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Comment by Ididntdothis | Hacker News Reader

“The hospital and its services are under no obligation to provide accurate pricing until ipso facto, and the pricing can often be changed because it doesn't stand up when placed under scrutiny”

That’s what’s driving me crazy. No other business can make up charges repeatedly and when found out, say “oops” and change them a little. In what way is this not fraud?

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Try being uninsured. I had a woman come into my room (!) during my ER visit and ask for payment. I asked very clearly if this was covering the cost of the visit. I made it clear I understood the doctor and xrays would be billed separately. I paid. It wasn’t cheap.

I got the bill from the doctor. It was reasonable and I paid promptly. I got the bill for the X-ray and it was ridiculously low to my surprise. It was paid immediately. In my mind, I was done.

Then I started getting phone calls from a broken machine. Please call <actual silence> at <more silence> about your past due amount of <~$4000>. I assumed they were spam, but after about 10 of these calls over three days, the message variables were randomly filled or not on any given message. At no point was the message clearly about my hospital visit identified, but I figured it out by the phone number and the name of the parent company.

At this point I hadn’t even been mailed a bill. And I know they have the right address because the other bills came and I’ve only ever lived at my current house since the first time I went to this hospital.

So I went down to the hospital to sort it out. Well, they don’t have a billing department. They have “financial counseling” or something equally not what I need. And even though it was in the hours they are supposed to be there, everyone had gone home for the day.

I still haven’t paid. I haven’t gotten a bill, and I’m not entirely sure the calls aren’t just a scam someone is running.

Even when you're insured this happens. I had a woman come into my ER room and demand payment of my full deductible. They ended up refunding me 2/3 of it about a year later.

yep, same thing happened here. I'd seen pictures, but.. yeah.

Wife cut her hand Thanksgiving night - had to go to ER - bleeding pretty bad. Initial triage was a few minutes, then in to an ER room to 'wait'. Someone came in after about 10 minutes with a portable POS on wheels, saying we had to pay $450 for the ER visit. No explanation about anything, and... I paid, but... I was in no position to 'shop around', nor even be confrontational. If I make a scene, or refuse to pay, or ask for more details, will they make us wait 6 hours? Or 8? I wanted this addresses ASAP, and paid. And... we still ended up getting bills for around $3400 (total of 9 stitches on her hand). This is with 'full insurance', which, we pay $1k/month for for 2 people.

That anyone defends this system as 'the best' is beyond me.

I couldn’t even imagine going to a hospital uninsured. It means you are pretty much giving them a blank check to take all the money you have.

What's your other option? If you're critically ill/injured, the hospital/ER is where you go - that's who can treat your problem immediately.

it can work out exactly the same later on if your insurance it decides that they don't agree with doctors about a procedure being necessary, putting you on the hook for whatever.

Yep. My wife was billed almost $500 for out-of-network pregnancy testing when she went in for an injury, as they needed to confirm before they could give her painkillers.

She was certain that she wasn't pregnant, given she had seen her GYN just two weeks prior and was on implanted BC.

We're still fighting the appeal and the hospital regarding the use of an out-of-network lab instead of the in-network lab then used for the rest of tests.

I have read and been told repeatedly that if you are not insured, you can typically negotiate any fee down to a reasonable rate, so long as you are diligent about it.

“Reasonable” is relative. Also first try to pull this off yourself. It’s not a pleasant process and takes a long time.

If you owe a bank thousands, you have a problem; owe a bank millions, the bank has a problem. It isn't in hospitals best interest to have people go bankrupt.

College prices are kind of like this, in that they follow the simple formula

tuition cost = how much you can borrow + how much you can pay

What is strange is why do we stand for huge price discrimination in college and medical care, but not for buying a candy bar?

Somehow doctors and colleges have maneuvered themselves into a position where they act like greedy companies but have a reputation for working for the greater good and should be trusted more than regular companies . Also people still believe that non profits are dogooders which is completely untrue in the case of schools and medical facilities.

>tuition cost = how much you can borrow + how much you can pay

I need this flushed out a little bit more. I have worked in higher ed for decades, and have never encountered a college that charges in that manner. They have a flat tuition, and the student fills that payment however they are able. But it's not like it changes based on how much capital they have access to.

Can you please explain that statement?

No, the generous "financial aid" policies of many universities amount to perfect price discrimination. They meet "one hundred percent of demonstrated need"; their phrase, not mine. This means they calculate how much you can afford to pay and charge you that much. That' is every monopolist's/oligopolist's dream. Oh, and they don't show how they calculate that "demonstrated need". I got prices much higher than what I could afford.

It's not on the level of individual student, but overall market. As ability of whole group of students to pay goes up, the price also goes up.

Just wait until Uncle Sam foots the bill directly.

He has quite the "ability to pay".

Right, but he also then has a lot more incentive to keep costs down and the power to enforce some requirements and controls to keep costs down.

Seems to work OK in every other civilized country on Earth.

It sounds to me like your parent is describing financial aid at high end colleges. The college has a sticker price, say $50k/y, and for people that can't afford it they have need-based financial aid. They ask you lots of details about your family's income and assets, and come up with a number that they think is the most you can pay.

It's price discrimination, in that it's charging people in proportion to what they can pay.

Are you referring to the loan-based "financial aid"? This is one of the most hypocritical terms I came across. It's a loan, not an aid. An aid would directly reduce the amount of money you have to pay (discounts, scholarships, grants, etc.). A loan is not an "aid".

I'm primarily talking about grants, not loans, since that's where the price discrimination is clearest. They're effectively setting the price at exactly what they calculate you can pay.

This is what I don't get about "financial aid". The "elite schools" name an outrageous figure, charge the rich kids, give money to the poor ones, and ignore the middle class. This is probably intentional: they want either students whose daddies will donate or students who look good on press releases about "diversity". Now that the feds have nationalized student loans, colleges can continue these stupid policies knowing that the bottomless credit card of the American taxpayer has their back. Federal student loans don't consider a student's major, either; there's no way a "xyz studies" or poetry major should get the same loan at the same rate of a stem kid, even if that student has the same financial situation. From an actuarial perspective, it's nuts: one is going to end up a starving artist and the other has a promising career.

Oh, and my two cents: if you want to end up with larger numbers of under-represented groups in higher-paying fields, maybe making the long-term outcomes clear at that stage would help. Saying, "follow your dreams!" is very, very stupid advice to an eighteen-year-old.

That's not 100% accurate (the middle class is NOT ignored at the elite privates). For example, Stanford meets 100% of the tuition for students with family income <=$150k.[1] And the assistance doesn't evaporate completely at $151k. For families with incomes <$65k, tuition and expenses are covered. Most of the Ivies are similar.

The problem is really at elite publics, which don't have the massive endowments, so cannot subsidize middle class students.

We're at a point where it can be LESS expensive for many middle class students to attend Harvard than UMich or UVA.

1 - https://financialaid.stanford.edu/undergrad/how/parent.html

Colleges and doctors are both decommoditized and competed over by those seeking "quality" and the minimal end up comparatively shunned if at all aware or having an alternative. High stakes breed those sorts of markets - it is no accident that doctors and lawyers are synonymous with highly paid non-management roles.

They are also seevices which means there is no preserved buffering possible. You can't just have a factory of doctors fill a warehouse with 40 hours of medical care each every week. Given the opportunity cost trying to "squeeze in" what they can in a discard free knapsack problem sort of way makes sense given the incentives even if the outcome isn't ideal or fair.

In what way is this not fraud?

In the way where you buy the legal definition of fraud from the senate.

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