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Comment by retrac | Hacker News Reader

I would point out that the attending surgeon, the anaesthesiologist, and the hospital all bill the patient separately here for a surgery, in Ontario, Canada. (Most people will never see these bills and it's covered by the public insurance.)

The reason is that the service - the contract - is organized in that way. Between the patient and the anaesthesiologist, between the patient and the surgeon, and between the patient and the hospital. So three separate bills. The doctor and hospital will have their own contract. Legally, and in an important way when it comes to decide who to sue for malpractice, the hospital is not the provider or performer of the surgery. They just provide the venue and equipment; the doctors do the surgery.

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But why is done that way? Lots of freelance chefs move between restaurants but the bill is always between the restaurant and the people who dine there.

Server is better analogy. The wage you pay/owe the waiter is direct and (mostly) separate from meal, albeit informal with only shame as a deterrent for default.

I'm not based in the US, so my servers are paid a wage directly by the restaurant.

That makes sense, but the ah ah ah this isn't the US card comes unexpected on an analogy developed specifically alongside a US based topic.

I'm sorry? I was only asking a question about another culture.

Because the legalities of chef/restaurant malpractice are orders of magnitude less important than those of doctor/anesthesiologist/hospital.

Because historically doctors were in private practices. I still am, as an anesthesiologist. Many of the surgeons I work with are also private.

So, since neither of us is employed by the hospital, we do our own billing. If we were hospital employees, we could indeed do unified billing. That's a better analogy; your chefs are expecting to be paid by the restaurant, so it collects the bill. I am not paid by the hospital except a stipend for taking call for them - not for any specific services I provide to patients.

It's frustrating for patients and families, it's annoying for us, but it's the price of legal independence for us. If my hospital collapsed overnight (and they sometimes do), my group could go out and start working other sources of income right away, because we already have the business setup to do our own billing.

It's still better than billing to the hospital and the hospital billing to the patient, piling up taxes and comissions. The patient is also getting more cost transparency instead of a bundled bill one can never make sense of.

I don't agree with the last point and I think this thread is evidence of that. We cannot make sense of the myriad of bills we get from all the different providers, particularly since many or all of them are also being dealt with by our insurance and may have already been negotiated by the time we get the bills in the mail.

To that point, I went to the ER a few months ago and I've probably received ten or so mailings for unpaid bills, only one of which I actually ended up owing, but my insurance didn't make the claims visible until they were settled which was months after the fact. To make matters worse, I can still log in and pay bills which were settled by my insurance. And I've received bills in the mail -- late I assume -- after they were paid by me or settled by insurance, confounding matters further.

Transparency would be far more useful if it came before the service being rendered.

Obviously there are some practical limits in exceptional cases, but I can't think of another industry that has high-price services where providing estimates isn't standard.

The problem is that in many cases, there is no way for a patient to meaningfully review options, negotiate, or even consent prior to receiving treatment. For non-elective procedures, at best it's an "under duress" sort of deal.

This is why healthcare should be provided for free at the point of service, paid for by the government. It works very, very well for many other countries. The only reason we haven't been able to make it work here is the rampant lobbying.

Disagree.

To follow the restaurant example above.

And since the topic is debt, how do you think that affects the small private practice? The hospital, that has scheduled and contracted the doctor, on site, with the hospitals equipment is more able to have a loss column than an individual.

This seems like something the IRS should fix; as all of the above makes the contractor an employee of the hospital.

Can you imagine flying on a Delta flight and you have to pay a separate bill to a 3rd party maintenance company.

Your explanation doesn't seem like anything but a well polished justification for what is ultimately a dubious shakedown. Without actually consulting with a patient and agreeing upon pricing well ahead of a scheduled surgery, you have absolutely no business requesting any payment directly from them. These billing charades revolve around some utterly perverse idea that obtaining someone's identifying information somehow confers some right to unilaterally bill them arbitrary amounts. For sanity's sake, everyone else can only hope this broken and illogical system is on borrowed time and will get stamped out hard. And you can most certainly retain your legal independence and work for multiple vendors as a subcontractor, like in any other industry.

> Without actually consulting with a patient and agreeing upon pricing well ahead of a scheduled surgery, you have absolutely no business requesting any payment directly from them.

Well, if you want to turn this into a rant on how incredibly backward the way things are done is, I'll agree with you that it's a terrible method. But it is the way things work. Don't believe me? Ask your insurance company. Your deductible is not payable to the insurance company; they require the billing entity to collect it themselves (and thus spread the risk onto us - they don't pay our negotiated fee, they pay the negotiated fee minus your deductible and it's up to us to get it from you).

> And you can most certainly retain your legal independence and work for multiple vendors as a subcontractor, like in any other industry.

Again, look at how health insurance in the US, as a whole, works. And, for that matter, hospitals (for- vs not-for-profit is a mostly meaningless distinction in this).

> But it is the way things work

Sure, it's the way things are done. What I'm questioning is why it should even be expected to "work", apart from people's seemingly misguided sense that what essentially amounts to a request for a tip is somehow a binding debt they're obligated to pay. What you've described is the exact same set up as a waiter at a restaurant. And yet despite waiters often handling identifying information, nobody gets a post-hoc bill in mail asking for arbitrary table service fees. And if some waiter did try this hustle, the recipient would likely roll their eyes and toss it in the bin.

> Your deductible is not payable to the insurance company; they require the billing entity to collect it themselves

Sure. I wouldn't call this backwards - rather inconvenient but still legally sound. The provider enters into a contract with the "insurance" company that requires this. The customer enters into a contract with the provider by requesting and using their service, so the provider can bill the customer.

What you (and most of the industry) are somehow claiming is that even though the patient already has a business arrangement with the hospital for treatment, that the hospital calling in a subcontractor means that subcontractor is somehow entitled to bill the patient directly despite having no business relationship.

And historically, grocery suppliers are not owned by the grocery store I go to, but it would be completely batshit insane for me to go to Kroger, buy a bag of potatoes, and then three weeks later get a separate bill from some potato farmer for it.

This doesn't endear me to the situation. :(

Sounds like the way hair salons and strip clubs are run in the U.S.

Not seeing these bills would be incredible. Having them all covered in the same way would be fantastic. Instead, for us, states need to enact surprise billing laws since each provider can mysteriously be out-of-network despite working within a hospital that is in-network. The in-network concept is complete bullshit to start with, but then you have to have complete documentation of every person involved in whatever care you are getting.

This is what infuriates me the most about healthcare in the US. I give someone my card, they enter the numbers with no indication of whether or not everything will be covered by insurance (they assume you just know).

Then, a month later, I receive a bill indicating a routine procedure that I assumed out of ignorance was covered by insurance (since they took my card and entered the numbers without saying anything to the contrary) for $500 (or, god forbid, more).

If I knew a salad at a restaurant were $200, I probably wouldn’t order it. There is no basic transparency in medical billing, and that needs to change.

It’s actually even worse. If you (or the Dr’s) could reliably tell how it was even going to be coded (aka categorized/identified) in the system in advance, it would already be a huge step up.

Then you’d only have a handful of different prices you might have to pay.

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