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.

The surprisingly easy to read law mandating GFE’s is here: https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-149/subpart-G/section-149.610#p-149.610(b). 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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