The entire sleep medicine field is deeply worried about a future where more testing is done at home since it means less money to be made for in-center test providers.”
To avoid having the bill sent to a collections agency and ruining their credit, the Mendozas agreed to a two-year payment plan. Their first installment, 214.87, was paid in April. Nancy said, “It’s not fair [for] people who are in the low end of the middle class.”