Comment by subhobroto | Hacker News Reader

Comment by subhobroto | Hacker News Reader

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TLDR: Stop capitalizing on suffering. The reason why people on this thread are complaining is not because they have a natural disposition against doctors: it's because they have been taken advantage of!

Long post:

Good point, except that get to see I see the invoice AFTER a service has been provided to me, sometimes MONTHS after the encounter EVEN AFTER SPECIFICALLY asking for an estimate upfront.

If you know a provider who works otherwise, feel free to answer this question: https://www.quora.com/How-do-I-find-a-general-physician-in-S...

No providers office I know of are willing to provide estimates to patients for procedures the same office requires the patients to be financially responsible for!

The reality is that the provider is like a programmer who builds what I discussed with her to build only that I get a $10k bill AFTER THE FACT without having a say in whether I am OK with it or not and she just went ahead and did the project for me without even asking me if I wanted her to do it.

If I don't pay, my credit will be trashed with a collection entry.

This is unacceptable. I am not sure if you agree.

Case in point: I went to a specialist to figure out the ringing in my ears. I made it clear to both the administrative staff and the doctor that I should be told of any charges outside the office visit fee before such a charge would be incurred.

The specialist looked into my ears and said my ears looked fine and the ringing could be due to stress.

A month later I got a $1500 bill for "in office surgery". Apparently, if a specialist inserts anything into my body, it's a surgery and billed in addition to an office visit fee.

I do NOT believe this is proper. The provider took full advantage of my inconvenience.

I am lucky it was a $1500 bill and not a $15000 bill. It could very well have been and I would have NO recourse.

I am happy to pay your negotiated rate as long as you tell me what that rate is and how many hours you estimate it will cost me.

What I am NOT happy to do is be forced to pay an amount that I had no say in the first place.

Providers ARE exploiting their patients and getting away with it by placing the blame on the faceless insurance companies.

Patients are not walking blank checkbooks. They are suffering and under pain and looking to you for a remedy.

Providers have a right to make money. Providers DO NOT have a right to exploit.

There's a lot of rant in this post which I'm going to leave to the side, because I have no idea what happened between you and that physician / billing agency / insurance. "In office surgery" may mean you got scoped, but I'm not an ENT, and I'm not going to speculate on what happened.

First point: If you're willing to pay cash and bypass the insurance / CPT / ICD10 / RVU rigamarole, I'd like to direct you to any number of concierge physicians who will gladly take your money, provide you their cell phone, and give you 24/7 availability. Simply Google "concierge physician san diego", and you'll have your pick of physicians from UCSD or Scripps or other great places in SD.

Second Point: You're conflating a whole lot of stuff. Your insurance doesn't pay us enough to do the whole "personal estimated bill". That's the patient's responsibility. You and your insurance company are the only people who know the status of about 10+ variables which will affect your out-of-pocket-cost. What's your deductible's status: Have you exceeded it? What's your out of pocket max for the year? Do you have a copay or coinsurance for ambulatory services vs hospital provided services? Are we in-network with your variant insurance company's policy? There's no API for us to query all this information from Aetna/BCBS/Humana/et al, and given how insurance companies LOVE to put up barriers to care via prior authorizations, that API is never happening unless mandated by federal law or built by yet ANOTHER company.

>The reality is that the provider is like a programmer who builds what I discussed with her to build only that I get a $10k bill AFTER THE FACT without having a say in whether I am OK with it or not and she just went ahead and did the project for me without even asking me if I wanted her to do it.

This is a false equivalence. The medical equivalent to this scenario would be calling and speaking to a physician on the phone about whether you even need an appointment and then receiving a bill for a consultation with lab testing. Our taking an interview with you, reviewing outside notes/labs/imaging, doing a physical examination, and providing our expert opinion IS our deliverable product, NOT the procedure and definitely NOT the medication we prescribe. You wouldn't engage a business consultant or a lawyer for advice and not expect to pay for their time? Why is it different with physicians?

The "I WANT AN ESTIMATE UP FRONT" request is fine for some areas of care, but if it were up to me, I'd simply give you my charge-master-highest-rate and say "I don't know what your particular insurance company has negotiated and which contract will be in effect at the time of bill submission, so the resulting charge may be lower than this. It will not be higher". For example, I'm in Radiology, so my billing is different. My deliverable is not an in-person consultation, rather a diagnostic imaging examination, interpreted to the best of my expert opinion. I can provide a concrete, encapsulated, whole estimate of charges for both the technical and professional fees, and that estimate will be the maximum I charge all 3rd party payers.

I agree with the answer provided by Quora. You're asking someone to do ALL the work, before you even decide to pay them. This is the equivalent of asking a lawyer to evaluate a contract and then offer you a per-paragraph rate of evaluation based on the projected complexity of each section, before you even then decide to pay them a dime. That estimate is difficult to perform without going ahead and just doing the work. If you're going to play that game in medicine, just pay the physician hourly like in law in 15-minute increments or get a concierge doc.

> Your insurance doesn't pay us enough to do the whole "personal estimated bill"

I respect that you are a MD from Harvard Medical School. Obviously you are very smart, and hard working.

Deep inside you, something must be telling you that it would make no sense for a provider to be in business of seeing patients if they were making no money in it.

I am also confused if you disagree with me that it is reasonable to be told of costs that one is expected to pay BEFORE one is made to incur those costs?

Someone is paying you and for the computers and GPUs you run your code on. Infact you made a very similar comment: https://news.ycombinator.com/item?id=10930242

But let's keep that aside; that's a completely separate discussion.

To clarify: I did not ask the provider to tell me what my OOP will be. I am educated enough to figure that on my own. I know how to call my insurance company and speak in English.

All I want the provider to tell me is what they typically bill during a routine service so I can figure out how much my visit will be billed to my insurance company.

I am more than happy to talk with my insurance company to figure out how that cost will be settled.

I don't want the provider to do anything extra for me.

> I'd simply give you my charge-master-highest-rate and say "I don't know what your particular insurance company has negotiated and which contract will be in effect at the time of bill submission, so the resulting charge may be lower than this. It will not be higher"

GREAT!

That is fine and I would welcome it! Seriously. Let me sort out what I need to pay and what my insurance pays.

Just tell me what my maximum financial liability could be and I am a happy camper!

I don't think you still have understood my "rant" but in this case I was not told about the possibility of a "surgery" before, during or after the appointment, with me asking the doctor and office staff at each of those steps if I owed anything. I came to know about it months later when I got the invoice with a due date.

Anyways, I do not want to repeat the detailed discussion that are already in the comments on the Quora post. You are welcome to expand the comments and read them yourself once you are over being condescending.

FYI, the last comment I made there clarified I am more than happy to pay for the consultations and estimates. No one works for free.

I would rather pay $500 for consultations and estimates to figure out what I am going to get and whether its worth it to me than $1500 that I had no say in that just happened to show up in my mail.

Since your first line is all so very dismissive of my whole rant, I will not longer engage with you, as it's probably wasted energy.

You read the anonymous answer, you agreed with it, got what you were already decided on and did not even bother to read further.

For your sake I hope you never get a medical bill you never even thought you would get that would end up destroying you financially and put you in extreme debt.

This actually happens to people in the U.S. on a regular basis, and I dont think that's normal.

I cant personally imagine why smart people even think this practice is OK.

What happened to me during that visit can be summarized by: "oh that peek we did into your ear? yeah, that's $1500. sorry we didn't tell you in advance. If you don't pay it, we will trash your credit".

For other people possibly reading this: the office did not even tell me that the visit might involve extra costs INSPITE of me EXPLICITLY mentioning that I would need to be made aware of such.

TLDR: I am HAPPY to pay for costs that are shared with me BEFORE they are incurred SPECIALLY when I am asking to be made aware of costs that I am expected to pay.

>> You and your insurance company are the only people who know the status of about 10+ variables which will affect your out-of-pocket-cost. What's your deductible's status: Have you exceeded it? What's your out of pocket max for the year? Do you have a copay or coinsurance for ambulatory services vs hospital provided services? Are we in-network with your variant insurance company's policy?

Stop talking about what the patient will have to pay out of pocket and start talking about how much you will receive. I agree that how much of that is covered by my insurance is between me and them, but it starts with what YOU charge for services. And back to my original point, that should be a fixed rate (of your choosing) charges to all of your patients (and their insurance company).

That's the big problem. What we charge is universal across carriers; it's the law. What the carriers then do is try and negotiate me down to accept some fraction. I could charge $5,000 to everyone for a PETCT; Medicare laughs and will pay a set amount. Depending on their market power, private insurance will pay a multiple of what Medicare reimburses. I would be stupid to set my "charge" lower than the maximum a given insurance will possibly pay.

If I charge under what they will pay, they aren't going to reward me with all that savings.

If someone wants to negotiate with me directly, I'll charge you some other price, then write off the rest, just as if you are phkahler insurance co. It's the only "legal" way to offer a discount.

What I want is not possible without legislation. I want you to charge your rate and the insurance companies not be able to negotiate other than walking away. The only way the insurance company can save money then is to not cover the full amount and pass the rest on to the patient. Now you have to compete with others like you, and insurance companies have to compete with others like them. The super-awesome doctors can charge whatever they like and only take cash because insurance companies won't cover their services, and that's fine too - I know of a couple guys like that already and they are awesome at what they do.

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