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Comment by mirimir | Hacker News Reader

Actually, as pmorici notes, there are three relevant prices. Without insurance, you will be charged the "cash price", which is always far greater (maybe 3-4 times) the price that they have negotiated with your insurance company. For large insurance companies, that price can be close to the lowest price that they will accept.

Even if you have insurance, they may be able to bill you for the difference between the cash and negotiated prices. It depends on relevant law and terms negotiated with your insurance provider. It's prudent to ask. Also, providers will sometimes "accidentally" bill you for that difference, even if they're not permitted to.

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> Also, providers will sometimes "accidentally" bill you for that difference, even if they're not permitted to.

It's been my observation that hospital billing departments do many things "accidentally". Strangely, these never involve under-billing. A lot of bad things would have to happen to them (and insurance) before I'd start to feel even a little bad about it.

when something involves lots of process, mistakes are inevitable. sometimes by mistake, sometimes maliciously.

It's worse than that, because there's adverse selection. The hospitals that make errors in the client's favor or that don't make errors at all are more likely to go out of business than the ones that make errors in their own favor. So guess which ones are still around when you need a hospital.

In other words, just because the errors are accidental, it doesn't mean they happen at random.

(This argument applies to any shady business practice that "looks" like an accident, for example dark patterns on websites, or having great customer service for taking your money but terrible customer service for refunding it.)

When the same agency is the one influencing, if not directly creating and enforcing, the process, my sympathy tends asymptotically to zero. Especially when said processes are largely driven by a motivation for profit, if not merely to exist as a middleman.

it's actually a little more nuanced than that. Hospitals/providers have what they call charge master. it is probably the cash price you are mentioning.

Even uninsured can end up negotiating the bill, albeit after the fact.

Sometimes, insurance might negotiate lower prices than what a certain procedure/treatment costs, i believe that's not uncommon. They make up for it from other procedures in general.

1. The lack of health care cost transparency reduces price competition. 2. people not asking for price in advance, or not caring because the are already past their 1. deductible 2. out of pocket maximum makes healthcare expensive[a]. Similar to reference pricing, high-deductible health plans (with added HSA benefit) makes people think twice before going to doctors. I also felt a lot of people are not price conscious about healthcare - just yesterday a friend mentioned "i picked the most expensive plan so i don't have to think about it". Completely reasonable, but one reason why prices get higher each year.

[a: reference pricing] http://www.nytimes.com/2016/08/09/upshot/how-common-procedur...

> Even uninsured can end up negotiating the bill, albeit after the fact.

Yes. One could say something like "I know that you're billing me three times what you get from insurance companies, and I know that you'd pay at least 50% to a collection agency, so will you accept 40% now?"

> Sometimes, insurance might negotiate lower prices than what a certain procedure/treatment costs, i believe that's not uncommon. They make up for it from other procedures in general.

True. Also from payers with less negotiating strength.

"Yes. One could say something like "I know that you're billing me three times what you get from insurance companies, and I know that you'd pay at least 50% to a collection agency, so will you accept 40% now?""

Unfortunately, this misses another pertinent point, that the provider/facility will be able to charge off and deduct as a loss either that 50% of the original amount they're going to charge you, as well as getting 50% from collections, or 100% if they're... 'creative'. This can often reduce incentive to negotiate.

that's still a hassle, though. there is a point, but it probably works better with individual practices than large hospitals.

Maybe so. But wouldn't that increase the incentive to negotiate?

How practical would it be to recreate the charge master through crowd sourcing? If everyone scanned their invoices and submitted the hospital name and insurer, a picture would very quickly emerge that might allow consumers to get a reasonably accurate view of what line items are typically in a certain procedure and what it all costs.

There's nothing which prevents the sharing of this information, is there?

Anecdote: My son broke his arm when I was between jobs and had no insurance.

The doctor had an x-ray machine on premise, but he admitted to me that his costs for it were high and that I could get a better price at the imaging place across the street.

Once there, when I explained my lack of insurance, I was told that not paying up front adds $75 because billing is a PITA.

Even though an insurer might be able to negotiate a good rate, they can't beat cash on the barrel head because cash pay doesn't require nearly as much work.

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