HHS announces rule to protect consumers from surprise medical bills
hhs.gov
hhs.gov
My father passed away before making it home, but when all was said and done, insurance was billed $10 million in total, of which the various doctors and hospitals billed the estate $2 million. My dad didn’t have an estate because he had no assets. But imagine your life + childrens’ lives being ruined for having insurance yet filled with invisible asterisks.
At the time, NJ laws were onerous in this regard and favored insurance companies so we had no recourse. The state had a process for dealing with issues like this, but it was more of a cursory “jobs done here boss” type process and didn’t provide consumers with relief. Because of that, I moved my family out of NJ. When all contingency plans are filled with asterisks, do you really have insurance/protection?
The only real benefit of having "insurance" in the US is having reasonable access to basic preventative care. Don't get me wrong, it is a massive advantage to have default access to basic preventative care (without it being a cost-benefit tradeoff each time), but that is in no way/shape/form "insurance" in the typical meaning of the term.
It's terrible that these things happen at all, and we CERTAINLY need to improve the US healthcare system, but exaggerations like "the only benefit of insurance in the US is access to preventative care" doesn't help. If people were regularly getting fucked like that the system wouldn't have the entrenched support it does from the "but I want to keep my insurance" camp, and so speaking in generalities like that just makes you appear uninformed to the millions who regularly see doctors, get treatment, have surgery, etc, without these problems.
It also cheapens the inequality problem: the gap isn't just "has access to preventive care" vs "doesn't have that access." The gap is "has hundreds of thousands of dollars, or even millions, of bills turn into nothing" vs "bankrupt if they seek treatment for any serious problem."
I don’t see how that follows.
The “I’ve got mine” camp doesn’t care that it happens to those other people, and also doesn’t understand that it could happen to them in their old age (or simply after bad luck) because they’ve only made short visits into the system.
I'm sorry, but I just can't see how this is true. Do you only go to the doctor for a yearly checkup, or something?
I've had "good" coverage (paid for by big employers with cushy all inclusive packages), and I've also had the cheapest option on CA’s exchange, and the only difference was whether I had to pay the receptionist $25 or $150.
The "we won't cover this" and the "surprise, this costs 50x what you were told!" billing nightmare comes six months later. This has happened with every insurer I've ever had.
In my experience it does help to have an HMO. My mom uses Kaiser. So there's none of this in- vs out-of-network. One billing system, one insurance, etc. She has nothing but positive things to say about them. My dad had a similar experience towards the end of his life. He loved 'em. And nobody was left destitute as the result of his medical care.
Lets look at it this way: If that was the true price, what percentage of the US population do you think has the funds to actually pay $420k/year in for medication?
> what percentage of the US population do you think has the funds to actually pay $420k/year in for medication?
Zero, plus or minus. That's why the manufacturers basically give it away to people who can't afford it. Because they can, and it helps them somewhat mitigate the bad PR.
I'm not sure what point you're trying to make, but it sounds like you're making the claim that people in the US don't regularly end up with massive surprise medical bills? This entire conversation is about action the government is taking because it happens so often.
> "has hundreds of thousands of dollars, or even millions, of bills turn into nothing"
That's not really how that works. It's not like your insurance company is actually paying "millions of dollars", they're paying some level of reasonable negotiated rate. If they actually had to pay "millions of dollars", that's when they claim something is not covered and you get stuck with a bill anyways.
Edit: First quote was just wrong from a bad copy/paste
Of my different health insurance policies, the longest duration in an ICU that was covered by any of those insurance policies was 60 days. My father was "lucky" in that he was on a subsidized Obamacare policy that "only" charged $350 per month (which was cheaper than my employer's policy) but was FAR superior to any of my employers' health insurance in every aspect.
What insurance do you have where the cost of the annual premium is less than what the out of pocket costs would be for annual checkups for the covered individuals?
I have the cheapest insurance I can get. Yes, it pays for basic preventative care (basically a checkup per person per year), and it also costs more than my mortgage.
Wouldn't it be better if you went to the hospital, gave them your insurance information, and that's the last you ever were involved with anything regarding payment? Isn't that one of the reasons we have insurance?
People also want cutting edge care from some of the smartest and most highly educated people in the world (which is in short supply) for cheap.
That can't be true, everyone knows that people are only greedy and stupid, and it's really the citizens' fault for the prices of the current healthcare setup. The industry itself is all made up of kind-hearted super heroes who would never think of manipulating prices to syphon more money from patients.
And no one can really afford that, but instead of spreading the costs around to all taxpayers, we were spreading it around by inflating everything else. ACA helps with this, but today’s announcement about out of network care will help more too.
Actually, people just want someone to help them with their health issues and not treat them like shit.
Sure, I guess you could find people with the above attitude, but it's mostly a straw man you are using to deflect responsibility from the health industry.
Perhaps what we need is something like the WTO's most-favored-nation rule for domestic insurers, but imposed statutorily. If you're treating an out-of-network patient extemporaneously, you can only charge that person's insurer at the lowest rate you'd charge an in-network provider.
This would remove the incentive for out-of-network providers to eagerly provide many services. That has its own downsides, of course, but it might help to resolve many of these billing nightmares.
But, heck, maybe something like that already exists. Obamacare (aka ACA) comprehensively thought through many of these dilemmas. But enforcement has been gutted by the GOP.
To be fair, Americans have a very low standard for “functioning healthcare system” due to the American healthcare system.
As far as whether facilities could be "nicer", I mean... maybe? I actually kind of prefer healthcare to be like schools in this way— if I don't think it's nice enough for me, then I need to lobby the province to collect more taxes and make it nicer for everyone rather than just taking my dollars elsewhere.
And that doesn't even address the whole billing-surprise angle. I would happily wait forever if the alternative was not knowing if I was going to randomly be stuck with a $10M bill.
I also do not buy that doctors do not know which code will be used. I don’t care if the doctor themself does not know, surely someone that works with them knows and can provide it.
It should be dead simple to go to a doctor’s website and find the codes for routine procedure that they will bill. If something in the visit happens outside of that, the doctor can feel free to say that is outside of the scope of the visit, just like a mechanic can tell me he will not fix the transmission if I am in for a brake job.
I would also point to the unnecessarily arduous and lengthy process of becoming a doctor in the US as one of the US system’s problems.
If I’m going to be asked to sacrifice all of my 20s and maybe early 30s and worked on 24 hour shifts during the prime of my life, I am also going to be making sure I get paid a ton for it. Otherwise, I would choose a different career.
I know a lot of doctors that advise their kids to not pursue medicine even if they want to do it, simply because the cost benefit is not worth it anymore (if you have other options).
I recently had a family member get surgery for a life threatening condition where a cutting edge treatment greatly reduces complications. The equipment only exists in a small number of hospitals on the planet and their normal hospital, which wasn’t even a particularly fancy US hospital, had one. It's probably not an issue for small and rich countries though. Probably more-so for medium income countries.
There are plenty of medical practices and institutions that function well and deliver good value to the patient. But there are many that do not.
As someone who doesn't have friends inside the health care industry, it can be extremely difficult to figure out what to do in an emergency. Quite often your options are limited especially if you are caring for a loved one rather than yourself.
The best advice I can give is to find good doctors before you need them, and when conversations come up about someone else's medical care, be willing to ask, who is your doctor and how good are they? Or, which hospital did you go to, and do you feel you had a good experience?
Often there is little out-of-pocket difference between the cost of excellent medical care and lower quality care, if you have good insurance.
If you don't have good insurance and you are looking at a potentially significant medical procedure, ask to speak to someone about financial assistance. Good practices and good hospital systems are not looking to bankrupt their patients.
most US doctors are part of a bigger group in order to provide more comprehensive coverage (and due to systematic buyouts), which in turn have preferred insurance providers and additional out-of-network providers, and emergency services are generally for wherever an ambulance takes you. your physician may be great, but they are just a tiny cog in a broken machine
one of the only outs, afaict, is something like working & living near a big & strong HMO like kaiser. but that comes at the cost of pretty firm boundaries on what services they allow: capped care
(my SO is also a physician at one of the nation's best hospitals, and despite that, patients struggle w the broader system outside of her practical daily control)
Transferring assets isn't crazy but you do need to be careful if you want to do it in a non-taxable manner (you can't just give your kid $500k cash without them counting it as income).
I think it's worth noting that while this may be true if you're dead, it's not the case when you're still alive.[1]
Filial responsibility laws mean that adult children can be legally required to pay their impoverished parents' medical bills. The above cites a case where a man was required by the courts to pay $93,000 for his mother's rehabilitation.[2] From what I've read, Pennsylvania may be particularly onerous compared to other states, but it's not a slam dunk kids won't be on the hook.
[1]: https://en.wikipedia.org/wiki/Filial_responsibility_laws
[2]: https://abcnews.go.com/Business/pennsylvania-son-stuck-moms-...
More info is here:
https://www.nolo.com/legal-encyclopedia/your-obligation-pay-...
Because Wikipedia only talks about their existence, not a discussion of them.
I have to imagine that it's pretty rare, and I don't think it's appropriate to generalize from what appears to be a pretty sensationalist case. I expect the laws are usually structured to ensure that children don't fleece their parents out of money and turn them effectively into wards of the state, etc. It doesn't seem unreasonable to me that states would encourage families to take care of each other, though PA seems a bit of an outlier in this regard.
Typically when it's used it's to recover money in cases of fraud. For example, where the parent or child conspires to hide money from the state to avoid paying for care. To the best of my knowledge, PA is one of the only states that allows private entities to sue. Some states are like Ohio where it's a criminal statute, so only the state has standing to bring charges. All said, don't get legal advice on the internet, this is an armchair discussion by laypeople.
As an aside, I don't see why the children should have any specific burden to take care of their parents medical expenses now that we have Medicare and Social Security. We've decided it's better to have all of society to take care of our elderly rather than tie it to their children's ability to pay.
Pennsylvania has filial support laws which mean that children can be held directly responsible for the medical expenses of their parents. This requires that Pennsylvania have jurisdiction over the children, of course.
The parent does not need to live in PA at all, but a suit needs to be brought against the defendant to make them pay, and therefore the court needs to have jurisdiction over that person in order for the lawsuit to succeed.
France: https://fr.wikipedia.org/wiki/Obligation_alimentaire_en_Fran...
Germany: https://de.wikipedia.org/wiki/Elternunterhalt
Asia has a ton, I'm sure.
And if they do that well enough to have you make a payment, most legal systems will consider that acceptance of full financial responsibility on your part.
Hospital billing practice are pretty horrible. If a more compliant person had received this bill, they might have paid it, even though there is no way it was legit.
https://en.wikipedia.org/wiki/Filial_responsibility_laws?wpr...
That is literally inheriting debt. That should be illegal, yet almost half the country allows this.
This reminds me of tobacco tax to pay for children’s healthcare initiative. As if the responsibility sits directly with cigarette smokers. It sits on all of us, not one person. Impoverished elderly people that need medical care should receive aid from the state indiscriminately where we all foot the bill.
It sounds like a good startup. Do background checks on homeless people, see if they have any living relatives, and if so you can house them in a nursing home and charge the relatives.
Are they fair? I mean ... sometimes? These laws (supposedly) solved a problem where parents would bequeath their estate to their children prior the parents' death and, then, the children would leave their parents destitute. It's not clear how much of a problem this really was (think "19th century); it was probably just a popular image that politicians used as a talking point?
My suspicion is you'd need to use jury nullification to make the law "go away".
https://www.medicaidplanningassistance.org/medicaid-look-bac...
EDIT: Some argue here that it'll average out, however at what cost to others? [1]Here's article about African Americans getting limbs amputated as their treatment for diabetes.
[1]https://features.propublica.org/diabetes-amputations/black-a...
How much of that are salaries for underperforming, bloated structures in charge of "management" and billing?
[1]https://www.theglobeandmail.com/life/health-and-fitness/heal...
So during your life - broken bones etc - roughly equal.
But if you are stuck in ICU for a year when 75+ - that's uniquely American and incredibly expensive.
"Numerous articles on EOL costs show that a large proportion of Medicare expenditures occur during the last 6 months of life.1-9 This phenomenon has continued for many years as the number of Medicare decedents has increased with the aging American population. Medicare expenditures for EOL have increased dramatically from 1983 to 2016, primarily because of the increase in the number of decedents. Other articles compare EOL expenditures in the United States to other countries10,11 or focus on Medicare expenditures for specific diseases.12-14 A recent development in the literature challenges the idea that EOL costs are responsible for a high percentage of health-care costs.15
This study suggests that your interpretation is not correct: https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0174 Mean end of life spending is only marginally higher in the U.S. than in other countries.
Extrapolated cost for Canada: 6,758.2
[1]https://www.longwoods.com/content/20878/healthcare-quarterly...
In any case, it's not the correct number. Quebec data from the study I cited showed 60k per capita on hospital alone, with incomplete data to characterize the remainder of the costs.
I've also heard that something like 5% of folks generate 50% of costs.
So the argument has been that because in the US total expenditure can go so high (ie, we will easily spend $10M on one person where other countries won't) that you end up with a serious spike as a result of last year of life and extraordinary effort costs.
Other countries have less variance (including income inequality)
Insurance is more effective at dispersing that cost when the pool is larger, so the most effective scenario would be for everyone to pay in via taxes and simply… be covered.
Edit: I don't understand the point you're trying to make with your edit.
Assuming nothing else changes, it'll about double the cost of what people pay now for private insurance (in terms of taxes).
However, there's no reason to assume nothing else changes. The US spends an atrocious amount on the overhead of bookkeeping our "free-market" semi-adversarial healthcare system. Estimates over the past 22 years range from 13 to 25% of the cost is raw administration. Assume most of that cost goes away (let's say 90%, which seems fair) and you're left with Americans paying about $250-400 a month more on average in taxes for healthcare than what is paid now.
Since it's taxes, the progressive tax rate would kick in and this would translate overall to most Americans paying almost nothing more, the middle class getting squeezed (this could be ameliorated with laws, but if nothing else changes the middle class gets squeezed), and the wealthy and super-wealthy shouldering the bulk of the cost.
Problems are often not addressed in a reasonable time frame because many people don't have access to reasonable health care. Even they they do, they may be hesitate to use it. Anecdotally, last time I went for a preventative check, I was given an FAQ sheet when I signed in reminding me that if I ask about anything specific, or diagnostic, that is not preventative (as if I'm supposed to understand the difference), then it would have to be billed separately and may-or-may-not be covered by my insurance. That was almost enough for me to not ask my doctor questions while I was at the office.
I would imagine that more widely addressing issues early on before they become expensive would remove another large portion of overall US healthcare costs.
"Invisible asterisks" captures the reality perfectly. The asterisks are invisible and infinite. I think even Kafka would be horrified.
We've turned medical billing into an impenetrable Byzantine hellscape, and I fear that the only way to fix it would be to nuke it from orbit and start over.
People complain that all the people in private insurance will be put out of their jobs - I view that as a feature, not a bug.
They sent me a bill for $350 then I called up to complain and suddenly the bill goes away because it’s billed to my other insurance that I didn’t even think I had anymore.
If I sent a client a random bill for $$$ things would not go nearly as nicely, but they have so captured the regulators and politicians that this is the world we live in now.
I want nothing to do with many of the policies of the left, but this would make things so much easier for small businesses and people Changing jobs in the labor market.
A primary breadwinner should carry at least 10x his family's annual living expenses in term life insurance coverage.
Once the size of his retirement accounts exceeds this, he can start thinking about reducing the insurance.
Both will pay directly to beneficiaries in the event of his death.
A parent’s debts cannot be put on to their children. Once your father died, anything not covered by his estate had to be written off by everyone.
Parents, talk to an attorney while you're healthy. Some of the states have rules that will surprise you.
So I immediately imagine an absurd nonsense like "liquid gold transfusion", then I realized it's 800g gold per day in the current gold price.
My pathetic mind can't even imagine the how absurd that is.
Let's say you get a hypothetical procedure. Insurance has already agreed to pay in-network providers between $1-3K for this procedure. But you got this procedure out-of-network. Why is insurance's liability suddenly $0 instead of whatever the lowest in-network fee schedule would be ($1K in this example)?
See I can understand insurance not wanting to foot substantially higher bills than in-network providers charge, but I cannot understand why it drops to $0 reimbursed when you leave network. It seems like an immoral "gotcha."
But then again I'd like to see insurance discounts/agreements banned. Make everything and nothing in-network and also normalize the insured/uninsured prices. No more "$100 for a band-aid, -$99 discount" shenanigans.
Obviously single-payer would be better yet still, but if we must keep using this broken private employer-linked insurer system let us at least keep band-aid fixing it until we can get enough political support to scrap it.
$40/hr payout for physical therapy + translator contactor.
I cut my hand open climbing in northern New Mexico, bandaids and gauze weren't stopping the bleeding, so I went to the nearest town clinic/urgent care. Ultimately got 8 stitches.
My insurance denied (almost) everything. They would later explain that I was supposed to drive myself several hours to Albuquerque to get my hand looked at instead.
I say almost because the covered $70 for the lidocaine shot, but literally nothing else. Why they deemed the lidocaine necessary but not the stitches could not be explained. Clearly they had a way to pay the clinic, so wasn't that.
Another whacky thing I discovered: the insurance company gets to decide how much, if any, of your uncovered, out-of-pocket bill counts towards your deductible. In this case they deemed $109 of $832 to be the right number, with no explanation as to how they arrived at that sum.
So the insurance is saying "If you paid $80,000 for a medevac, we would have covered your hospital bill".
https://arstechnica.com/science/2021/06/biggest-health-insur...
> Doctors and hospitals are condemning plans by UnitedHealthcare—the country’s largest health insurance company—to retroactively deny emergency medical care coverage to members if UHC decides the reason for the emergency medical care wasn’t actually an emergency.
Multiple attempts on my part to resolve this yielded nothing. I contacted the state of TX, who brought suit against both parties (insurance & service provider). Somehow, the day before the court appearance they all agreed to settle the claim at no cost to me.
ER visits for emergencies are also covered as in-network care under the ACA, even if you're half way across the country. I know cuz I was 1500 miles into a road trip when I went to the ER. My insurance covered it as in-network.
Thankfully the bill I did receive was somewhat reasonable, and I was able to pay it without much issue.
Not that I think much of the likelihood of success, but aren't you, for any such decisions, entitled to (a) receive a justification on request, and (b) appeal that decision?
Hours, literally, of on-hold time, likely more than once, and if you're trying to get them to pay for something they don't want to, you're likely going to need to get state regulators or lawyers involved, which means even more time (and money, in the latter case). Probably you'll end up having to do the same thing with one or more hospitals or healthcare providers, playing go-between with them and insurance, and usually those places subject you to the same malicious-incompetence as the insurer does.
As for saying you should have driven hours with bleeding you couldn't stop--do you have any sort of appeal process? That certainly doesn't sound right.
An urgent care might not count.
Ot is even possible for German citizens living abroad (I think outside the EU) to pay into a special insurance to maintain the German health insurance. Around 100 bucks or so, but I would have to read up on it again. Which is nice, e.g. because you travel full time or are an expat (the US comes to mind).
Edit: That's one provider, the 1 year plan is 35 Euro, ythe 5 year plan 59 per month.
https://www.hansemerkur.de/langfristige-auslandskrankenversi...
EDIT 2: Including the US and Canada prices increase by roughly 3 fold.
Not sure how plausible that is though--I suppose they could data-mine frequency of follow-up treatment required per doctor--but I've never observed in network/out of network to correspond to a meaningful metric (our local dentist recommended by all the dental specialists around doesn't deal with any insurance companies, while the in-network dentist is pretty clearly padding their work)
If there's reason to not trust Dr. Nick, then surely the insurance company must disclose it. If there's reason to not trust Dr. Nick, then surely Dr. Nick would have trouble maintaining a medical license. If there's reason to not trust Dr. Nick then surely Dr. Nick's own malpractice insurance would become too onerous for him to keep.
No, this smells exactly like what @Someone1234 stated:
> Out-of-network was always just a sketchy way for insurance to avoid paying what they should have paid.
That should include "we think Dr. Nick makes fraudulent claims"
When it's a third party HMO network and you've got stuff like a medical office where only some doctors are in network and others aren't, so if your doctor is behind or out sick and you're offered to see another doctor in the interest of time and then you've seen an out of network doctor, that's a totally different deal. Then you've got things like in-office X-ray analyzed by an off-site radiologist whose identity and network status wasn't known before hand.
I'd like to see non-emergency medicine take up the same kind of quoting requirements as auto repair. You can't always stop a procedure to update the quote, so provide several quotes for the likely outcomes.
When insurance companies sign up doctors to their network, doctors agree to lower fees (lower profit) but expect to make it up in volume, because the health plan will send them more patients.
But that only works if patients are made to stay in-network, which produces the guaranteed volume. So health care plans won't pay if you go out of network. The economics would fall apart otherwise -- plans wouldn't be able to negotiate the lower prices because a doctor's office wouldn't see any uptick in volume.
Now it depends on the plan, but there are often exceptions for when you're traveling and need emergency care -- they'll pay network rates toward that because it's not a visit that an in-network doctor would have lost.
Also, plenty of "gold-plated" plans will cover anything out-of-network as well -- because they're expensive plans they're willing to pay doctors more, and so don't need to provide doctors with volume.
The out of network provider in an in network hospital is probably the most perverse thing to happen. One could be unconscious at a hospital and have out of network provider Dr Smith LLC stop in for a few minutes and send you her own bill.
At least all the insurance I’ve had will pay using some formula like “we will cover 80% (instead of 90%) of charges up to the allowed amount (what an in-network would receive”.
The issue is that many providers balance bill, so everything above that is billed to the patient and since some negotiated rates are 50% or less of charges, the patient can own more than the insurance.
Basically insurance and providers fuck over the patients together.
Note that ground ambulances are excluded from the legislation that Congress passed last year, cf. https://www.nytimes.com/2020/12/22/upshot/ground-ambulances-....
"Family Gets $18,000 Hospital Bill After Their Son Was Treated with a Bottle of Formula and a Nap"
That kind of stuff stresses folks out!
https://abc7news.com/zuckerberg-san-francisco-general-hospit...
Nobody should be afraid of calling an ambulance. Nobody should need ten years to pay debts for medical care, regardless of procedure.
Another example, age 28 I was diagnosed with colon cancer. That meant a shit load of colonoscopies since then, removal of parts of the colon and 6 months chemotherapy. Overall bill: around 50 bucks per months for the chemotherapy. Luckily I had supplemental insurance covering my salary, also my employer back then continued to pay after the legal 6 weeks. The risk you run in Germany is loosing your salary after 6 weeks, making that salary insurance so important. It is also dirt cheap, I pay roughly 15 bucks a month, it never increased since my studies. Health care should be a human right.
Honestly, it's remarkable how different it is here across the border here in Switzerland. An ambulance was called to me within the same city from a few km away (although I was across the street from the main hospital), performed an ECG/EKG on me, didn't pick me up or transport me anywhere, and I was billed about 700 bucks for that privilege.
Additionally it seems we have a supply vs demand issue if healthcare providers have such pricing power. Maybe it's time to open up the training supply and let folks with a 3.3GPA become doctors?
EDIT: looks like maybe the supply issue is more about residency than med school https://www.fiercehealthcare.com/practices/more-medical-stud...
Devil is always in the details of these rules but on the surface it looks like a good attempt. It is a sort of a bandaid though.
To understand why this occurs know that most jurisdictions have certain staffing requirements for service lines. You must have X many neurologists covering X shifts. There is almost universally a shortage of these folks for other reasons, so you end up with a lot of non-staff doctors to fill the coverage requirements. Those non-staff often have different insurance relationships than staff doctors and so are "out of network".
The two serious changes that would have a more durable impact on this are to free the lock the AMA has on residencies that exacerbates doctor shortages and to dramatically streamline the way insurance program enrollment is done for doctors. Further opening up interstate health insurance would also probably help.
Can't wait to race to the bottom on this one. Which state wants to roll out the red carpet for insurers most? If I ever have a problem with Montana BCBS I'm sure, once I fly over, I'll be able to explain to the arbitrator in Butte exactly what my issues are and get a fair hearing.
It's multiple cartels vs us.
These cartels have spent literally 2 billion dollars on lobbying politicians.
So the real question is, how does this hurt us? How is this helping physicians build mansions, hospitals get record profits, etc...
Would probably make for a good movie concept - kind of a modernization of Falling Down.
We just got a bill last month for $300. This was on top of 3 other bills we have already paid over the years for the same visit.
The insurance company said they only knew about it a few days before us. So it was a surprise to them too. But by nature of their agreement with the hospital, they were not allowed to fight it.
I still wonder how many more bills we can expect.
"Bans high out-of-network cost-sharing for emergency and non-emergency services. Patient cost-sharing, such as co-insurance or a deductible, cannot be higher than if such services were provided by an in-network doctor, and any coinsurance or deductible must be based on in-network provider rates."
This to me seems to just completely eliminate the difference between in-network and out-of-network billing. What am I missing?
The actual rule also goes into things like consent to be balance billed for your knee surgery, is not consent to be balance billed for the ICU care when that surgery goes wrong and you nearly bleed out, and suffer major organ damage, etc...
This consent option is not always available, an in those circumstances, balance billing is simply prohibited, and in network and out of network are fully equivlent in those cases from a patients' perspective.
This doesn't help anyone paying cash for services, and it really just invests more into the current broken system.
I think the solution is that all healthcare providers must provide upfront pricing for you.
Right now, almost all medical billing is surprise billing. It's basically the only sector where this is true.
There will be some qualifiers to that, like the provider must indicate what conditions the patient is being treated for to qualify for the procedure, and if the patient doesn't actually have that condition, then whoever falsified the information (or was grossly negligent in diagnosing) is stuck with the bill.
Once that is in place, then you can require the providers to give quotes beforehand.
This seems like a really big loophole. I was just at the hospital for the birth of my daughter. My wife and I checked in at the OB desk where they asked for acknowledgment that we may be seen physicians that aren't part of the hospital (out of network).
We acknowledged, so surprise medical bills are fair game now?
There's no market of rational decision makers, no choices you can make and really know the outcome when it comes to health insurance.
My health insurance is pretty good and yet they randomly send me letters saying that they think the procedure should be covered by some other insurance they THINK I might have.
In the meantime they stop covering things and the providers send me bills with no health insurance coverage ....
They do this about every 18 months, I think hoping I just pay the bills and not notice.
They said that I had out-of-network coverage after a $750 deductible they would pick up 80% and I would be responsible for 20%.
The out-of-network provider had quoted me $6700 for the service, so my responsibility should be $750 + (20% * ($6700 - $750)) = $750 + $1,190 = $1,940.
I wasn't happy about having to shell out nearly two grand while having the best possible employer provided healthcare, Anthem PPO where we paid the most per month to have low deductibles and high coverage.
At the end of the call, I tell the insurance company my understanding of what my responsibility is and what their responsibility is. Then they drop this on me, "Well we will pay 80% of the allowable price for the billing code the out-of-network provider submits."
Good thing I asked, this was the first time they said anything about an "allowable price" so I describe the service and ask "what's the allowable price for that?"
"Depends on how they code it"
So I go back to the out-of-network provider and ask them for the billing code, which being a doctor that doesn't do their own billing, they have no idea. So I wait a few weeks to get back the billing code, and I'm back on the phone with my insurance company.
"Hey, I have this billing code someone out-of-network will be doing, what's the allowable price on this?"
"We can't tell you that, you'll have to submit a claim."
"But when I submit the claim you will have this billing code and my member id and you will know the allowable price so you can figure out how much you are going to pay, you have that information now. What's the allowable price for this billing code, performed by someone out-of-network, with my plan?"
It took them 2 weeks to come back and say that their "allowable price" was $1,658.
So to summarize, it took me nearly two months of phone calls between myself, the insurance company, and the provider to find out what this service would actually cost. I only avoided accidentally getting hit by a massive surprise bill because of a combination of persistence and luck.
It is nearly impossible to have any reasonable idea how much anything will cost, much less to comparison shop, when it takes months to get answers to basic questions.
Six months later received an itemized bill for another significant amount. The worst part about it is theres no way to know if the bill is correct, or if insurance should of covered one of those line items. They really could just make up whatever they want as the system is so opaque, no one knows how much anything should cost.
> Today's interim final rule with request for comments implements the first of several requirements passed with bipartisan support in title I (the "No Surprises Act") of division BB of the Consolidated Appropriations Act, 2021.
Maybe not bad in the long run but that must be the least efficient possible way to solve this problem.
USA is dumping twice as much money in as Canada/Europe for worst outcomes.
Warren Buffet has described our insurance system as the "tapeworm of the American economy".
I believe that comes down to the fact that in those countries, you don't have to already be wealthy enough to afford the $36k in premiums alone each year in order to just insure a family with one kid on the individual insurance market. That $36k doesn't include the $18k+ yearly deductible, nor the co-pays or cost of care or medicine when actually utilizing the insurance.
[1] https://www.oecd.org/sdd/business-stats/EAG-2018-Highlights....
One thing I liked a lot - for basic health care - you could really just walk in and get near immediate service for a modest fee (doctors did not live in oceanside mansions). Prescriptions were laughably easy to get as well - antibiotics etc that in the US meant going to doctor, getting scrip, calling it into pharmacy, going to pharmacy etc - all that appears just much less regulated in some of these places. Basic imaging services / dental services also inexpensive.
They just didn't have the super advanced stuff you see in the US. So I just don't think you could spent $10M during last 12 months of life there, they don't have infrastructure / equipment to do that even if you wanted. So folks probably die earlier as a result?
US still ranks as spending almost double (in total) per person than any of those countries. Does it have better outcomes? Better late stage life? Does it even have the same level of outcomes, with the higher price?
From someone living in a country (Australia)with proper government medical support, this seems insane!
I can’t imagine any other industry getting away with this.
I wish the Democrats had had any courage to go for Medicare for all. It’s an established system that could be tweaked to expand coverage. Instead Biden will make some half assed moves which will immediately be obstructed by the republicans.
And so this travesty will keep going for many years more.
And it seems there is no hope for change.
Because US citizens know that increasing the amount of healthcare provided will increase taxes. This whole game is being played because we want to have our cake and eat it too, with many in the middle and upper deciles betting that they will be better off without a universal healthcare type system.
>I wish the Democrats had had any courage to go for Medicare for all.
We are lucky the Democrats are even trying, and that ACA even got passed, with the compromises that had to be made. They simply do not have the numbers in Congress (and will not based on population trends) to do any more.
And yes, the bigger issue is reducing hospital bills. Again, look at the line items and you'll see a big large number next to admin costs of processing insurance. Add the cost of profit for the insurance company and their cost of running the business and you know where this is going.
https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...
We spend more than 2x per capita than most other countries, and we don't even provide care for everyone.
Infrastructure and schools face similar issues in the US. I don't know what the answer is, but dumping more money into these systems will only make them more inefficient.
That's the problem with Obamacare. It just pumped more money into a corrupt system. The result is that premiums are going up like crazy.
For the same reason I am against cancellation of student debt. If we don't stop the increases in tuition we are just shoveling money to corrupt institutions.
ACA is explicitly a wealth transfer from the young to the old and from the healthy to the sick.
The young to the old because the highest premium for 64 year olds is capped at 3x the premium of 21 to 24 year olds.
The healthy to the sick because insurance companies can only charge people based on age, location, and smoking status, and cannot refuse anyone for any reason.
On top of that, healthcare cost increases slowed down after ACA. So ACA is working similar to universal taxpayer funded healthcare (which would require tax increases). It is not perfect, and it is quite likely there was a better alternative, but there were a lot of compromises that had to be made to even get ACA.
There is only one party fighting to get people healthcare, and they do not have the power on Congress anymore. And likely never will again to be able to do things with it having to heavily compromise.
Your average US citizen has no choice in the matter.
Edit: I'm wrong, it's been legislated! Link in reply below
1. https://www.nytimes.com/2020/12/20/upshot/surprise-medical-b...