The fees charged by the hospital are really not too surprising; but the implied claim that Medicare approved them is BULLSHIT. Medicare may have authorized slightly higher fees than smaller clinics are allowed; but almost never actually pays more than about 40% of what's billed (national average, last time I looked).

Although Medicare is "managed" (note the euphemism) by each state, and rules do vary, the way it works in my state is that the provider bills $1,000; Medicare informs them they are only allowed to charge a Medicare insured patient $400. Medicare pays 80% of the $400, or $320. For those who have a "secondary insurer" a usual secondary insurance payment is at least 80% - and sometimes all - of the remaining $80, and the patient pays what's left (up to, perhaps, $16).

The provider bills $1,000 and gets $400.

If you're uninsured, you pay the hospital the $1,000.

If Medicare decides that a procedure is not an authorized procedure and is not covered, the provider is not permitted to charge the patient anything unless they were clever enough to have the patient sign a waiver before the procedure was performed.

If the patient is uninsured, the patient pays whatever the hospital imagines they can charge.

It should also be noted for those unfamiliar with it that Medicare insurance is not free. An insurance premium is deducted from your Social Security payment every month, and it is fairly substantial relative to your income if SS is all you've got.

ALL INSURERS have similar "standard fees" similar to, although sometimes a little higher than, what Medicare imposes. Insurers who allow providers a higher fee generally pay a lesser percentage of the allowed fee, leaving more for the patient to pay.

A provider who doesn't agree to accept the fees imposed by an insurer is generally unable to offer services to insured patients (more than once per patient?), so they're pretty much blackmailed into agreeing. (... since many uninsured are unable to pay even as much of the amounts billed as the insurers do?)

The higher fees billed mean that the UNINSURED are forced to subsidize the insurance companies (including Medicare). If they can't pay, it usually ends up with some "social welfare" agency working out a settlement which means the taxpayers as a whole pay the subsidy.

(For most clinics/hospitals, it is illegal to refuse to provide "medically necessary service" to anyone, regardless of insurance or other ability to pay. This just results in lots of quibbling about "is it really really really immediately necessary?" ... and sometimes the patient dies while waiting for a decision(?).)

John