Long read, but a little foot injury and medical billing follow-up
Posted By RichC on September 7, 2025
There’s nothing like the frustration of going to the doctor and thinking they are being paid for what they are worth … but then getting a follow up “Explanation of Benefits” (EOB) from your insurance company letting you know how much they were billed and how much YOU now owe. ☹️ 
Last month I finally went to see “the specialist” (higher copay than PCP) who had me walk into the room next to his examination room for an X-Ray (more on this at the bottom). No problem and as expected. I thought to myself that “I like it when a doctor has the equipment right in his office” and my Medicare Advantage insurer has a better negotiated rate for in-office and out-patient X-Rays. Of course … none of this is really known by the patient or is even something we sleuth ahead of time — I merely check to be sure the doctor is in-network.
Anyway I was efficiently seen by a competent foot specialist who glanced at 
the image said as if he was reading from a script, “stay off the foot and wear a boot.” I asked if I could just wear a “hiking boot or something” … since I knew the specialty boot wouldn’t be cheap … but the answer was no. So I was sent home with a medical boot (bill by another company) and was told to wear for a month and see him again (follow up appointment and another co-pay and I’m sure bill).
A few weeks later the bills begin to show up from the insurance company (EOB) … FOUR separate charges to be precise … and each had the “full price charge” and then the “negotiated price” for in-network negotiated rate (all unknown unlike traditional Medicare according to AI). The full price is eyeopening and perhaps seeing the lower negotiated rate is supposed to make you feel better … it did not especially after seeing the Medicare rates (see below).
BILLING FROM INSURANCE EOB STATEMENT:
- New patient consultation and visit (assume $314 will be more than the follow-up, but I don’t know yet for sure?)
- The X-Rays – three views taken in the same office, but billed by the local hospital (remember above, different rates for hospital X-rays vs Outpatient X-rays vs in the doctor office X-rays — guess which one can be billed at the highest rate? Yup, the one billed by the hospital – $456 — my call to the insurance company gave me the 3 different reimbursement rates)
- The radiologist bill which came after the other bills but suspect it was in the above charge since I was told by the insurance company that it was currently listed at $0.
- The boot from yet another company (amount billed for the boot $425 but in-network cost $188.33. I would have preferred a new pair of hiking boots.)
Anyway to make an already long post shorter, even though I still pay a premium for health insurance, the out-of-pocket dig is still pretty deep for the 20 minute visit … and am not sure that I really want a follow-up visit!
I decided to call the insurance company just to double check the amount due .. and then decided to plug the billing codes into Grok AI … just to see what original Medicare would cost. Maybe “Advantage” isn’t really an advantage?
Original Medicare Costs (per Grok)
- CPT 99214 (Visit): Medicare-approved amount ~$130–$150. Your cost: 20% = $26–$30.
- CPT 73630 (X-ray): Approved amount ~$30–$40. Your cost: 20% = $6–$8.
- HCPCS L4361 (Boot): Approved amount ~$150–$200. Your cost: 20% = $30–$40 (if applicable).
* Total:
- Visit only: $26–$30
- Visit + X-ray: $32–$38
- Visit + X-ray + boot: $62–$78
* Clarity: Costs are predictable using Medicare’s Procedure Price Lookup or CMS Physician Fee Schedule.
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