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Comment by hermannj314 | Hacker News Reader

I asked if I could pay cash for an MRI rather than wait for insurance approval just to speed up the process of booking. I offered to manually file a reimbursement later if it was approved or pay cash if it wasn't.

Apparently, in the United States that is considered insurance fraud or something, whereas when I lived in Luxembourg that is how the system worked. I don't even understand what world we have constructed in the US.

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Idk what happened on their end, but someone close to me was recently diagnosed with cancer. After the biopsy came out positive, they wanted to do a pet scan, but had to wait for approval from insurance (which apparently could take several weeks). I offered the same as you, and they agreed and did the pet scan within days.

Keep in mind that the facility is likely making an error. But you won’t convince them of that if any of the staff suspects anything could be perceived as fraudulent (even if it’s not) - they’ll just avoid the risk.

That's not insurance fraud, that's (one way) insurance works, so I'm not sure who told you this was fraud or why. If you pay in cash, then submit a claim, your insurance company can very well deny you, but as long as you weren't reimbursed through some other process, there is no fraud.

I had an MRI last week. Cost me €35. Though if you miss the appointment, or fail to pick up the results, the penalty is €215. Me...doctor...hospital. No other parties involved. Especially not an insurance company - but those do exist, if you wish. What, indeed, have you constructed in the US?

That sounds like it might be the staff just being uninformed because nobody has ever wanted to do that before.

But a likely practical problem with that plan is that the cash price is unrelated to the price the insurance company has negotiated with the facility, and the negotiated price is a secret, so if you pay the cash price you won’t be reimbursed for the amount you paid. You’d need to get them to agree to refund the difference if insurance approved later.

For imaging in particular, there are some facilities that can handle direct payment rather than expecting everything to be paid by insurance. Maybe look for one of those if this comes up again.

Yes, this is very messed up. Welcome to the USA!

Are the negotiated prices secret? I've never had a major hospital visit. But every time insurance has covered something for me, I could look on my account claims and see both the official price, and the negotiated price.

I also had an "amusing" experience with my dental insurance, where my provider went out of network, and I didn't know until I was in the chair (at which point I was at least asked before they proceeded). When I went to pay, they gave me a bill that listed only something to the effect of "anticipated insurance payment", which is what I was charged. They also filed an insurance claim on my behalf, which was eventually reimbursed fully. However, when I got the reimbursement notice from my insurer, it list a cash price about 50% higher than what I paid, which my insurance company was able to negotiate down for me.

Yes, they are secret (otherwise it wouldn’t be a very good negotiation!). You will eventually see some form of the negotiated price for your insurance on the bill, but you won’t see the rebates and so forth that are in the broader contract, so that isn’t equivalent to a cash price. Also, you will probably not be able to see what the price is until it is actually submitted and covered.

Unless you actually spoke with someone on the legal side in billing, the assumption passed through hospital systems is to stay way away from things which could possibly be seen as fraud, quid pro quo, kickbacks, or any host of financial crimes that are unusual. The staff are taught “You are not a lawyer, let us handle that, here is your playbook” and not to deviate from that.

That disposition of bracing against legal wrangling underscores most of the annoying parts of healthcare, especially the cost.

-I work in a hospital system’s technical department.

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