This Monday I’ll be heading to St. George Surgical Center for my ninth eye surgery in the past two years. Yes, ninth. I’m basically a punch card away from getting my 10th one free, like a coffee shop loyalty program, but with more anesthesia.

Someone needs to pay for this fancy new building. Might as well be me.

The plan this time? Oh, just two “routine” procedures:

1. Yank out the cataract in my left eye.
2. Remove the silicone oil they installed last year during Eye Surgery #6 — apparently not a permanent décor choice.

Two different doctors, one right after the other. Efficient, right?

Well, efficiency stops the moment billing enters the chat.

The Call
Pre-op was done, life was good — until I got The Call from the surgery center. I’ll call her Marge to protect her identity (and because “Marge” sounds like the name of a medical biller who thinks ‘HIPAA’ is a yoga pose and will still correct you with the confidence of someone who skimmed one training video in 2009 all while playing Candy Crush with the volume turned up).

Marge: “Your facility charge will be $12,860. With your 20% copay, you’ll owe $2,575.”
Me: “That’s impossible. These are two routine procedures. You’re mis-coding this entire thing.”
Marge: “I’m just going by the coding your doctors gave us.” (Translation: Let me just roll these guys directly under the bus for you.)
Me: “This would be the single most expensive cataract surgery in human history. If that’s how you want to run your facility, I’ll cancel and go somewhere else.”
Marge: “You need to call your physicians.”
Me: “They bill separately. So whatever you’re charging me, their bills will be in addition — plus anesthesia. We’re looking at a $20,000 price tag for a routine eye tune-up.”
Marge: “I don’t know what to tell you.”

Oh, I know you don’t, Marge.

Here’s What Marge Doesn’t Know
I used to be a hospital CFO. I’ve built outpatient surgery centers. I’ve set up billing systems. I’ve negotiated insurance contracts. Basically, I know how the sausage is made — and in healthcare, the sausage is mostly made out of pure markup and moral flexibility.

So I did a little fact-checking. My procedures have actual names in CPT code land:

• 66840 – Cataract removal
• 67121 – Vitrectomy with silicone oil removal

Both routine. Nothing exotic. No platinum-plated scalpels involved, no wellness retreat with kombucha, and no vintage bottle of 1962 anesthesia… a very good year.

Enter: Cigna, Villain #2
Now, I’m no fan of big insurance. Cigna made $8.63 billion last year. You could fill a swimming pool with that cash and still have enough left to buy a few members of Congress.

But when I called them, they actually helped me. (A sentence I never expected to write.) They spilled the beans. They told me the contracted reimbursement rates for these codes at St. George Surgical Center are:

• $1,426 for the cataract removal
• $4,260 for the vitrectomy

Grand total: $5,686. Oh, and — when you do both in the same visit? Insurance usually wants a 50% discount from the facility on the second procedure.

So, not $12,860. Not even close.

The Magic of Up-Coding
CPT codes are what the medical industry uses to determine how to bill your procedure. There are thousands of codes, one for every symptom known. They’re listed in a huge book.

What St. George Surgical Center was doing is called up-coding — picking the fancier, more expensive CPT codes, like ordering lobster when you actually got the chicken special. It’s not technically illegal — if the provider can justify it. In fact, they teach classes on how to do it. Consultants come in, wave around PowerPoints, and show you exactly what magic words to put in the chart so you can bill for yacht money without breaking the law.

Done right, this can add millions to a provider’s revenue. Done wrong? You get caught by a very annoyed former hospital CFO.

(Side note: I wrote another article on some of the reasons for the ridiculous cost of American healthcare, along with suggestions on how to fix it. If you’re interested, read it here.)

Busted
I called Marge back. No answer. Left a voicemail with the actual codes that should be used — 66840 and 67121 — plus the fact that the second one should be billed at 50%.

The next morning, she called back:
“Your total is $4,410, and your copay will be $882.”

And just like that I shaved $8,450 off my bill.

• No context.
• No “We’re sorry.”
• No “Good news! We’ve adjusted your bill to reflect the much lower amount we always intended to charge you… after you noticed.”

I was up-coded and they knew it. I should start a coupon app for surgeries.

The Moral of the Story
If you’re wondering how often this happens, the answer is: constantly. It’s a Tuesday afternoon activity in American healthcare.

Most people wouldn’t catch it, because most people aren’t wandering around with an unholy amount of healthcare finance experience and a better-than-most knowledge of CPT coding. But here’s the ugly truth:

If you’re not watching your own medical bills like a hawk, no one else will.

And that’s why your $5,000 surgery costs $20,000 — until you say something.