2025 Endocrinologist Good Faith Estimate

Treatment
1

I had an appointment with an endo that I’m 99.999% sure my health plan isn’t going to pay for so I made sure to get a good faith estimate. The law requiring GFEs took effect in 2022 so they’re still kinda new in health care. I had to do some work to get one, I’m hoping this will also make it easier for someone else. Also I wanted to share the price as more health plans are succumbing to the plague of coinsurance.

To get a Good Faith Estimate (GFE):

  • Ask for one when you schedule an appointment
  • The provider is required to give a GFE only if either
    • An individual who does not have benefits for an item or service under a health plan or
    • An individual who has benefits for such item or service under a health plan but who does not seek to have a claim for such item or service submitted to such plan or coverage.

In my case the endo I had been seeing submitted a referral to my health plan who approved and sent it to UCSF Health. So they knew I had insurance when I made the appointment and didn’t have to provide a GFE. I had to call and ask because my plan pays $0 for out of network specialists. Even then the first response I got was “$40-$400”. This is not a GFE. While they can be verbal they have to be specific and if there’s a discrepancy later they have to be in writing so always ask for one in writing, accessible and in a language you understand. The GFE has to be provided in 3 business days if the appointment is in 10 or more business days, within 1 business day if the appointment is in 3-9 days.

Here’s what I finally got, with all my personal info removed:
Endo GFE.pdf (244.2 KB) $559 for CPT code 99205 Office/Outpatient New High Mdm or 60 Min.

Love the fake “discount”. If you are paying for an endo in the US and not using a health plan or other financial assistance how much are you paying? I’m hoping this being a long new patient appointment in a crazy expensive city makes this the high end of endo prices these days.

Edit: All licensed facilities and providers have to provide a GFE. In the case of multiple providers, for example a surgery, the one you schedule with has to provide a GFE with all the other providers included.

The surprisingly easy to read law mandating GFE’s is here: eCFR :: 45 CFR 149.610 -- Requirements for provision of good faith estimates of expected charges for uninsured (or self-pay) individuals.. I also used https://www.cms.gov/files/document/gfe-and-ppdr-requirements-slides.pdf

2

I take the point about getting an estimate. I’m amazed how many people don’t ask for estimates, not just healthcare; construction, cleaning etc. It’s more something contractors do to ensure they can get paid rather than something people do to ensure they don’t get ripped off.

With a 50% “discount”. The way I look at numbers like this they are marked up for the insurance company but then most docs give a “cash” discount. Here’s my last-but-one endo appointment bill (without the CPTs, though I think I can get those from my Medigap provider or Medicare):

04/17/25 Complex e/m visit add on 51.00
04/17/25 Office/Outpatient Established Mod Mdm 30 Min 325.00
04/17/25 Continuous Glucose Monitoring Analysis I&R 108.00
05/05/25 Cigna Medicare Supplement Solutions Payments 0.00
Deductible: 118.71
04/24/25 Medicare Payments 0.00
Deductible: 118.71
Insurance Adjustments -365.29
Your Responsibility 118.71

This was not an initial visit. Because this was the first Part B expense I had on Medicare this was under the Medicare deductible ($257 IRC) so it’s possible to see what happened:

  1. They billed $484
  2. Cigna/CMS dinged them $365.29
  3. Leaving me owing $118.71 (and that wipes out almost half my deductible; after the deductible I pay nothing more.)

However I was also charged for using the “Asante Rogue Regional Medical Center” on the same date, thus:

Treatment Room 533.80
05/15/25 Cigna Medicare Supplement Solutions Payments -4.86
Deductible: 138.29
05/08/25 Medicare Payments -19.03
Deductible: 138.29
Coinsurance: 4.86
Insurance Adjustments -371.62
Your Responsibility 138.29
type or paste code here

In other words I was separately billed for the use of a “treatment room” from which my doc operates, $533.80 for 30 minutes; this wiped out the $257 Part B deductible all in one visit when added to the $484 the doc charged. The billed total for the 30 minute was therefore $1017, so cheaper than $1118 but that was for a 60 minute initial appointment (though you will probably get billed for the “Complex e/m visit add on 51.00” too if you ask any questions.)

Yeah, it is tempting to believe that SF doctors will charge a lot more than Medford doctors, but that’s not what seems to happen. It probably helps that the doc works for UC, not a private company like Asante, but it’s not just that. ACA insurance plans are cheaper on the peninsula than they are where I live, in Josephine County Oregon. Ok, they are HMOs (not available here), but I still don’t understand why.

Getting care round here without insurance is itself a challenge; having insurance is the ticket. Using it isn’t always such a good idea.

3

Facility fees are a good reason to get a GFE and part of why the law was called “The No Surprises Act”. Ways around facility fees are to ask the doc if they see patients at another office not associated with the hospital or medical group or find another doc. I was amazed UCSF Health didn’t have one. From the training PDF:

The good faith estimate will also include items or services reasonably expected to be provided along with the primary item(s) or service(s), even if the individual will receive the items and services from another provider or another facility.

Things can be added to the final bill or the codes can change, the GFE has to be within $400 of the final bill unless something really terrible goes wrong.

@John_Bowler thanks for being willing to add your numbers. I thought cash prices would be helpful to people who are looking for a ballpark on how much an endo might cost if they were looking out of network like I was. Your numbers are Medicare contract rates which is why the bill looks so low until the facility fee scam (some may say market correction) kicks in.

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4

This is on par with what I would pay in Minneapolis. I might pay $400-some for an apt in Jan before I have reached my deductible (they cover 20% until that is deductible is reached).

My premium is up to $500/month, but I still have a low deductible plan. It’s privately held - not thru ACA or an employer.

5

Maybe I’m wrong, I thought that even when you hadn’t met your deductible the charges were still at your insurance plan’s contracted rate? Do the prices for the same code differ on EOBs for appointments before and after you meet your deductible? Maybe an easier question for @John_Bowler to answer since Part B EOBs are all online.

Unrelated to GFEs, I got a copy of the PA for my endo appt. in the mail. It was coded for a 15 minute appointment and doesn’t have a doctor’s name but says “contracted provide only”. A pity PA? They aren’t saying no but aren’t saying yes. Another example of how healthcare here is broken.

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6

That is correct for both ACA compliant plans (pretty much all plans these days) and Medicare. So long as the provider is “in network” or, in the case of Medicare, has “accepted assignment” the amount paid is the negotiated price, or the contract price for Medicare. For drugs it’s the formulary price though because that is a percentage for higher tiers (above 2?) it can, and often does, change through the year.

In all cases the only thing that changes before/after deductible is who pays. On Medicare and I think most individual plans it’s usual to pay 100% before the deductible except that Tier 1 and maybe Tier 2 drugs get paid at the formulary rate and do not count towards the deductible and certain preventative services get paid at 100%. As of last year on Medicare this also applied to insulin; the $35 does not count towards the deductible.

Employer plans have to meet a set of minimum requirements defined by the ACA but they can offer better coverage, for example paying 20% of the cost before the deductible, though I can’t see the point of that. Bear in mind that office visits sometimes combine preventative care (100%, no deductible) with other care.

Some individual plans are available “on market” and “off market”. The “off market” plans are still compliant but the premium may be less and no premium tax credit is available. moda pointed this out in the plan change information for my wife’s plan and it might be worth her going off market next year because our income is too high to get the PTC credit. This is the big deal ATM because no one knows whether the PTC expansion will be continued.

Because I went on to Medicare in April I had the prior appointment on my prior, individual, plan. This was last year, after I had met the deductible and the out-of-pocket-max (they are equal on my plan) but the procedures are the same and the billing numbers are similar:

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The thing that is distressing, however, is that my insurance company was paying a lot more than Medicare for identical treatment just four months earlier. moda paid $960.72, whereas Medicare, four months later, paid (including my payment) $276.03. I don’t think I got that wrong and the total billing amount was $1219.90 last year (moda) vs $1017.80 in April. The numbers are there if you think I got this wrong.

I guess that makes your point about getting an estimate; the numbers the docs and the hospitals are billing are just pure fiction; the amount paid bears no relation to the bill. It’s like buying a car.

If I read the moda records right the “facility fee” only got added in Q3 or Q4 2024; prior to that the billing amount (for my June visit) was just for the endo and matched (approximately) the later billing amount.

My prior moda plan was an “EPO”. Technically this means that they won’t pay a dime for visits to providers who are not contracted in though it seems the 2026 version of this plan, while remaining an EPO, uses the Aetna PPO network for out-of-state stuff.

When I checked individual plans on the peninsula (Mountain View) they were all HMO (the reasonably priced ones) or PPO. The employer plans I had when I worked there were PPO (IRC, Aetna, though the second was self-insured).

I don’t know how HMOs work with out-of-network but my assumption is that they work like EPOs. PPOs (my Oregon plan was PPO until a few years ago) cover out-of-network at a reduced rate and the out-of-pocket-max is higher (I think that is still ACA compliant). Traditional US policies of course just cover any doc but are there any of those left?

So far as I can see there really is no option any more for going out-of-network other than having the money and getting the estimate (or, better, a quote) up front.

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7

This all sounds correct to me.

If I go out of network, I pay a higher rate - I think 80% until I reach 5K (as opposed to 1K deductible for in network). After that 5K, they pay 80%.

8

Thanks @John_Bowler and @mohe0001 I appreciate the help. Just to compare to your numbers I did get an estimate before the real one saying the Anthem contract rate for a 1hr new patient appt. was $530.

9

I left out what kind of providers this applies to… All of them.

45 CFR 149.610(a)(2)(viii)
Health care provider (provider) means a physician or other health care provider who is acting within the scope of practice of that provider’s license or certification under applicable State law, including a provider of air ambulance services.

Examples (from the training slides):
• Encounters;
• Procedures;
• Medical tests;
• Supplies;
• Prescriptions drugs;
• Durable medical equipment; or
• Fees (including facility fees).

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10

Throughout the 1990’s I was uninsurable (self-employed T1) and occasionally priced out an endo visit. At the time full price for the office visit was $100-125. That was more than a quarter century ago so… inflation.

BUT the kicker back then was the labs. Full price for say an A1C and Metabolic Panel was several hundred dollars. Then in 2000 I got insurance - and I saw insurance company paid like $7 for the same blood panel.

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