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Comment by binarymax | Hacker News Reader

Surprise! Pricing is "transparent", although massively complicated.

There are several systems, but let's take a look at Outpatient procedure pricing...

A good outpatient pricing guide is here: https://www.cms.gov/Outreach-and-Education/Medicare-Learning...

And coupled with the OPPS dataset here: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Paymen... as well as a couple others, along with a quick read of the federal register, you can kinda figure it out on your own (/s).

Every bill you get must also have the codes and modifiers on it by law. Its interesting to download the dataset and look them up.

--EDIT-- I incorrectly linked to the COBOL PC Pricer code above for OPPS! Here is the pricing data: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Paymen...

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Pricing is not even nominally transparent. By law, you can get access to the chargemaster, which is the list price that nobody actually pays. If you try to get access to the negotiated price your insurance company will pay, you'll quickly discover that it's confidential up until the point where the provider actually issues a bill. Medicare pricing is a special case, but you can't get that price without being on Medicare. Also, many providers won't accept Medicare because reimbursement is meager and often unprofitable.

I wonder if there is a straightforward way to aggregate people's bills to estimate the cost of a procedure (eg appendectomy) at a given hospital. Eg pay people $1 to scan their bill. This would only work for common procedures I suppose.

HIPAA was passed largely to prevent this potential catastrophe for healthcare executives. b^)

So build it in Europe?

De-identified data and data contributed by people (read, not Covered Entities) is not covered by HIPAA. Someone could build a database of procedure cost comprised of these data sets, but price transparency isn't so easy due to the nuances of the problem (See Castlight Health).

That's a great idea because the codes are usually on the bill, too. The problem, of course, is keeping all of that volunteered data secure.

> Medicare pricing is a special case, but you can't get that price without being on Medicare.

As far as I recall, Medicare pricing is defined by law as a percentage of the lowest price the provider ever charges to anyone else. For the sake of this comment, call it 40%.

If Medicare pricing is public, you can look it up and try to negotiate for 250% or whatever of the Medicare price.

Replying to myself because I can no longer edit: California law requires public access to the chargemaster. This is not true in other states.

If you're uninsured and unable to pay you may be able to get the Medicare rate as a "I will pay you this amount to settle this in full, and I will pay it today" because that rate is still higher than they'd get from selling it to collections.

If it's massively complicated and obscure, then it's not transparent. Transparent means the information is available up front or for the asking, not that it's possible to obtain it if you have expert knowledge.

What you're sharing is great information and a fine foundation for people to build on. But pateients shouldn't have to go off and do a pile of research, they should be able to get a straight answer from their health provider when they ask for one.

If you have a pet and have to visit the vet, you already know they prefer to get paid up front. They'll generally tell you there's a fixed fee for the consultation/ Then depending on what's wrong with your animal they offer a treatment estimate, which is prepared within minutes and about which the administrative staff are generally competent to answer questions (eg why there might be variations in price for some items like anaesthetic). Animal medicine is at once less complex than human medicine (narrower range of treatment options, fewer administrative/legal considerations) and more complex (considerable variation among species).

I've been to good vets and bad vets, but the administrative aspects of both regular and emergency care have been painless and yes, transparent. Until we get universal healthcare, veterinary service would be an excellent model to imitate.

Yes, hence the "transparent" in quotes and the overt sarcasm (apparently harder to detect than I intended). Of course patients shouldn't need to download a dataset and figure it out on their own! But please see my other response to see why it is tricky.

Regarding pets, they are not beholden to hospital/insurance provider duality, and it follows that since it is out of pocket, you would not be able to afford a $60k set of procedure if your dog had a broken leg...so the prices stay affordable.

Tbh if I broke my own leg I think I'd rather have the vet do it. Every time I have had to bring a friend or family member to hospital I'm just appalled by it all.

> "And these are your reasons, my Lord?"

> "Do you think I have others?" said Lord Vetinari. "My motives, as ever, are entirely transparent."

> Hughnon reflected that 'entirely transparent' meant either that you could see right through them or that you couldn't see them at all.

-- The Truth, by Terry Pratchett

This is why the Dutch system is interesting. They have a two-tier model of private and public coverage. For short-term, low-cost care, the private market operates (under regulation) and for long-term care they have a state supplied universal coverage system.

I suppose this would be helpful if they gave us the pricing before the decision of where (or, for many unfortunate people, if) to have the procedure or test done.

You seem to be talking about medicare and medicaid, and not about private hospital services. Is that correct?

Yes, also sorry for the insensitive sarcasm in the previous post. It's a chicken and egg problem. In many cases you don't know if you need a test unless you've already had it. In the case of a procedure, there may be things that come up while it's happening that may complicate things. The irony is that OPPS/IPPS (inpatient) and APC (ambulatory) are meant to simplify things. Doctors and nurses usually do their best to know ahead of time, but medical procedures are complicated.

Fraud does happen most often against medicare/medicaid (as covered in this article with one trick known as "upcoding"), but I believe these codes are used with insurance providers as well. If a hospital or doctor is in your provider network (HMO/PPO) then there is a pre-agreed cost between the two set on these fees. Out of network occurs when there is no agreement, so there is no "trust" between the two and the insurance provider offsets the cost to you because they are legally able to do so.

In my opinion - overbilling is really caused not by pricing complexity, but by the control of the hospital and insurance provider duality. If there was no such thing as a network, and you were covered everywhere, then shenanigans with certain hospitals and providers would be more difficult.

> In many cases you don't know if you need a test unless you've already had it. In the case of a procedure, there may be things that come up while it's happening that may complicate things.

If you're getting something like a chest x-ray (posterior and lateral views), or an abdominal ultrasound, or a lipid panel, you should be able to call around to various labs with the appropriate CPT code(s) and ask them what the price would be.

What's you're talking about would be something like if they order a test and based on the result of that test, they need to perform more tests to confirm or eliminate a possible diagnosis. But for each test, you should be able to get the price since each test has a couple of possible CPT codes that it would fall under for billing purposes.

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