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Comment by aeturnum | Hacker News Reader

It seems like the AIs role was in applying lengthy and complex medicare billing rules - it did not do negotiating and it doesn't seem like the accuracy of its understanding of medicare practices was actually checked. The author reasonably accused the hospital of gouging and the hospital came back with a much lower offer.

I'd be interested to hear from a charge coding expert about Claude's analysis here and if it was accurate or not. There's also some free mixing of "medicare" v.s. "insurance" which often have very different billing rates. The author says they don't want to pay more than insurance would pay - but insurance pays a lot more than medicare in most cases.

It's pretty clear that even access to a potentially buggy and unreliable expert is very helpful. Whatever else AI does I hope it chips away at how institutions use lengthy standards and expertise barriers to make it difficult for people to contest unfair charges.

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having hired an expert in this field, I can tell you they aren't really that sophisticated. I found myself with an absolute mountain of cash after an accident as part of a settlement. My medical insurance won't pay claims until I've exhausted that cash. The claims I had were much higher than even the mountain of cash. The lawyer I hired use a pretty effective strategy: he contacted all of the claims against me and told them we could engage in N-way negotiations amongst all the parties until we came to a settlement so everyone got their nibble of the pie. Or they could get X today, where X was some amount that was a bit less than the rate the industry actually gets paid for those services. They all accepted.

The discounts he negotiated left me with tons of cash & were in excess of the fee he charged me.

He literally did a prisoner's dilemma on them. Love it.

The thing is the prices are all made up anyway. The hospital hallucinates prices, so they don’t blink an eye when an llm does the same.

Yeah, US hospital billing is based on the idea that the patient has insurance and won't really care about what their insurer gets charged. (The wider implications of this are left to the reader.)

For the uninsured this sort of thing is actually really common. Had an online friend who had to get emergency treatment and they sent him a bill for $20k. His response was, "lol I'm uninsured and don't give a fuck about my credit score, so, fuck you basically." The bill was revised to $500, which he paid just to not have that debt on his record.

A large portion of the US economy is based on this entire grift pipeline (settling before getting to court). And it's very costly and pushes up insurance costs and costs in general for everyone else.

When people talk about government inefficiency, I always think of how prevalent these kinds of shenanigans really are. I think they are more costly than inefficient government.

It's incredibly costly, and I think it's also incredibly costly in difficult to measure ways. The main method that the average American (read as: not incredibly wealthy person who has lawyers retained) uses to deal with the early stages of this pipeline is engaging in interminably long phone calls, going back and forth between multiple stakeholders, and trying to negotiate as to what actually needs to be paid or done individually. The incentives are aligned for various members of this process to make it a complicated and frustrating experience for customers, because they often benefit from increasing friction for the insured party. I think if you measured working hours lost or impacted by this it would be startlingly high.

Having to settle because court cases take too long to resolve is due to inefficient government.

Not only does the actual court case and appeals process take years, but even after you “win”, the collection process takes years after it has already been determined who owes what.

See Alex Jones for a ridiculous example. He should have been homeless and shirtless a long time ago.

While you're not wrong that most "justice" processes are expensive, I think the parent-poster is referring to a different kind of "government inefficiency", things like:

1. Single-payer health insurance.

2. Laws that insurance-companies must actually use X% of their premiums on payouts.

3. Laws requiring disclosure of negotiated prices, to encourage competition via free-market forces.

The government does it too.

Pretty much every 4+ figure civil violation, fine, etc, etc, is assessed on the basis of "what's the most we can get away with that won't have them taking us to court where it'll get knocked down or cause a public outcry if they tell the news"

The private sector is more efficient at extracting a profit. That doesn't mean they will be better at providing a service, however.

>The wider implications of this are left to the reader.

IMHO, it's actually worse than we realize. The Medical Loss Ratio requirement is good because it requires insurance companies to spend 80% or 85% of premiums on health care. It's bad because one way for insurance companies to make more money is to have inflated health care prices to justify increasing premiums so they can get 80% of a bigger pie. It also gives them incentives to provide care themselves so they can capture some of that 80% spend.

> For the uninsured this sort of thing is actually really common. Had an online friend who had to get emergency treatment and they sent him a bill for $20k.

I experienced this personally with my own insurance. My bill was over $20k, and it took a year to convince the insurance company that removing a few feet of my intestines was actually emergency surgery. I ended up paying $800. My roommate in the hospital had no insurance and ended up not paying anything (which I did not begrudge them at all, since the reason for no insurance was debilitating back pain that led to unemployment)

> one way for insurance companies to make more money is to have inflated health care prices to justify increasing premiums

This only makes sense if they have no competitors since another insurance company would just steal their customers by having lower rates.

The truth is though, healthcare providers are ultimately responsible for prices.

> since another insurance company would just steal their customers by having lower

LOL. Meanwhile, in real-life America, there are only four or five major carriers that control the market, and none of them are incentivized to do this "competition" thing you speak of by engaging in damaging price wars. Why would they when continuing to be part of the problem makes them more and more profits each year? See also: military contracting. Do you see them constantly undercutting each other? No, they buy each other, reducing the number of bidders on every contract.

The military encourages them to buy each other because it's much easier to regulate an industry with fewer companies in it.

>Why would they when continuing to be part of the problem makes them more and more profits each year?

In real-life America, they don't even earn enough profit to earn their shareholders a better return than SP500:

https://news.ycombinator.com/item?id=45736978

And in real-life America, the only people health insurance companies engage in price wars with is the state insurance regulator who gets to deny requested price increases.

Fascinating observation, thanks for challenging my assumptions here. Just seems to further point out how useless health insurers are, even to their shareholders.

My most sincere wish is that all insurers would be nationalized, every last employee summarily fired, and their HQs all imploded and replaced with memorials to all the people whose lives they have cut short over the years. Not a thing of value would be lost IMO. Worse than paying people to dig holes and fill them in again.

Four or five competitors is plenty for a healthy market.

Where I live, they do compete on price - prices vary by about 30% for similar coverage. They can't engage in the kind of price war you're thinking of since insurance companies, by law, have to maintain a fund able to cover costs, have to get rate changes approved by regulators and are largely banned from price discrimination.

I understand the desire to shift blame entirely onto insurance companies rather than providers. After all, one is all about money and the other is seemingly all about healing.

Heck, when a provider does bill people directly because an insurance company refused to pay, we blame insurance companies - even when the charges on those bills are highway robbery - like those in the article itself.

The fact is, the net cost of health insurance was about $279 billion in 2022. Meanwhile, $3.7 trillion went to healthcare providers, pharmacies and the like for care. The ones who stand the most to gain from higher prices are providers.

Frankly, decades of lobbying from the healthcare provider lobby to enrich themselves should have made it this obvious, but sadly, people see doctors as selfless angels and it blinds them.

Providers have certainly gotten greedy but still can’t compete against hospitals when it comes to ridiculous billing.

I practically damn feel sorry for surgeons when I see what they get from insurance versus the hospital for providing the operating room or bed.

> This only makes sense if they have no competitors since another insurance company would just steal their customers by having lower rates.

This assumes the competitors are not all colluding to raise prices across the board

Then they must suck at collusion, given they can't even beat a risk-less broad market index.

SP500 10 year annual return: 14.6%

UNH: 13.59% Elevance: 10.79% Cigna 9.42% Humana: 6.1% CVS: 0.55% Molina: 9.42% Centene: 0.9%

Or, the likelier explanation, is that health insurance prices are highly regulated and have to get their prices approved by a government official(s), and B) they don't have a lot of pricing power due to the competition and they are not colluding.

Executives earn more based on revenues and thus prices and not stock returns.

See almost any of the proxy filings and you will see much of the compensation is based on hitting targets other than just revenue, and most of the compensation itself is equity:

https://www.unitedhealthgroup.com/content/dam/UHG/PDF/invest...

https://s202.q4cdn.com/665319960/files/doc_financials/2025/a...

The executives seem to have a heavy interest in equity returns.

Aren't they doing some kind of turf non compete agreement like isps do?

I had read that comcast won't go into century link territory and viceversa, and something along those lines for the major isps, in order be local monopolies and set prices as they like.

Insurance companies are required to spend something like 80% of premiums on claims.

This sounds like a really good thing, almost everything coming in has to go back out…

What it really means is they love high “allowed” prices. They live on the 20% and want to see the pie as large as possible.

Healthcare costs go up? They raise premiums — win-win.

The road to hell is only paved with good intentions.

Fuck those assholes!!! From 20k to 500… how do you name that?

> to justify increasing premiums so they can get 80% of a bigger pie.

Wouldn't it be 20% of a bigger pile?

I used to live with a guy from Guatemala, who at some point or another wound up at the ER. At the time his insurance apparently had some huge deductible for ER visits so he got the whole bill in excess of $1000. He was going to pay it, so I suggested he just call and tell them he was planning to leave the country and not come back. I told him to tell them there was no way he could pay the full amount, but didn't want to leave a debt out there like this. They lowered the bill to $150 after a few minutes on the phone.

Many years ago, I managed to stab my face with a screwdriver (not my proudest moment), and had to go to the ER. After the stitches, I was asked whether I wanted to pay with insurance. If I did, it was something like $2,000. If I didn't, there was a 75% discount off MSRP. My deductible was like 25%, so it ended up basically being the same out of pocket either way.

The fact that there seems to be a 4x markup means makes me think insurance companies are in bed with these hospitals. If you can mark up prices arbitrarily high, the insurance "discount" is fake.

There's all kinds of shenanigans that these prices enable: https://archive.is/jPE3n

There are cases with prescriptions where its actually better to claim to be uninsured

At Costco Pharmacy I stopped using my insurance plan as the co-pay was more than the no claim cash price. I learned later that my health insurance company owns its own pharmacy and they design the claims process to bias you toward their own pharmacy. Since medical loss ratio must exceed 85% on employer health plans they realize their excess profits by jacking up prices at their pharmacy subsidiary and using their pharmacy benefit manager subsidiary and insurance product to steer you toward overpaying if you just take their suggestion (e.g. $100 if you use OptumRX mail order Pharmacy for the "savings" versus $20 cash price from Costco).

From what I heard, doctors’ bonuses rates per unit of work are entirely calculated based on the specific hospital’s revenue from medical insurance claims; smaller hospitals can’t get as many patient payouts so their rates are lower and so are not as attractive to doctors compared to hospitals that can scalp well. So the prices do relate somewhat to what the hospital must spend on personnel, even if it’s arbitrarily engineered in the first place.

> Yeah, US hospital billing is based on the idea that the patient has insurance and won't really care about what their insurer gets charged.

Not quite: US hospital billing is based on the idea that the insurance company does the haggling for you.

Insurance companies negotiate (cough) "the best rate that the hospital has to offer," therefore: What the insurance company pays is confidential, and the official unnegotiated price is highly inflated. That's why hospitals will always negotiate with uninsured patients, because they're deliberately inflating their fees.

---

In 2011 I had surgery. The first bill was for $100,000, which was sent to the insurance company. Then the insurance company got a letter (cough) "reminding" the hospital of the negotiated rates. The next bill was $20,000. On a follow-up visit, they did an X-ray, and sent me the bill. I sat on it, and then called my insurance company. The insurance company called the hospital to (cough) "remind" them that the negotiated rate for that kind of X-ray was $0.

I know a couple that avoided marriage so she could negotiate the childbirth bill on the basis that she was an uninsured single mom who didn't own property, etc, etc.

> Yeah, US hospital billing is based on the idea that the patient has insurance and won't really care about what their insurer gets charged. (The wider implications of this are left to the reader.)

Don't leave out the part where the consumer doesn't even shop (or sometimes pay) for the insurance policy either, it is determined by their place of work.

So the consumer of healthcare is doubly shielded from any price signals the market might supply.

this looks like shopping in Moroccan bazaar with no price labels. But here you bargaining not for couple fruits but for your health and price range is in thousands. WTF :)

It’s worse than that. In a bazaar there are only 2 participants and they are looking out for their own interests. Most Americans don’t choose their own insurance their _employers_ do.

The insurance company has no reason to make the health recipient happy and the health recipient has little agency in pricing.

> Most Americans don’t choose their own insurance their _employers_ do.

I don't have an employer, but I still only have one company selling health insurance in my county, so... that's all I can buy.

In a bazaar you can examine the fruit or rug yourself.

An average person cannot call up $750K in a year to pay for cancer treatment. But for-profit businesses (and any organization for that matter) treat you much better if keep the carrot of another payment in front of their face. If you've forked over the whole wad of cash upfront they immediately de-prioritize keeping you satisfied.

Yeah at this point this is more like a cultural ritual. You know like howin some cultures you have to refuse a gift 5 times with increasingly stubborn facial expressions, and the gift giver has to insist through it all, and then accept and say thanks. As the default.

Or where you as a guest announce that you now go home, and the hosts have to insist you stay for some more tea or whatever and then you have to again and again say you're now going really and they insist you stay so you chat more in the hallway etc. And it's just how it always is and it would be super rude to just leave or if the host didn't demand that you stay.

Similarly the US developed this traditional ritual that the first bill is outrageously expensive and everyone knows that everyone know, but the ritual protocol say you gotta start with that, we are civilized people, we say hello, so in Healthcare the hello is the huge price, and the interaction always ends in a lowered rate, because that's also part of the protocol.

It's just a cultural difference.

It's even weirder than that, because in healthcare you consume the product&service before anyone even starts to talk about negotiating the price!

Health Care Sharing Ministries (HCSMs) are an interesting loophole in healthcare regulations that excepts uninsured people that participate in an HCSM from paying the tax penalty.

HCSMs are membership organizations in which people with common religious or ethical beliefs share medical expenses with one another. They are not the same as traditional health insurance.

Because patients are considered "self-pay", they negotiate their own prices with providers and they are likely to get an 80% or more discount on "list price" for the service. They are reimbursed by the HCSM if the HCSM approves the reimbursement.

As of 2025, approximately 1.7 million Americans participate in Health Care Sharing Ministries (HCSMs), which amounts to about 0.5% of the U.S. population. In Colorado alone, HCSM enrollment (at least 68k) is equivalent to 30 percent of Obamacare enrollment.

Because HCSMs often exclude essential health services and are therefore more attractive to people who are relatively healthy, enrollment of this size, relative to marketplace enrollment, may increase premiums for marketplace plans.

I am not promoting HCSMs but I did research it when I lost my COBRA coverage a few years ago. I do find it an interesting alternative approach to paying for healthcare. We really do need to explore options in this country.

I can definitely see AI being applied in the HCSM context.

https://www.commonwealthfund.org/publications/fund-reports/2...

https://www.youtube.com/watch?v=oFetFqrVBNc

Warning! As grotesque as health insurance companies are, in theory they are obligated to pay valid claims under your policy. Health sharing ministries can exercise discretion to deny payment because they disagree with your lifestyle choices. Or for any reason or no reason given at all. They are subject to far fewer regulations and audits and in some extreme cases the administrators just pocketed the money.

More and more states are auditing them. But yes it's a faith thing. And definitely not insurance. Works better for tight-knit communities where there is trust.

So you're saying one solution is to get rid of all insurance and make hospitals charge a reasonable price. Sounds good to me. You sound conservative!

We are self-employed in the US and buy our own high deductible plan on our state's marketplace. One of my family members needed a fairly routine planned surgery, so I went through the effort to try to determine in advance how much I would be billed. What a waste of time. My favorite was the hospital who told me the fee for a one night stay would be 73k. But, good news! Your insurance has a contracted discount that brings it down to 13k. So what does the 73k price even mean? At this point I shelved the effort as I correctly concluded we would hit our household max out of pocket for the year, so anything above that would not affect us.

And hey! Silver lining: in a year when we max the out of pocket limit, no more cost-sharing on any other services for that calendar year! Time to pack in some care we have been deferring mostly due to cost. Except the care providers and insurance company are well aware of this, so they don't bill you for up to a year from the date of service, so you can't be sure you "hit your max" until the subsequent year.

It is enough to induce strong negative emotions.

The Surgery Center of Oklahoma publishes all their prices, and do not take insurance:

https://surgerycenterok.com/surgery-prices/

They're the pioneer, but there are other clinics like that.

The “full” prices are basically just made up. If this was like the insurance company negotiates a 15% discount than OK. But the reality is crazy stuff like the “full price” is $7,623 but “your insurance company paid” $34.12. It’s totally bonkers and should be illegal.

But that’s expected. Even in a restaurant it’s not like each dish is priced as cost to make plus a markup. It varies widely, what matters is that the prices make sense in the market and over a week/month the overall numbers work out.

A hospital is vastly more complex. They have huge costs (for things they must have) that can’t be recovered 1:1 with services.

What the author calls criminal is the way hospitals typically bill Medicare and private insurance providers.

If the OPs brother-in-law had had insurance, the hospital would have billed the insurance company the same $195k (albeit with CPT codes in the first place).

The insurance company would have come back and said, "Ok, great, thanks for the bill. We've analyzed it, and you're authorized to received $37k (or whatever the number was) based off our contract/rules."

That number would typically be a bit higher for private insurance (Blue Cross, Blue Shield, United Healthcare, etc), a little lower for Medicare, and even lower for than that for Medicaid.

Then the insurance would have made their calculations relative to the brother-in-law's deductible/coinsurance/etc., made an electronic payment to the hospital, and said, "Ok, you can collect the $X,XXX balance from the patient." ($37k - the Insurers responsability = Patient Responsibility)

Likely by this point in a chronic and fatal disease, the patient would have hit their out-of-pocket maximum previously, so the $37k would have been covered at 100% by the insurance provider.

That's basically the way all medical billing to private and government insurance providers in this country works.

"Put in everything we did and see what we can get paid for by insurance" isn't criminal behavior, it's the way essentially every pay-for-service healthcare organization in the country bills for its services.

I don't say that to either defend the system, or to defend the actions of the hospital in this instance. It certainly feels criminal for the hospital to send an individual an inflated bill they would never expect to pay.

I think the argument is that it’s criminal to take advantage of the patient without insurance and ask them to ruin their life trying to come up with 195k when your system is setup to reasonably profit off the 37k you get from the insured patients. I firmly believe that even in a capitalist society the idea of profiting off of anything let alone healthcare in the thousands of percentage points is criminal.

I think he meant literally criminal.

The hospital double billed for over $100k worth of services on the original invoice.

At a certain point a pattern of issuing inaccurate invoices crosses the line into negligence.

If a business just have a habit of blasting out invoices that bill for services never received, and they know that they keep doing this, and only correct it when the customer points it out, at a certain point it turns into a crime.

From a quick Google query, it says that ~%90 of Americans have health insurance (which seems higher to me than I'd expected). I'd be very interested in knowing the number of uninsured, negligent/nefarious, and exorbitant invoices that are issued as a percentage of all invoices, for the purpose of determining the scale of criminality with respect to your description.

double charging on purpose systematically sounds slightly criminal to me

> What the author calls criminal is the way hospitals typically bill Medicare and private insurance providers.

Interestingly enough, the FBI considers double billing and phantom billing by medical providers, to be fraud.

https://www.fbi.gov/investigate/white-collar-crime/health-ca...

And yet Florida elected a Senator who earned over $100M doing just that.

https://en.wikipedia.org/wiki/Rick_Scott

Yes. Though I think technically none of that happened here.

If I sound like I'm defending the morality of the hospital for billing a private individual $190k for services they'd expect to be paid $37k for, please know that I'm not. But it helps to understand WHY the hospital billed that much, and whether it's legal for the hospital to bill that much.

The biggest semantic "mistake" the author makes in their thread is saying, "Claude figured out that the biggest rule for Medicare was that one of the codes meant all other procedures and supplies during the encounter were unbillable."

The Medicare rule does not make those codes "unbillable" - it makes them unreimburseable.

The hospital can both bill Medicare for a bigger procedure code, and the individual components of that procedure, but Medicare is gonna say, "Thanks for the bill, you're only entitled to be paid for the bigger procedure code, not the stuff in there."

Neither the FBI nor Medicare is gonna go after the hospital for submitting covered procedure codes and individual codes that are unreimbursable under those procedure codes. That's not crime, that's just medical billing.

Actual double billing would occur if, say, your insurnace paid the hospital for a procedure, and then they came after you for more money, or billed a secondary insurance for the same procedure. Or if they'd said, "Oh no, the OP's brother in law wasn't here for just 4-hours, they were here overnight so now we're billing for that as well."

NOW - a much better way for the hospital to handle this scenario would be to see that the patient is cash-pay, and then have separate cash-pay rates that they get billed that essentially mirror Medicare reimbursement. That's essentially what the author got them to do, and it absolutely sucks that's what he had to do.

I briefly worked in adjacent space. While I hate the way it works, it makes a lot more sense when you understand that the billed amount is essentially just a negotiation tactic that represents a price well above what they ever expect to be paid (and a bit added to that for safety).

Then, they negotiate with all of the in-network providers for some number that’s well below the billed amount. That number varies a bit based on how effective various negotiations are.

Realistically, OP simply found the number that insurance was going to pay out anyways.

Exactly. You can do this with anything where the racket is based around the layman not being able to take in the amount of arcane subject matter info they'd need to argue their case, not just medical.

Tons of institutions that specialize in screwing people are built this way because it's pretty hard to "overtly" build an institution to screw people.

Not just arcane subject matter, but numbers so high any sane person panics.

Hospital: "Here's your bill for $1,000,000." (a figure which is 100% fictional) Patient: <panic> "Oh shit, I don't have $1,000,000!" Hospital: "Oh, we'll reduce it to $30,000. Aren't we nice!" Patient: <slightly less panic> "I don't have $30,000 either, but it might not bankrupt me immediately, so I guess that'll do..."

Never mind that the same procedure in most of the EU was either "free" (to consumer at time of care) or a fraction of the cost.

The whole system is fucked.

In the EU you can also generally look up the cost, even in cases where the patient doesn't pay, there is a bill and fixed costs. The costs are what the government pays or what a foreigner with no medical coverage and insurance would pay. It's also generally a tiny fraction of the cost in the US.

This! People underestimate the extent to which lawyers are negotiable also. “I’m not paying that” is a surprisingly effective method; they’re often willing to compromise on payment terms, work at-risk subject to a successful outcome, significantly reduce their rates, etc.

In my experience, most people underestimate what's negotiable across the board. Especially those making enough to do most of their business with mass-market operations, like big-box stores and retail service providers, that profit by doing many, many standardized transactions every day, with minimal discretion or even personal involvement.

Below that, lots of haggling and informal trade often help people get by. The costs of that process can be another burden on the poor. At the high end, it's worth involving people with discretion on the sell side. Additionally, sales are often one-off and customized. They may also bundle a bunch of different items and benefits without clear line-item breakdowns.

When hiring a lawyer, I'd nearly always recommend getting terms down in a written and signed engagement letter before work starts. That is very much a negotiation, but it's fine to ask questions and comparison shop.

If you're starting with a call, it's perfectly normal to start by asking whether initial consultation will be billed or not. If it will be, ask the rate. If it won't be, expect some limits on what can be discussed. The best lawyers I know aren't cheap or easily tricked into giving free advice on consultation calls with speedrunners, but they are up-front about what they charge for and how.

Disclosure: Am lawyer. Negotiate professionally.

> it did not do negotiating and it doesn't seem like the accuracy of its understanding of medicare practices was actually checked. The author reasonably accused the hospital of gouging and the hospital came back with a much lower offer.

Im increasingly of the opinion that AI gives people more confidence than insight. The author probably could have just thought of the same or similar things to assert to the hospital and gotten the same result. However, he wouldn't have necessarily though his assertions would be convincing, since he has no idea whats going on. AI doesn't either, but it seems like it does.

I've found LLMs helpful for figuring out what I don't know, then I can go and look up how those things work, again together with an LLM.

But in the past, once I got to the point where I know I could maybe do something about it, but not exactly what, and I don't know any of the domain words used, you got pretty much stuck unless you asked other people, either locally or on the internet.

At least now I can explore what I don't know, and decide if it's relevant or not. It's really helpful when diving into new topics, because it gives you a starting point.

I would never send something to a real human that a LLM composed without me, I still want to write and decide everything 100% myself, but I use more LLMs as a powerful search engine where you can put synonyms or questions and get somewhat fine answers from it.

Absolutely. It's cheap (as far as the user is concerned) to just fire off a question. And it can even be really fuzzy/ambiguous/ill-defined sometimes. It's a great starting point.

"But fight with knowledge. My $20/month subscription to Claude more than paid for itself. Yes, AI assistants can hallucinate and give you garbage. So I didn’t rely on it. I spot checked by looking up its big findings myself and found it was right. I also had ChatGPT, to which I subscribed for one month just to do this, read the letter and fact check it. No notes."

> The author reasonably accused the hospital of gouging and the hospital came back with a much lower offer.

This will always happen, especially if you don't have health insurance. I had to have surgery without insurance in the early 2000s, and I was able to knock off a large percentage of the bill (don't remember how much, it's been decades) by literally just writing back to the hospital and asking them to double check and verify the line items I was being charged.

(edit: more stories along similar lines in this thread: https://news.ycombinator.com/item?id=45735136)

Totally agree that even this buggy expert can empower patients.

But you better believe that hospitals all over the place are also using AI to find ways around Medicare/Insurance rules to maximize their profit too.

The rules are probably going to get WAY more complex because they will rely less on a few humans, and more on very powerful AIs.

So what you're saying is we've injected a whole smorgasbord of electrical dumbasses into a system already rife with corruption, greed and exploitation that provides services no person can do without and is frustrating to use at every juncture.

Yaaaaaaaaaaaaaaaay.

Old poker adage: "The more wild cards and crazy rules, the greater the expert's advantage."

Poker has nothing on Commercial Lawfare.

This reflects a common complaint in social engineering.

People keep trying to enact rules to stick it to the elites and make the downtrodden better off.

And as the rules get more and more complex, the position of the elites gets more and more solid.

Exactly. The elites hire experts to do it for them, while everybody else has to deal with the complex rules themselves.

It's like auditting tax returns of the rich - of course they didn't cheat, they already lobbied for the loopholes making their shenanigans legal.

>It's like auditting tax returns of the rich - of course they didn't cheat, they already lobbied for the loopholes making their shenanigans legal.

The IRS disagrees every single year.

They say they can easily recover significant revenue from tax cheats if they were staffed and funded enough, to the point that every dollar you fund the IRS recovers 1.6 dollars.

The rich people who say they are just getting their fair deductions then refuse to fund the IRS.

If they weren't cheating, they wouldn't have to kneecap the IRS.

Adding complexity is just one aspect. Everywhere there is someone whose job is to ensure the bottom line never changes and status quo for the powerful is preserved. Insurance, taxes, rents.. in the absence of effective regulation, the average number of successful appeals will simply get factored in and average costs go up so that profit stays the same and grows at the same rate as before. Similar to how chains factor in losses due to spoilage or theft.. of course they don't actually take a profit loss, they just price it in.

I really don't get people who see this kind of thing as empowering because in the end your (now strictly necessary) appeal with lawyers or AI to get a more fair deal just becomes a new tax on your time/money; you are worse off than before. A good capitalist will notice these dynamics, and invest in AI once it's as required for life as healthcare is, and then work on driving up the costs of AI. Big win for someone but not the downtrodden.

Oh wow, I had independently formulated that as the duality/parallel between corruption and cheat codes: "The more out-of-band information you need in order to be treated normally/fairly, the more corrupt the system is."

https://news.ycombinator.com/item?id=9933801

I suppose a saving grace there is that Medicare is incentivized to help people or at least not incentivized to provide the minimum amount of value for maximum profit.

Lol. Who do you think makes the Medicare rules?

CMS?

> Yes, AI assistants can hallucinate and give you garbage. So I didn’t rely on it. I spot checked by looking up its big findings myself and found it was right.

The funniest bit about all this is that this is all just laziness all the way down. People complain about AI-written articles. When the article is written about a human, they fall over themselves to point out potential flaws, like "well it looks like AI hallucinated" and it gets voted to the top. Then it turns out that they themselves did not read the article. Just a damning indictment of the quality of online discourse in year 2025.

Often with these kinds of things it's not even as much about being specifically accurate as it is about presenting yourself in a way that makes the other party believe that have sufficient understanding of the issue at hand and the escalation paths available that you won't just go away if they don't play ball. That is, make yourself credibly as a Dangerous Professional, in patio11 parlance.

I just did this with a pet insurance bill, and ChatGPT was very helpful. They denied based on the pre-existing condition exclusion even where it was obviously not valid (my dog chipped her tooth severely enough to need a root canal, and they denied because years before when she wasn't covered under the policy, she had chipped the same tooth in a minor, completely cosmetic way).

I was sure they were in the wrong and would've written a demand letter even in the pre-AI days, but ChatGPT helped me articulate it in a way that made me sound vastly more competent than the average consumer threatening a lawsuit. It helped make my language as legally formal as possible, and it gave me specific statutes around what comprises a pre-existing condition in CA as well as case law that placed very high standards on insurers seeking to decline coverage by invoking an exclusion (yes I checked, and they were real cases that said what it thought they said).

Gave them fourteen days to reverse the denial before I filed in small claims court, and on day fourteen got a letter informing me that the claim would be paid in full. It's of basically no cost to them to deny even remotely borderline cases, so you have to make them believe that you will use the court system or whatever other escalation paths there are to impose costs, and LLMs are great for that.

>It seems like the AIs role was in applying lengthy and complex medicare billing rules - it did not do negotiating and it doesn't seem like the accuracy of its understanding of medicare practices was actually checked. The author reasonably accused the hospital of gouging and the hospital came back with a much lower offer.

What exactly do you think negotiating is? Real negotiation in business transactions is more often based on agreements around certain facts than emotional manipulation.

People want so badly that AI won't be useful that I feel like they will diminish everything they do. I also get that they probably feel like it's all hype, but there are plenty of examples of real value that AI brings to the table.

I guess I would think that negotiating at least involves communicating with your counter-party. Its role here feels more similar to being a billing consultant. There are plenty of people (and systems) that pass messaging over to the actual AI - which was my expectation from the title and why I noted it didn't happen.

> the hospital came back with a much lower offer.

Yes, because, there is an entire department _dedicated_ to this function. You just call them and say "I can't pay this" and you'll get the same result.

The author mentioned in a reply in threads that most of the fees was Facility Fees. That might be just wrapped up in a code for cardiology sure, but its just profit chasing hospitals because that practice can wildly inflate the cost and billing and that can be fought.

> I'd be interested to hear from a charge coding expert about Claude's analysis here and if it was accurate or not. There's also some free mixing of "medicare" v.s. "insurance" which often have very different billing rates. The author says they don't want to pay more than insurance would pay - but insurance pays a lot more than medicare in most cases.

I'm a cofounder of Turquoise Health and this is all we do, all day. Our purpose is to make it really easy to know the entire, all-in, upfront cost of a complex healthcare encounter under any insurance plan. You can see upfront bills for many procedures paid by various healthcare plans on our website.

The information posted in the thread is generally correct. Hospitals have fictional list prices and they on average only expect to collect ~30% of that list price from commercial insurance plans. For Medicare patients, they collect around 15%. The amount the user finally settled for was ~15% of the billed amount, so it all checks out.

The reason for fictional list prices (like everything in US healthcare) is historical, but that doesn't make it any more logical. Many hospital insurance contracts are written as "insurer will pay X% of hospital's billed charges for Y treatment" where X% is a number like 30. No one is 'supposed' to pay anywhere near the list price. Yes, this is a terrible way to do things. Yes, there are shenanigans with logging expected price reductions are 'charity' for tax purposes. But there isn't a single bad guy here. The whole system that is a mess on all sides.

Part of the problem is that the US healthcare billing system is incredibly complex. Billing is as granular as possible. It's like paying for a burger at a restaurant by paying for separate line items like the sesame seeds on the bun, the flour in the bun, the employee time to set the bun on the burger, the level of experience of the bun-setter (was it a Dr. Bun Setter or an RN bun setter?), etc. But like the user said, some of these granular charges get rolled up into a fixed rate for the main service.

However, the roll-up rules are different for every insurance contract. So saying the hospital 'billed them twice' is only maybe true. The answer would be different based on the patient's specific insurance plan and how that insurance company negotiated it. Hospitals often have little idea how much they will get paid to do X service before it happens. They just bill the insurance company and see what comes back. When a patient comes in without insurance, they don't know how to estimate the bill since there is no insurance agreement to follow. So they start from the imaginary list prices and send the patient an astronomically high bill, expecting it to be negotiated down. In some areas, there are now laws like 'you can't charge an uninsured patient more than your highest negotiated insurance rate' but these are not universal.

If you find yourself in this situation, there are good charities like 'Dollar For' that can help patients negotiate this bill down for you. We are trying to address this complexity with software and have made a lot of progress, but there is much more to do. The government has legislation (the No Surprises Act) that requires hospitals to provide upfront estimates and enter mediation if the bill varies more than $400 from that amount. But some parts of the law don't have an enforcement date set yet, which we hope changes soon.

Thanks for your insight!

I was going to say please use and donate to 'Dollar For' [1] which provides this service, which is likely a better choice for this type of problem than trying DIY.

[1] https://dollarfor.org

EDIT: adding in a link to 'Dollar For'.

> even access to a potentially buggy and unreliable expert is very helpful

Which is a great description of the American health care industry, even before its involvement with AI in any capacity.

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