2. Insurance says "nah, we'll give you 18k"
3. Hospital goes "ok".
4. Hospital writes off as a 72k loss, which essentialy is a "tax deduction".
This is good for me, but such a perverse incentive for the hospital.
- $90k bill - you pay your annual $10k deductible - the remaining $80k is only covered 80% because emergency visits only have 80% co insurance - you now owe $16k, after you've already paid $10k out of pocket for the deductible
This is a real thing that happened to me recently. Not to mention I pay $1500/month for a family of 4.
Nothing, absolutely nothing about the U.S. healthcare pricing structure is good for patients.
It seems to have worked out for you because you appear to have very good insurance. Most people are like me, and have the type of insurance that should be illegal.
Most of us now have very few employer-based options, which happen to be almost always better because the employer subsidizes some. So it's not unlikely to see that the options you'd prefer are not available. High deductible, but OOP maximum very close to the deductible? Sorry, not available, go look at the secondary market for more insurance. It's a very difficult environment to make decisions on, and most people are just not all that well equipped financially to deal with it. The products have gotten way too complicated for the vast majority of people.
Roofing and construction contractors would be all over this if they could avoid taxes simply by negotiating down an invoice.
In the grand scheme of things, this causes multi-level market "malfunctions". First, hospitals are incentivized to bloat bills, making healthcare virtually unaffordable if you don't have the bargaining power of an insurance company. Worse, this ties employees to their employer who subsidizes their healthcare plan (for another tax deduction I presume), thus twisting the dynamics of the labour market in favour of the employers.
Hospitals and payers negotiate rates and contract at that rate before the service is provided. Assuming the service is not denied by the payer, the hospital knows that they'll only be reimbursed 18k from your insurance company (or at least has the data to know in advance, putting aside whether any one person could tell you what it will be). The 90k only served as a starting point for negotiation with payers and is usually obscenely high due to other regulatory and contractual reasons related to the negotiation process. Their "list rate" is shown on your bill, but was absolutely never expected to be received.
As a result, it's not a "loss" of revenue at the time of service, and isn't recognized as one.
Now, because GAAP requires revenue be recognized when realized and earned, that service became "revenue" to the hospital after service, even though they haven't been paid. They might later "write that off" (I.e. recognize a loss) if the payer ultimately denies that claim, or you refuse your responsibility (I.e. your copay). But in that case, the hospital did not, in fact, make the money.
Lets be real its due to greed nothing else.
To be clear, I’m not defending the system either. It’s fundamentally broken by design. But it’s certainly not solely the greed of hospitals that got us here.
But that wasn't enough to juice profits so pricing had to be made as opaque as possible to screw over anyone who isn't a giant insurance company ensuring the little guy without insurance who "pays his bills" pays more than 10x anyone else in the system.
I don't know of any other industry with this level of depravity and greed.
It seems hard to search on, but it doesn't really look like there are tax benefits from contractual adjustments.