Naomi Radcliff had been coughing for a year and a half when her doctor referred her to an ear, nose and throat specialist in February.

Both her primary care doctor and the specialist are employed by Medical University Hospital, where Radcliff has been a patient for 17 years, so she was confused when the hospital billed her Medicare plan $326 for a new patient appointment.

"All of my info the last 17 years was already in MUSC's computers," she wrote in a letter to the hospital's billing department on March 7. "(The doctor) merely had to pull up my patient info on her office computer."

But Radcliff's complaints with the hospital bill don't end with the new patient fee.

The hospital also charged Medicare $1,239 for her "laryngoscopy w/stroboscopy," (a throat exam), $312 to remove four hairs from her ear canal and $81 for a "binocular microscopy," (an ear exam).

The total bill for the Feb. 11 appointment was $1,958, according to a copy that Radcliff, 66, a Charleston resident, provided to The Post and Courier.

"They're not just gouging me, they're gouging Medicare," she said. "It's ridiculous."

The problem is not a new one, but as more consumers pay a larger portion of their medical bills, transparency about medical expenses has become a national issue. A report issued Tuesday by the Health Care Incentives Improvement Institute and Catalyst for Payment Reform gave South Carolina, and all but five states an "F" on billing transparency. None received an "A."

The problem is not only what charges are made to the patient but also the responsiveness of hospital billing departments.

For instance, Radcliff has not received a reply from the hospital's billing department yet. MUSC spokeswoman Heather Woolwine acknowledged that the institution's structure can be confusing for patients because the hospital, the university and the physicians' group operate as separate entities. That may explain why an existing MUSC patient would be considered a new patient by another MUSC doctor, Woolwine said.

Also, she said new patient appointments are longer than normal appointments, so they cost more.

"Even though you may be with a primary care physician, when you see a specialist, you are a new patient for that physician, hence the new patient charge," Woolwine said.

To further confuse the issue, the hospital and doctors often send separate bills for the same appointment, although this is a process that MUSC will start streamlining on July 1, she said.

"It's a bit much," Radcliff complained.

Health policy experts acknowledge that patients like Radcliff shouldn't be surprised by charges on their hospital bills, but this isn't a problem unique to Medical University Hospital.

"You go back in the industry, even a few years ago ... most people didn't really care or want to or need to know what the pricing was because they weren't paying the lion's share of the bill," said Jeff Lehrich, CEO of Palmetto Primary Care Physicians.

Lehrich's practice will publish prices for tests and procedures on its website starting next year, he said. "It's becoming much more like retail for the health care services."

He said health care consumers, particularly patients with high-deductible insurance plans who pay a significant percentage of their bills out-of-pocket, want to know up front what they'll be charged.

"I think we have miles to go on this front," said Jim Ritchie, executive director of the S.C. Alliance of Health Plans.

On the report, South Carolina received an "F" for health care price transparency in part because some of the initiatives in the state that would improve the problem have yet to come online.

MUSC, for example, has a transparency task force - but S.C. Hospital Association President Thorton Kirby said he was not sure that any hospitals in South Carolina post a comprehensive list of prices for consumers, although there may be some that publish prices for select services, he said.

South Carolina doesn't have an "All-Payer Claims Database," either, which is widely considered the gold standard for health care price transparency, but a new website called SCHealthData.org promises to provide prices for many common hospital procedures in the future. The S.C. Department of Health and Human Services and the South Carolina Hospital Association collaborated on this project, although none of the hospital prices have been published yet.

"We know there is a need in the marketplace for this information," Kirby said.

DHHS Deputy Director John Supra said consumers will be able to see information about the prices Medicaid pays for common hospital procedures on the website by the end of April.

"I think (SCHealthData.org) is a good first step," said Ritchie, with the S.C. Alliance of Health Plans. "I think the test will be how user-friendly it is and how comprehensive the data is. If you can't access it and understand it, it will have limited value."

Reach Lauren Sausser at 937-5598.