Girl’s $143k bill for snakebite treatment reveals antivenin price gouging | Hacker News Reader

Girl’s $143k bill for snakebite treatment reveals antivenin price gouging

arstechnica.com

193 pointspseudolus181 comments

Buddy of mine breaks his collarbone, gets some pins put in. They drop him a bill for $25k.

He says "I'll give you $1500 now, or you can send me to collections."

They took it; now I use this technique all the time.

They make up a number which is how much they hope to get out of you, and you should return the favor by make up another number. Then scream at each other on the phone for a few hours before coming to terms.

Sad that it's come to this, but medical billing is a shell game. You can play it too.

> Sad that it's come to this, but medical billing is a shell game. You can play it to.

All irregular billing is a shell game.

Thank you for pointing this out. I really hate articles that treat the rack rates presented to uninsured consumers as a fixed bill; it's not. I think this is something where articles could do a better job of explaining to readers how the rates are really an opening to negotiation (the negotiations already done by insurers).

The problem is that it’s not presented as a negotiation to consumers. Negotiation/bartering are far from the norm in our culture.

I do agree; it's taken me years to overcome my aversion to negotiation. It wasn't until I saved a million dollars on a contract just by asking(!) that I appreciated the process and how many transactions can be negotiated.

The interactions you have where you could possibly save a million dollars on a contract are not the interactions of an average person

We were charged $9000 for epidural during our first child's delivery. After a lot of back and forth between me, the hospital and the insurance company I ended up paying $99. I never tried to understand the logic.

The logic is that anyone who does pay makes them a ton of money.

Yet hospitals are not killing (no pun intended) it like apple or Microsoft. The massive margins are getting eaten somehow. Expensive equipment, salaries, commissions, patients telling them to shove the bill. I don’t know something is missing

There is another dirty side to our healthcare. They generally lose money on the uninsured and in some cases Medicare/Medicaid. Essentially we pay for that coverage with our dollars.

The "emergency rooms must treat" law (I forget the name or how long ago it was, sorry) resulted in state governments stopping funding public hospitals - which made this state of affairs basically inevitable.

Transparency is missing

I had two insurance companies when our first kid was born, and the hospital completely botched the filing leading to both companies denying the claims because of late filing and so on (we gave them additional the info they needed a few days after the initial claim was denied — they didn’t refile until nearly a year later).

They tried to come after us for 10s of thousands of dollars in bills.

After much back and forth with insurance companies and the hospital most of it was either discharged or paid for by insurance, they eventually sent us to collections for $1000.

Unfortunately for them, I had been taking detailed notes of conversations, including people I talked to and dates and times, and had gone through itemized bills, noting things like duplicate charges, and multiple times I had been lied to on the phone by the billing department about what paperwork they had filed with the insurance companies and when along with documentary evidence by the insurance companies.

By my reckoning they actually owed me an $800 refund from a check I had sent them earlier to cover a charge that an insurance company later paid.

I said if there isn’t a check in the mail today for $800 and the collections notice retracted, I’m taking all this information and filing in small claims court.

It was taken care of that day.

My kid was already walking by the time the billing was handled for his birth.

It’s so depressing because as a hospital, we have absolutely no complaints about the care. It’s hard to believe that they can be so competent at delivering care and so completely incompetent at billing for it.

I'm depressed just thinking of the admin battle and stress you went through!

I paid £2 a day for parking when my first child was born, requring an emergency c section and 4 days of intensive care.

Hospital food was shit, but medical care amazing.

You still should have filed a complaint with the State Attorneys General of all applicable jurisdictions.

Hah.

Seriously you should. Companies fear State Attorneys General. I filed a complaint against one of the major wireless carriers with my State Attorney General office. Within days I had someone from the executive offices at head quarters calling me to resolve the issue. Companies know that State Attorneys General have teeth and resources to sue or fine companies found to be breaking laws or being abusive. I suppose it also helps to have a consumer caring (rather business caring) State Attorney General.

Won't the healthcare market fail at some point if this keeps going on? I mean there might be some big loan somewhere that will default one day. No idea what will happen then.

There is a whole lot of accounting magic, and forecasting that goes on. They know that they won't get a lot of it, but there are several things they do to "mitigate" their "loss". They get to write it off on their taxes. They'll often sell unpaid debts to 3rd party debt buyers. They'll get some money out of bankruptcy etc.

A lot of hospitals own debt collection agencies and if that doesn’t make you angry, I don’t know what to tell you.

vertical integration FTW

That depends on how much it actually costs to deliver their services, in aggregate.

What market? If you get problems from regulation and the solution is always more regulation you eventually get a Rube Goldberg state run health system. If the US wanted cheaper medical care they could disaggregate medical care and actually try to drive down costs. As it is the supply of people who want to be doctors just keeps going up and there are plenty of foreign doctors who would be delighted to work in the US who aren’t allowed to do so. The AMA doesn’t want nurse practitioners and it doesn’t want foreign doctors and they’re winning. Hell, look at India, they have something close to a free market in medical care and factory line hospitals where people get better at the procedures they do by doing one thing many times and list prices. Why can’t the US do that?

https://www.chrisstucchio.com/blog/2015/medical_tourism.html

> One of the things I like most about India is it's medical system. As an American, I've experienced both the Indian and US medical systems, and at this point I have a very strong preference for the Indian one. Somewhat surprisingly, the Indian medical system is based on free market capitalism, and as a result it tends to provide a much better experience than the US system.

>They took it; now I use this technique all the time.

I’ve done this once for a $12,000 bill for a few stitches. They refused any deals, until I showed I actually took video of hospital staff promising it wouldn’t be more than $2,000 before treatment, in response they waived the entire bill.

The way you phrase this though...how often are you receiving acute medical treatment?

I should do that

Everytime some staff member says "it will be covered we are just doing x, y, z this is covered"

and then you get a bill from the insurance company and the doctor's office says "we THOUGHT it was covered"

Video recording like that is totally throwing the staff under the bus (they will undoubtedly be talked to about making commitments like that).

I'm sure hospitals will all include a "all promises maid by staff are null and void unless documented in writing" waiver if the practice becomes widespread.

>I'm sure hospitals will all include a "all promises maid by staff are null and void unless documented in writing"

Despite all the FUD about health care prices, most states have consumer protection laws that require providers/hospitals to provide estimates for services upon request. Therefore, by law (state by state) the hospitals could not employ the tactic you suggest.

Which states specifically have these laws? What's the typical legal name for these laws? Couldn't find anything on this in a few quick Google searches.

In Florida you can checkout Florida Statute 395.301 (Price transparency;itemized patient statement or bill;patient admission status notification).

I know this off hand, and don’t have the time but from there you could probably find a few websites that will reference comparable laws for each state, if they exist.

Thanks. Working from there, this website list many state health care price laws in a PDF:

https://www.pcpcc.org/resource/report-card-state-price-trans...

This is just what I could find quickly. There might be better resources on these laws.

Looks like a really good resource/starting place.

Law is an unforgiving beast so you would always want to refer to the source law they cite, and finding case law (much more difficult task) which references said Law and see how it’s applied/interpreted in practice.

What you linked is certainly much more practical for educational/informational purposes.

And the patient getting thrown under the bus by getting screwed with a 5x bill is fine?

Recording sure sounds like the lesser evil to me

>And the patient getting thrown under the bus by getting screwed with a 5x bill is fine?

Where did I say or imply that?

I think it's fully worth it and wouldn't lose sleep over throwing the staff under the bus. If you want to work for an establishment that screws people getting screwed back occasionally is just one of the risks.

As a British person living in the UK reading stories like this seems so crazy. The very idea that when Americans are ill they need to negotiate with these huge institutions seems so utterly bizarre and messed up.

Surely if people know they could be fined thousands for simple treatments like stitches they avoid medical care altogether? Then things could get worse and even more expensive...

I mean, you are also seeing the extreme cases float to the top because articles like these attract anecdotes. It's hard to tell how widespread the problem is because people who pay a more reasonable amount for stitches don't comment in these kinds of threads. For all we know this only happens .1% of the time

FWIW, I've never had such extreme bills. The largest bill I've received in the last few years was $2000 for my wife's epidural, but I only paid about $400 of it (insurance paid the other $1600)

Most people hand it off to insurance and don't look at it twice. My parents have a story of looking at a paid by insurance bill that included $2,000 for two ibuprofen pills. They questioned it, and everyone involved (including the insurance company) said "why do you care, insurance pays for it?"

They don't pay list prices either, and have negotiated something much less. The list prices are basically a fantasy hoping to gouge the unknowing, while the rest of us feel like we got a discount.

It's simple fraud in many cases.

Patient has a 20% copay. The provider bills $100,000. The provider "pays" $80,000. The patient pays $20,000.

Provider then pays a $70k kickback disguised as a discount on other charges, fees for participation in the system, etc. (or never even pays the EOB amount). In fact a total of $30k is paid for the services, and 66% of that comes from the patient.

Insurance gets away paying $10k instead of $24k (80% of $30k). Provider gets the business by being on insurer's provider list. Patient thinks "I'm glad I paid $20k for Insurance. My health-care-spend ended up being $40k instead of $100k." In fact, they'd have been better off without insurance, which would have only cost $30k.

are you claiming most people don't have deductibles and copays? or no in & out of network coverage. if so I'll call BS on this. I've had instances of being billed from out of network provider even though I went to in-network hospital. this is such a common occurrence that John Oliver did an episode on it.

Nearly 100% of people spend some time in a hospital in their lives.

Unless you're claiming that hospitals only gouge some tiny subset of people and are benevolently generous to everyone else, that number is going to be much closer to 100% than 0.1%.

When I lived in the US, I have personally experienced this, even with top-tier insurance--from both ends: I've had insurance decline claims arbitrarily and pass on five-figure costs to me, and I've had hospitals misclaim things. In both cases, I had to spend dozens of hours on the phone to resolve it.

Most people in the US are far less privileged: Their insurance is not as good, and they don't have the luxury of spending dozens of hours on the phone.

It's just a matter of time until you experience this.

> Unless you're claiming that hospitals only gouge some tiny subset of people and are benevolently generous to everyone else, that number is going to be much closer to 100% than 0.1%.

Actually, yes. Doctors and hospitals have relationships. When a hospital is aware that a good referral source referred them a patient, they will try to keep the patient happy to maintain that source of business.

They're very selective about who they try to screw.

Now if you walk in with no referral and no family doctor, then you're their source of profits and the party they'll try to milk.

> Now if you walk in with no referral

You mean like, say, an ER visit?

Though, actually, the one time I've been referred to the ER by a doctor (he called ahead and everything), the billing was still a shitshow. Insurance delayed paying for months while they tried to work out a way to claim it was a pre-existing condition (this was pre-Obamacare), until the hospital gave up and tried to send me directly to collections for upwards of a quarter million dollars.

Given that most private practices (around here, anyway) usually have lucrative hospital affiliations, the incentive to keep doctors happy by keeping patients happy really doesn't exist.

I'm reading what you're saying, and it makes me sad - as if you don't believe that people without insurance are just liars. People are avoiding getting medical treatment because it may financially ruin them. Do please believe them.

Take another look at that chain of bills. I would guess that if the initial bill was for $2000, the hospital only received $800 or so total. So insurance paid half, you paid half, but you think insurance paid for much more when really they just swatted away a fraudulent price.

Yes, very few here have been on the receiving end of a $143k magnitude extortion. The people who have are less likely to be writing HN comments and more likely to be slaving away in the mines of Rura Penthe. But these exceptional stories fit the exact pattern that anybody who has interacted with the healthcare racket has experienced, even though most ultimately dodge the (biggest) bullet.

They do. And we wonder why our medical costs are completely out of control.

>Surely if people know they could be fined thousands for simple treatments like stitches they avoid medical care altogether?

This is what happened to myself. I've had persistent breathing problems and the last time I went to a specialist for it they charged me $3,000 to breathe in a tube for 15 seconds and say they don't have any ideas as to what was wrong. I haven't been back and try to ignore the fact that I have trouble breathing daily.

There are two options for you you can set up a fake business and buy health insurance for your employees as long as you have two such as you and your spouse. Another option is to visit a private urgent care clinic. The doctors and prices at urgent care are usually pretty good. Make sure the urgent care is not attached to a hospital.

Your anecdote reads like something out of a Neal Stephenson novel, writing style and all.

Same with me and these random chest pains I get. I've wiped out my HSA, still not close to meeting my deductible. Hooked up to an EKG for 15 minutes and monitored for an hour in the ER? That'll be $5k. 15 minutes on a treadmill with an EKG attached for a stress test? That's $2.2k. I would continue to pursue until I had an answer, but I simply can't afford it.

As a Japanese, It's crazy too. The government approved treatments are all strictly priced. No more and no less.

2k USD for a few stitchies? That's still insanely high.

> The government approved treatments are all strictly priced.

I kind of like Japan's system based on what I've read so far, but I'm still not sure of one thing:

Does regulated pricing have a chilling effect on drug companies?

It seems like it would be impossible for a Japanese drug company to be viable if the government gets to fix the price so that anyone can afford it seeing as new drugs can cost billions to develop.

No, it doesn't have a chilling effect because pharmaceuticals are a global market. The dirty little secret is that the US having crazy rates like "$2000 for two ibuprofen" as mentioned in another anecdote in this thread is exactly what enables price fixing in most of the rest of the world to be functional.

The disaster that is the US healthcare system is architected to eliminate any concept of price transparency to directly confound free market processes, and is costly to line the pockets of middlemen and pharmaceutical and medical/biotech firms, because their pockets aren't being lined elsewhere in what is an essential and large global industry. The US effectively subsidizes healthcare around the world by paying out the nose, and the entire thing is perpetrated against the American people by intentionally introducing smoke and mirrors to the process.

I'm pretty sure "we're subsidizing foreigners" is one of those smokescreens.

It's almost Trumpian in its vague, implausible and detail-free appeal to the baser instincts in order deflect from clear and obvious fraud.

It would be astoundingly easy to fix. All you'd need is a law/regulation that says drug companies can't charge US customers more than the average price for the same drug in say, Canada, France, Britain, Australia, and Japan.

Suddenly we'd be paying a lot less and if we are subsidizing the cost it'll for them to raise prices in those other countries.

The government gets to fix a price doesn't mean the drug company has to make it (or exist), right? So presumably the price would be set at some point where there is still a profit to be made.

As someone from the EU, this reads like dystopian fiction. I pay about $120/month into the state (mandatory) health insurance system. In return, I get crappy first-contact healthcare, but I know I am covered in case anything bad happens.

Example: ending up in a hospital in Italy during a skiing holiday involves showing your insurance card (or simply giving the number). That's it: there is no payment, no negotiation, nothing — you just get healthcare services and you're done.

The EU gets criticized for many things, but universal healthcare across the entire union is something that should get more praise than it does.

>> As someone from the EU, this reads like dystopian fiction.

As someone living in the US (thankfully well insured and decently paid), I can confirm dystopian reality. Everything works well 97% of the time, until you have something that falls out of the confines of the giant decision tree -- and then things go really wrong. I used to think everything was well until we had a difficult pregnancy/delivery. In such cases, there are professionals who's service is bill reconciliation!

I had health insurance and still we were in a 10k shock for normal delivery. US healthcare is a mafia extortion industry.

US is the wealthiest nation but the deadliest nation too in terms of preventable deaths.

Even if you don't have health insurance, in most of Europe you are fine. Especially in Central/Eastern Europe, where doctors in public hospitals work extra hours privately to make a better living.

Well, I think in all of the EU, you will be treated no matter what in an emergency. It doesn't matter if you have health insurance or not. That's the whole point of universal healthcare, something I've come to regard as a basic right in a civilized world.

Same case for emergency care in the USA, even for private hospitals.

Yes, but if I understand correctly, you do end up with a bill afterwards.

Also a Brit. I think about my various trips to hospital throughout my life and cannot imagine the difference if I was coping with money at the same time.

As a child, breaking my arm was upsetting, but imagine if it put additional financial strain on an already strained family?

My motorbike accident age 18 would have just been flat out medical bankruptcy (and potentially worse/incomplete recovery). I was pretty miserable anyway, adding that would've been demoralising in the extreme.

The hullabaloo over "If you like your doctor, you can keep your doctor" goes a long way to explaining how health-care used to work in the US. Most simply it was a free market and free markets work.

In more detail: Independent doctors (and their staff) functioned as buyers' agents would refer patients to specialists. "Doctor-Patient Relationship" and "Referrals" were the two main components of the system. Knowing that DR. JONES referred PATIENT SMITH to them, the specialist would treat PATIENT SMITH well and charge a reasonable amount.

It was unfortunate in that you had to "get in" to the system by finding a good doctor. It was (and more now than ever is) hard to "find a good doctor." Most are no longer accepting new patients, but it served all those parties. Doctors would have repeat customers. It'd reduce their work of learning new patients. Etc.

Without such a family doctor, you would go to a provider without a referral. The provider would then know it could gouge you without risking a referral relationship.

However this system was sub-optimal for insurance company profits and large scale providers. Which is exactly who pushed Obamacare, and lead to the break-up of so many of these relationships.

As background, Health Insurance has lists of "approved providers" which they carefully curate. The most straightforward method of breaking up relationships is to exclude providers. They also put these "good doctors" (from the patients' perspective) into plans with expensive premiums. They also churn. By raising prices selectively between plans with different providers insurance companies can encourage patients to "try out" a new doctor this year. They also churn provider lists.

This means Insurance companies are now a more powerful source of referrals. They also prefer institutional providers. Between both of that, fewer providers care about where their patients are coming from. The patients often don't have much choice where they go (one of 9 different locations of the same conglomerate) and don't know enough to make an informed decision anyway (as their family doctor used to do for them).

All of this is brought about by the individual mandate. It's not a free market if you're not free to abstain. By being forced in, cash buyers became a smaller segment of the market. Cash buyers were the very people holding it all together by selecting doctors of their choosing and forming these relationships. With these doctors going out of business (largely retirement) and being replaced by institutional providers it's just getting worse.

In the free market what is the incentive for any doctor to take on a patient that has a condition so expensive the patient can't afford the treatment?

You are completely ignoring the insurance part of health insurance.

How do you negotiate with providers while having a heart attack?

Free markets depend on leverage.

I think their assumption is that you do all that thinking and negotiation while picking an insurance provider so it's covered.

But then you get carted unconscious to a hospital you are covered for but looked over by an "out of network" doctor, whatever that is.

Being an American seems like a full time job. You have to watch your back so society doesn't eat you. The frequent obsession over credit scores I see on Reddit is another one that baffles me.

Credit scores don't matter in the way it sounds. If you're trying to do tricky things like rotate through credit cards for their benefits (like airline miles), then it requires closer monitoring, and it helps to watch in case some sort of fraud is going on, but that's about it.

That said, keeping up with looking after your own back in America does feel like a full time job at times. :/

And leverage depends on clarity regarding price/performance. Neither of which is readily accessible for health providers. Way too many variables, of course, but some basic price facts would go a long way toward improving the situation.

> All of this is brought about by the individual mandate

Some of us are old enough to remember dealing with healthcare before Obamacare, and can testify to this having been the status quo long before there was an individual mandate.

There was also the scare-mongering associated with "keeping your insurance plan". Failing to realize that a great many people had been diligently paying for a plan that was NEVER going to pay out for any reasonable expenses. Plans so bereft of decent coverage that it would have bordered on criminally negligent had the ACA offer something like them. But how do you make that argument? You can't keep that because it's shitty and we can't offer something worthless? They should have made this point but it was honestly not on their radar, that something so miserably bad would be out there.

On the other man I am making the kind of money I can never ever make in UK, so US is optimized for individual gains and high health care cost are side effects this bal game.

Do you run a hospital, by any chance?

> The way you phrase this though...how often are you receiving acute medical treatment?

I was unable to a price quote of any kind before elective procedures, when I lived in the US (last year).

My insurance was good, but they would not say if they would cover the bill ahead of time.

I live in Mexico and have had to get stitches many times. Paid $4 per stitch in the private hospitals in Guadalajara. I paid $24 in cash with the pesos in my pocket and walked home.

Even the dentist system in Mexico is walk in, pay, walk out for high quality work. I tried to go to the dentist when visiting family in Texas and had to fill out paperwork and pay to be a member first.

Seems like the only benefit of the US system is when you have a nice job, everything is basically free. Probably why nothing will change too much anytime soon. To quit your nice job to try to start a business forces you to gamble with your healthcare.

isn't it true, however, that in MX if you don't already have the money to pay you will be turned away? If you walk into an ER in Guadalajara with a broken wrist and no money/insurance, what do they do?

lolwut? Even in my story above where I casually walked into the hospital, they had no idea about my ability to pay until after treatment had been rendered.

And just like in the US, you can walk out the front door at that point. But unlike the US, nobody is deluded into thinking you're bailing on a $12,000 bill because you got some stitches.

I got stitches in Austin five years ago after drunkenly slipping on a party barge and gashing my head open. The whole time I was getting stitches, someone was there using scare tactics to ensure I was going to pay for them, tried to take my name and info down, suggested that maybe we should only do 3 stitches instead of 4 if I wasn't going to give them my info. Probably extra pushy because I was drunk.

They billed me thousands, I gave them the $100 in my wallet and walked out the door.

My experience in Mexico for basically everything related to healthcare has been superior to the USA, from drugs to child birth to surgery to other healthcare fields like dentistry. I'd probably rather get cancer here, too. I know a Mexican here with a brain tumor that gets operated on every year. He can walk in to a public hospital, but he prefers the private ones. His last operation, he paid $1,500 cash. I don't even want to know what that would cost in the USA. Probably the rest of your life in servitude.

The USA is nice when you have a cushy white collar job like most HNers, and that's what I don't like. I don't want to work a cushy job all my life. I want to live off my savings for years at a time, live on a beach, take risks, start things, yet not lose half my savings when I have an accident. As far as I'm concerned, the USA can't deliver that.

I've asked Mexicans living in the US what happens if you go to the hospital and have anecdotally been told that they will absolutely turn you away for inability to pay unless you are dying from trauma, hence why I asked.

Two storys now, you've told me of people who have actually paid for healthcare in MX. What happens if you are destitute and need gallstones removed, for example?

Doesn't surprise me. Look how ignorant Americans are of their own system as well. In this very thread Americans are revealing that it's possible to counter-offer at hospital checkout to save $10,000. Should be common knowledge, no?

Instead it's a highly upvoted anecdote in every HN thread about American healthcare. It goes around like fire-side superstitious oral story-telling. What's even the limit on this story? The guy above offered $1,000. What about $100 or $10? What about just leaving with a $0 bill? Since the latter is possible, is the $1,000 a meaningless gesture so we don't feel like assholes? Is this the system?

Also, Mexicans in America are often of a Mexico-hating variety since they left Mexico, and in my experience they will often pander to Americans by dumping on Mexico. Just like what you see in Americans abroad that play up the bullshit.

The destitute in Mexico go to a public hospital under the Seguro Popular program. I lived across from one.

You can get a high level overview here: https://en.wikipedia.org/wiki/Healthcare_in_Mexico -- For example, it doesn't seem like you realize that Mexico has a universal healthcare system.

What happens in the US if you're homeless and have gallstones, and walk into a hospital asking for treatment?

go to ER after becoming violently sick, they send you to surgery within hours.

Interesting. There's a large homeless population in my town, and I've always wondered how difficult it would be for them to get emergency medical care.

The odd thing here is that in the US, dentists work more like you expect doctors to in Mexico.

You can generally go to any arbitrary dentist and ask "how much does procedure X cost?", and get an itemized estimate that will be very close to what you actually pay. I have never heard of paying to be a "member" first.

It was explained to me that the reason dentists operate differently is that historically very few people had dental insurance (either their plan didn't offer it or they declined coverage), so dentists developed fair pricing and kept price lists so their patients would know if they could afford a particular procedure. Now that dental insurance is common, the practice remains because most plans have a yearly maximum, so if you need expensive work done (e.g., multiple implants), the dentists/oral surgeons will work with you to schedule work so you are only billed up to your yearly maximum.

It's far from a panacea but it works better than the medical insurance system.

Algodones, NM is a medical and dental border town. Wife of a friend had to get the majority of her teeth worked on or pulled and US dentists and their insurance quoted them around $16,000 out of pocket.

They flew into Algodones and got a hotel, walked across the border and had it done for $2,000 total for a multiple day procedure, anesthetics, and pain relief meds. The dentists are board-certified what from I understand, but don't ask me about the particulars or malpractice statistics.

IIRC, there were about 300 dental clinics alone in the local area to choose from but I don't know if that's an exaggeration.

Yikes. Think I'm going to learn to do my own stiches.

In what way are these guys different from mob guys running a protection racket? They seem to operate exactly like thugs that come to a restaurant, ask for money for "protection" and then often walk away with 10% or less of what they asked for.

If mob guys lobby politicians to make their protection racket legal, then no difference.

There is a long history of the mob paying off cops and politicians....

they will probably still send him to collections, just later. thats what happened to my friend who needed surgery on his hand.

Yeah, but medical bill collections has way less weight on your credit than (say) a car bill past due.

They send so many people to collections that even creditors don't care about it anymore.

About ten years ago, my wife had to get her gallbladder removed; they had a bill of $75,000. Her family was very poor, didn't have insurance, and they similarly made an ultimatum of "you can either get nothing from us, or you can get $5000", which the hospital accepted. $5000 was of course still a struggle, but how absurd is it that they were effectively doing a 1500% markup for a life-saving procedure?

If they hadn't known about this trick, there's a good chance that her family would have had to declare bankruptcy to pay for this, which of course means that the taxpayers are stuck footing the full bill.

Well, they took some amount that covered their costs. It's not clear they made a profit or not. They know some will not pay and pass the cost onto the rest of us.

Fair enough; I guess I would just be happier if we had an NHS-style system where taxes just cover everyone. The reason my wife had serious gallbladder issues was because she didn't go to the doctor to get it treated when she first started showing symptoms (because she couldn't afford it), and then had to go to the emergency room.

Anyway, I get that they pass the costs onto the rich people and/or the insurance companies to cover the people that aren't paying, but it's still depressing, since a lot of people don't know that you can "haggle".

Do most hospitals run billing systems supplied by Oracle? That would explain this "size-'em up" pricing strategy...

This seriously can backfire, though. The hospitals where I lived... they took folks to collections. They would take you to court for a fairly low amount of money and garnish your wages. Sure, it takes longer, but they'll get their money. IIRC, in the state I lived in, they can take 25% of your pay as long as they leave you an amount equal to 30 hours at minimum wage.

It generally just takes years longer.

How can you avoid the "backfire" of having to pay the whole bill? Just pay the whole bill straight away?

People should be honest and pay reasonable bills. But forcing collections and/or lawsuits is one way to put on display for everyone how bad our medical care charges can be.

I have had some issues getting sent to collections before I get any bill, or not sending me the right bill and still sending me to collections after I try to figure out what I actually owe.

I learned to just pay like $10 a month regardless of what happens. Then if insurance decides to pay for it I get it refunded or it's put towards my deductible. The clinic sees me "trying" to pay for my bill and don't send me to collections now.

I doubt it would work everywhere, but it's beyond frustrating.

When using the technique, be sure to get confirmation in writing that the bill is paid in full.

I've used it twice before. Once the hospital offered to consider it paid in full if I paid my entire $500 copay at time of discharged (i.e. anything left after copay + insurance payment would be written off).

The second time, I was able to get a facility fee negotiated down from $5k to $1k. The $4k difference found it's way to debt collections and onto my credit report due to the way the payment was written down in the system, and it was hell getting it dealt with since I didn't have explicit confirmation that the $1k wasn't a partial payment on the full bill.

Meanwhile in Costa Rica the treatment for even more poisonous snakes would cost zero dollars with zero zero cents (including helicopter or small plane, if required). Here antiofidics are produced by the Universidad de Costa Rica, and every public health center has a reserve of it. Those serums are exported too. I really can't understand how USA got public health so wrong. Here we pay like 9% of tax over salary and get "ALL the health cover you may need": broken legs, cancer, HIV, transplants... You name it: each and every treatment is free: no deductible, no coverage limits, no contractual exceptions, no preexisting conditions, not even a call to the insurance company before receiving treatment or having to provide your ID. Sometimes I had thought about applying to a cool techco at USA, then I remember the health system differences and I forget it.

But that's even worse - now the $143k bill is sent to the government which just shrugs its collective shoulders and pays it... until the money runs out.

As an Australia who enjoys universal healthcare, not once have I ever worried about being sick financially and how much it would cost me.

I can go to any doctors I want and easily afford the medication I may need, and may visit a doctor preemptively and without worry about cost.

It saddens me that American citizens are suffering with such an awful healthcare system, and no where in the galaxy would I ever wish a system like yours to enter Australia.

You should vote for universal, single payer healthcare.

No you should not. Can you please stop advocating for something that cannot be comparable to your specific case in Australia ? Do you know the costs of the real medicine and procedures that you mgiht never ever experience but they are still there ?

Happily, this extended to me (US citizen) while visiting and requiring stitches. No cost, wonderful people, even though I didn't have my insurance card with me at the clinic and they had to take my word on faith that I would call it in later.

Why would there be a $143k bill at any point? You only get that if there are profit-maximizing companies in the supply chain.

Wish I could upvote this more. This is on point. There never was $143k involved in that service.

That's not what happens in practice - a government has a lot more negotiating power, and less skin in the game, than individuals who need the treatment. Governments can and do sometimes refuse to pay treatments that are too expensive. This may cause citizens who want that treatment to be upset, but for 99.99% of treatments it leads to them being a lot more affordable.

Not really: hospitals are public, and doctors are on government payroll, which keeps their prices on check. For example, a similar emergency here would cost nothing to the patient, and less than $2500 to the public health system (mostly helicopter gas): more or less $0.001/tax payer. Costa Rica has around 1000 cases like this per year, so state of the art snake poisoning treatment coverage costs less than $1/tax payer/year (most cases doesn't require air transport).

The public health coverage covers everyone depending on the worker so the system receives money (from salary taxes) proportionally to the amount of people it has to cover (think of it like a non for profit health insurance company).

A nice result is that competition from government keeps private sector prices low, and more or less still accessible to most population. That is why here private hospitals are profiting from medical tourism.

Other countries spend substantially less on healthcare, not more.

You make it sound as if single-payer will lead to higher costs but that's demonstrably not the case. Look at the OECD healthcare spending, which includes both government and individual expenses: https://data.oecd.org/healthres/health-spending.htm

The US is over 2x the average with its free for all system while the single payer countries all pay substantially less.

What foreigners with socialized systems dont understand is that financing is not the same as cost.

The us has individual financing and high cost. The industrialized world has medium-high cost and no individual financing. Third world countries have no individual financing and low cost.

Individual financing does have an impact on cost, but thats not what makes healthcare in the US expensive as a whole. Its a combination of regulatory capture and subsidies and regulation. And the public is also very responsible for such a system because americans are very averse to sub-standard care.

How does any of this explain haggling over a medical bill?

That’s what individual financing means.

Most people who respond with mock disbelief in US medical discussions are actually responding to the perception of medical care being expensive, not in shock at the idea that anyone would ever have to pay out of pocket.

The point is that US medical care is expensive because we pay nurses and doctors an order of magnitude more than they’re paid in Costa Rica. That makes everything expensive; where that expense precisely gets billed is mostly window dressing.

Paying for healthcare you need out of pocket is pretty fucked up.

How does any of this explain haggling over a medical bill?

That’s... what I just explained? Haggling over a medical bill == individual financing.

That Costa Rica reference threw me off, I didn't realize that your claim is the haggling over medical bills is built in into the US health care system.

Costa Rica was the starting point for this thread.

Haggling over medical costs is built into individual financing, but of course most people in the US don’t do individual financing, so my argument is more that arguing over idiosyncrasies of individual financing is usually a red herring when discussing the US health care system.

As long as a human being provides a service and another human being wishes to consume it, there will be haggling. You just might not see it happening when a third party does it for you.

Taking this to the logical conclusion we have "I will break your teeth if you don't give that stuff of yours because I can". Social structures and laws evolved for a reason.

Thats violence. A doctor choosing to provide a service is not violence.

This has nothing to do with the practice of medicine, or choices doctors make.

Anyway it's a threat, just like "we will send a collection agency", or "your credit score will be affected"

> The us has individual financing and high cost.

I think that's quite an understatement given total healthcare spending in the US is over 2x the OECD average: https://data.oecd.org/healthres/health-spending.htm

Services are also very different. One must adjust to that: US has many more high-end healthcare services.

In any case, you cant lower spending and increase access by socializing care: government will have to ration it.

Well McCarthyism removed just about everyone who would have fought for public health care in the 60s with the rest of the western world.

This article is part of a “bill of the month” series between NPR and Kaiser Health News:

https://www.npr.org/sections/health-shots/2018/02/16/5855495...

Entire series:

https://www.npr.org/tags/585747919/bill-of-the-month

I think a handful of these have had significant HN discussion, but this is the only other one I can find at the moment:

https://news.ycombinator.com/item?id=18328934

When KHN questioned St. Vincent Evansville hospital on its charges for Crofab, the hospital noted that the snake-bitten girl’s family wasn’t on the hook for the bill. Insurance covered the price of the antivenin. And, in the end, the family’s insurer negotiated the $67,957 antivenin bill to $44,092.87.

So it wasn't the girl's bill, it was the insurance company's. What would they have charged the family if they were poor and uninsured? Probably a lot less than even what they settled with the insurance company for. Yes, U.S. healthcare is screwed up, but I don't think this case resembles what happens to people who actually falls through the cracks.

'What would they have charged the family if they were poor and uninsured?'

Probably a lot more

Do you work in medical billing? My experience is just the opposite, they try to extract marginal costs from those people.

I don't but have a cynical view on this based on experiences several friends have had. There are people who will question the charges and try to work something out. But there are also those who feel like there is no option for them so that dialog does not take place and then the debt gets sent to a collection agency and things just get worse.

Can they somehow extract this back as a tax deduction? The parties are remarkably willing to negotiate, whereas your mortgage provider won’t move very far at all if things get sideways. If they aren’t, I’m certain there are ways to financially engineer things to recoup at least some of the “loss.”

Most US taxpayers can deduct medical expenses which exceed 10% of their income (subject to some limitations).

This can be tax deductible if you use HSA (Health Savings Account)

They would have listed a charge for at least $67,957 if that's what they were tendering to the insurance company. Uninsured people do not get negotiated rates which are usually discounted. The final bill might have been lower if they negotiated. A lot of hospitals will lower the bill and then include that number in the amount of "charity" care they provide.

If companies can outsource jobs to other countries, we should be able to import drugs from other countries in the same way without restrictions. It's ridiculous that this isn't the case. This for profit drug and medical industry in they US needs to die. One way that could be achieved is by having a single payer system that negotiates prices. Don't want to agree to the new, reasonable prices? You don't get to participate in the system and therefore most patients will not be your customers. It's tiring living in a supposedly developed nation that doesn't even have proper healthcare. That's not developed at all and as Americans we should be ashamed of our healthcare system that prioritizes profits over health and lives.

Living in India, near Western Ghats being bitten by snake is one of the constant worries due to availability of anti-venom at the nearest medical center (Which usually is state run hospital usually located in the centre of the city). But if one is lucky to make it to the hospital, being state run, the cost of snake bite treatment isn't prohibitive.

But as with other health care related expenditure in US, snake bite treatment seems just as messed up.

Why would transportation cost 55k+ to begin with?!?!

I was in an ambulance. The bill was over 20k. This is a glorified RV. I can’t believe the helicopter was only 55k.

Had she been bitten by a venoumous snake? TFA says "Thought to have been a copperhead"... They don't always use their venom. My dogs kill a few every year, they've had a couple bites but nothing serious. On the other hand I've lost several dogs to moccasin bites.

They're not hard to distinguish from other snakes, but then again, how many people saw that snake, had they any experience identifying snakes, etc.

Surely they wouldn't go shooting up someone with anti-venoms until they determined whether it was necessary?

I'm not sure about that. Trying to find the article... but rabies shots, for instance, are very expensive and prescribed on a population level far out of proportion to the risks. Right, here's one such article (it's a county-wide review of prescriptions, not a huge study): https://www.seattletimes.com/seattle-news/health/half-of-peo...

They tried to charge me $7500 for a few stitches on my son's chin when he fell at preschool. Outrageous.

kaching

Yes, the US has a messed up healthcare system. It's terrible, but it's not something that tech can fix. It's a political problem, so this is politics and is disappointing to see politics at top of HN.

>so this is politics and is disappointing to see politics at top of HN..

Huh?

There's always politics at the top of HN.

Political problems are mostly communication problems, and communication is tech.

Can you expand on your point? Because it makes no sense to me.

Not OP, but if you put on an exclusively technical hat, nearly everything boils down into some combination of energy, manufacture and telecoms.

Political problems are generally solved by organizing, evaluating, and disseminating information. All of which are technical problems. In fact that's how all problems are solved, and every problem can be political under the right circumstance.

If all you have is a hammer then everything looks like a nail.

What if all you have is a human brain?

While one facet of politics is about control/power, another major facet of politics is just about public service and people wanting the same outcome, but disagreeing how to get there. With communication, both sides of an issue can find a solution that they both agree on to reach the same outcome.

HN isn't a tech-only place. There's plenty of politics, business & investment (with an emphasis on startups for obvious reasons) and other non-tech topics here all the time.

From the news guidlines:

> Off-Topic: Most stories about politics, or crime, or sports, unless they're evidence of some interesting new phenomenon.

I'd like to hear you out if feel this is a new or interesting phenomenon.

And yet there are political posts (as well as the other things I mentioned) all the time and they rarely get downvoted to oblivion or flagged.

shrug, I personally have very little interest in politics, so I'm with you on this, but the fact is that, against the guidelines or not, these posts happen all the time, get upvoted and generate lots of discussion (and in this particular case, I found nthompson's comment interesting enough that it was worth checking the comments)

Besides, the guidelines also say "Please don't complain that a submission is inappropriate."

> And yet there are political posts (as well as the other things I mentioned) all the time and they rarely get downvoted to oblivion or flagged.

Survivor bias. You can't downvote an article, but there's lots of them that reach high comment/vote radio or get flagged and you never see them.

Direct partisan advocacy gets rejected swiftly.

It's possible to have an interesting discussion on issues that have a political side, like health care, if you can live within the constraint of avoiding excessive partisanship and focus on the more abstract problem. Health care pricing is actually a great example and I've learned a lot from discussions of it on HN.

Frome a game theory perspective, the ongoing price gouging in US healthcare is certainly an interesting phenomena.

I think it's an interesting phenomenon.

HN isn't only about tech.

A lot of people here try solve problems by starting companies or creating technology. So instead of solving the "problem" of serving more ads like a lot of the best tech people do at Google and Facebook I am happy that the people here care about this very real problem and hopefully some of us will do something about it.

This again? Why doesn't anyone read the guidelines, or see the 1 million other posters who ask this same question, only to be corrected and sent a link to ... the guidelines!

https://news.ycombinator.com/newsguidelines.html

Maybe I'm old and grumpy, or maybe I've been on HN too long but this comes up waay to often. /rant

The poster had addressed that already: https://news.ycombinator.com/item?id=19797003

"already"... their post came after mine. rolls eyes

Their post has id 19797003, yours 19797206. When I posted theirs was "5 hour ago", yours "4 hours ago".

I hear you, but I can also guarantee you that comment was not there when I made mine. There was the parent comment, and maybe 4-5 replies, no nested replies at all.

Even if it was, my point stands. Offtopic? Politics? Downvote - no need to comment and derail the conversation.

Hilarious that you tracked that down, that's perfectly demonstrative of what I love and hate about sites like this. It's been fun arguing with you Internet stranger!

So this seems to me to be an instance of the system working. For example, the girl's family wasn't actually charged. The article notes the insurance paid for it. Keeping the price high here helps the hospital cover the costs of people who cannot afford treatment (I don't think this is a good sign, but it is how our system works).

The article also notes that due to competition, the price of the medication is now significantly lower. I guess I don't really see the issue here. This is to be expected... if there's a cheaper drug produced elsewhere that works the same, then it will become more used.

keeping the price high is why people cannot afford treatment.

Reply on news.ycombinator.com