The Medical Bill Mystery | Hacker News Reader

The Medical Bill Mystery

nytimes.com

66 pointsprostoalex55 comments

The entire medical bill and insurance system is insane. I say this after going through 2 pregnancies (with my wife) and now with 2 young kids.

The process is that you go to the doctor, they will NOT tell you how much it costs out of pocket because that amount is probably insane anyway but you need insurance to "bill" that insane amount to the insurance company. The doctor will send say $1000 bill to insurance company for a simple checkup (yes, it can be that bad). THe insurance company then will say "no no sir, we only allow $200 for this specific item". Then insurance company will figure out how much you the patient ius supposed to pay out of that $200 (copay, co-insurance etc) and THEN they will pay the remainder to the doctor.

See the issue here ? The price of a simple checkup is inflated from $200 (we can argue on this too) to $1000. This $1000 is just to scare you but really does not mean shit.

Imagine that the doctor could bill you that $200 directly anyway or whatever amount they eventually get from insurance company. It will save their time, your time, their staff hours and probably save more for them in terms of resource usage.

What we need is a system where not everything goes through insurance. This scare of having mandatory insurance is the root cause. Doctors/hospitals need to have transparent pricing just like other businesses and insurance should only bee needed for really catastrophic events like cancer, major accident etc.

I would much rather pay $200 to a couple of visits instead of paying insrance $1000/month just to "insure" myself.

Or you get a single payer and this charade goes away because the single payer's price list is fixed. This is how the rest of the world does it.

Western Europe != rest of the world.

The Indian system is a 1 billion payer system. The single price is also fixed and usually written on the wall, or maybe in a big book of prices. You ask for a price quote, receive it, pay that much and get it done. If the price is too high you go elsewhere.

It works nearly perfectly. For any medical conditions I have that permit flight, I'm voting for it with a plane ticket.

As a counter-point, a lot of Eastern European systems are single-payer (inherited from the Soviet days of free medical care), and because the fixed price amounts to pretty much nothing, there's lack of supply of doctors and implied cash gifts for each and every transaction you undertake at the hospital.

You can have a fixed price list without single payer. Examples include Germany, Japan, and Switzerland.

"What we need is a system where not everything goes through insurance. This scare of having mandatory insurance is the root cause."

I think providers should not be allowed to bill patients any more than what they would bill insurance companies. Period.

Also, they should streamline 'accumulators / indemnities", which are dirty insurance tools designed to not pay. Copay was simple enough. But now we have co-insurance, deductible, out of pocket cost, out of pocket maximum, health savings accounts, family vs individual deductible and/or maximum out of pocket, etc.

Nobody really understands this.

We should have two things: percentage-based co-insurance payment where insured people pay percentage of the service, with adjustments for people who have pre-existing conditions.

If you've delivered a baby under anesthetic/epidural then you've probably also encountered the "independent" anesthesiologist who works as subcontractor to the hospital and not the OB delivering the baby.

So now you have everything in-network, except the coin-flip of a guy that shows up 30 minutes before you hit the end of early labor. One time I got hit with an out-of-network refusal on the epidural and I flat out refused to pay it. It eventually (mysteriously) changed to an in-network charge.

Insurance is a problematic industry in general, because the insurer's incentive is to fail you when you need them: to take your premiums while things go well, then fuck you over when a disaster happens, often on a technicality (e.g. "you had hurricane insurance but no flood insurance" in Katrina). It's just a terrible model for health issues, which are generally more complex than event-based insurance policies. We should have gone single-payer in the 1940s; we didn't get it then, because a bunch of Southern racists didn't want to desegregate the hospitals.

Doctors themselves often don't know what their services cost. The hospital does the billing, not them. And hospital bills are obscene, bizarre, and intentionally obfuscated. An aspiring costs $70 and a box of tissues becomes $150 "mucus collection therapy".

It's absurd, but it also performs a social function similar to the persecution of witches, heretics, and old eccentrics. (Yes, this sounds like it's coming out of left field. Please continue.) Namely, witch hunts were mostly economic in nature; you had middle- and upper-middle class (but not rich or important) older people, often women but some men, who'd amassed sizable savings that, being weakened by age and declining health and social isolation, they couldn't really defend. Witch hunts were a great way for corrupt clerics (Catholic, Protestant, both "sides" were in on it) and enterprising inquisitors to yank the savings of old and modestly wealthy people, in a way that had enough official muscle (religion) behind it that a large portion of their heirs wouldn't deign to go into the fight (for fear of being labelled heretics or witches themselves). Witch hunting was about many things, but raising money was a primary and overlooked motive.

Older people tend to have savings without the ability to defend it. When you have undefended money, there's a risk that someone will try to steal it. In the 16th century, witch hunting was the means. In the 21st-century U.S., it's medical bills: cooking up a way to suck savings off of people who are close to death and won't need them anymore. (The 25-year-old who gets denied cancer treatment is seen as just a casualty, but she's not the main target.) Medical bills are basically an inheritance tax built to fuck the middle class, yet the conservatives (who get up in arms if you apply an estate tax to double-digit millionaires) have absolutely nothing to say about it.

The healthcare system is not a way for corrupt clerics to suck savings off of dying old people. Also, "conservatives" aren't getting rid of medicare any time soon, and you'll find that most would have a lot to say about how our healthcare system works and why it's expensive.

I agree that the specific formulation that grandparent used is probably unnecessarily provocative, and also posits a measure of intent or malice aforethought.

But re-read what he's written while thinking about the effect of our healthcare payment structures and policies, not necessarily the intent, and it makes some sense.

The great bulk of healthcare costs are due to end-of-life and chronic condition care. Even if you don't think there are nefarious plotters sitting around scheming to rob old people's savings by billing them for outrageous healthcare, in effect, that is what Medicare is. It is a way to funnel money from everybody (or, everybody who is poor enough to make their money by earning wages under 100k) to people who bill for end of life and chronic care. The role of the old and dying in this scheme is as concentrated conduits for the capital to flow to the billers. (Billers, here, meaning providers but also the cut going to the payer/insurer/processing infrastructure as well as supplies, pharma, etc -- the medical/industrial complex if you will.)

I'd also like to point out something that is little-known by the typical early- or mid-career, technologically savvy and well-employed HN poster (including may I say myself, before some family experiences clued me in otherwise): in the case of Medicaid, at least, the state puts a property lien on all assets of the beneficiary and tries to claw back amounts paid after the beneficiary's death.

In other words, there really is a department in the state government that is in charge of taking title to a dead old person's house and car, and auctioning them off to repay amounts that the state had advanced to the medical-insurance complex on that person's behalf.

So. When I think of that, and when I think of those TV ads that promise they can sell scooters to sickly oldsters who can little afford them except for a Medicare subsidy ... it has more than a mere echo of resonance with grandparent. In other words, much of the medical system sees "dying old people" as pretty instrumental for concentrating and slurping up cash, if not to say "suck[ing] savings off" of them.

> It is a way to funnel money from everybody (or, everybody who is poor enough to make their money by earning wages under 100k) to people who bill for end of life and chronic care.

You can say those words (modulo one hundred thousand) about many single-payer healthcare systems. It is not right to do this, to interpret medical systems under a cynicism maximization principle. It doesn't tell the Truth. After all, these services also provide concentrated conduits for medical care to flow to the citizens.

> So. When I think of that, and when I think of those TV ads that promise they can sell scooters to sickly oldsters who can little afford them except for a Medicare subsidy

I think those scooters greatly improve some people's quality of life. If you want to hear stories about companies trying to take advantage of medicare/medicaid, I could tell you quite a few myself -- I have a close relative that worked on the government side of things there.

No, it's not a way for corrupt clerics to suck savings off of old dying people. We're not in the Wars of the Reformation anymore. It's a way for corporations to suck savings off of old dying people, and it works.

Do you have anything more to say?

this is actually a striking good analogy

The most important thing I've learned is that the "bill" is not like the bill that comes at the end of the meal at a restaurant. Medical bills are more like the first offer in a long negotiation process. Unfortunately for the uninsured who get serious illnesses these days, it often just amounts to an impossible demand that is then graciously negotiated down to merely everything they have.

Basically, Oracle pricing.

I had four surgeries last year. In all cases I was given a price quote plus a ballpark on the cost of incidentals (things purchased outside the hospital, e.g. antibiotics to consume at home). For example, I was told that my spine surgery would cost 1.4 lac only. The final bill: https://imgur.com/Dbkrmo7

In all cases the final price agreed with my initial quote down to the rupee. The cost of the incidentals was also within the ballpark that I was told (and minor in any case - e.g. 1.4 lac for surgery and 2-3k for post surgery pills).

One of the wonderful things about India is that the medical system is almost entirely consumer driven - you have a problem, you pay the doctor, and he does his thing. Customers choose a doctor based (in part) on price, resulting in price competition. Nonsense like refusing a price quote will result in customers walking away.

Given a choice, I'll always choose to consume medicine in India. It's just a vastly superior system to anyplace else I've tried.

Couldn't agree more. I am an Indian and when I first came to US, my biggest surprise was that jobs would advertise 'health insurance' as a benefit. I never understood it till I had to obtain medical care.

If you want to experience true free market health care, you must go to India. Whenever I visit India, I make sure to get my teeth cleaning done. Person in my home town has a choice to get teeth cleaning done from 500 INR (7$) to 3500 INR (55$). On the low end, you get a clinic which is not in the hip part of the town, equipment is not the latest and greatest and the waiting room will be non air conditioned. On the higher end, the clinic will be fully air conditioned, serve you tea/coffee and will use the latest equipment. On my last trip, a real dentist (not a hygienist) performed my teeth cleaning and they took my teeth x-ray using those new machines where you stand up and the machine takes 360 degree scan. After the cleaning, the doctor took me to her office and reviewed the x-ray with me and then gave me a CD with all the x-ray images so that I can use them with my next doctor in case I decide to go somewhere else.

How long did the dentist spend cleaning your teeth? My experience is hygienists spend more time and are more thorough because that's their one job. Also, several dentists over the years have recommended to me seeking a dentist that an employs a hygienist for this reason.

I have done teeth cleaning in both US and India and I don't think there was any difference in terms of the time spent.

For non-Indians, a lac (Lakh) is 100,000.

http://en.wikipedia.org/wiki/Lakh

As someone who has recently gone through a property purchase and had to deal with the forms mandated by the new "reform" laws mentioned in the article, it's pretty clear that the laws have made things much more confusing. I've purchased property before, and this time around the forms were much more confusing, and downright misleading at times. Talking with the pros involved in the purchase, they unanimously agreed - they were constantly having to explain what the forms meant to seasoned home buyers. It's clear that gov't bureaucrats should not be trusted to specify forms that are intended to make any sense.

This article is a good sign that now that high deductible plans are becoming the norm, people are actually interested in what's being billed and in controlling costs. Hopefully this will lead to a reform where health insurance is more like other insurances (purchased by the person needing it instead of employer, purchasable across state lines, ...). I know that one of the reasons I keep my car insurance company is that the mechanics of doing business with them is nearly frictionless.

I had surgery last year. There was a steady stream of bills, some duplicates, some not, and I had no idea how much I needed to pay (to say nothing about what the charges were for). My wife went to the hospital to clear things up and they couldn't even tell her how much they wanted me to pay - and this was months after the surgery. Finally, after a couple weeks had passed, they decided what I was supposed to pay. Good chance someone just wrote down a number.

My feeling is that the experience could be improved dramatically right now if instead of ever directly paying providers, we instead always paid the delta to the insurance company. My experience with provider billing offices is that they actively weasel and trick you into overpaying the negotiated rates and hope you don't go over the bill. And then they stall and "forget" to refund. Nothing ever makes sense until the explanation of benefits document is generated.

In other words--if we're not going to do single-payer, then it should at least be single-payer-per-patient.

I guess insurance companies don't want be involved in the collection business.

So much so that, my dental insurance company (Delta dental, funny enough) cuts me the reimbursement check. And I have to pay my dentist.

Of course they don't. Everyone wants to externalize the unpleasent parts of business.

There's one simple fact that can save patients real money: network providers generally can't go after patients for fees that aren't covered by insurers. Forgoing that right is typically part of their deals with insurers. They often go ahead and bill patients anyway. But they back off when challenged, saying that they billed in error.

Can you explain further what you mean? I recently had an x-ray that was not covered by my insurance, and the hospital submitted it to my insurance to ensure that it would apply to my deductible.

I guess you mean a fee that is uncovered in the sense that it would not apply against the deductible.

(It's total BS, the price I paid was 5x the medicare reimbursement rate, like 15x the medicaid reimbursement rate and I would speculate at least 2x what the insurance company would pay (based on researching the 'typical cost' of the particular x-ray on the internets).)

I was specifically referring to stuff that's covered, and where the provider bills the patient for it's cash-price fee, less what the insurer paid. Network providers generally can't do that. But out-of-network providers certainly can, and those fees can be huge.

In your case, I'm guessing that your insurance doesn't cover outpatient services (or perhaps just imaging) at hospitals. Even if the hospital is in network. If that's the case, make sure to have that stuff done at stand-alone clinics, where it should be covered.

It was the imaging. Good to know that it should be covered at a clinic (I was actually at the urgent care clinic adjacent to the hospital, but they get their imaging services from the hospital).

Was this in-network? Typically if something is in-network but applied to your deductible then the rate you pay is your insurance company's "allowed amount", the rate they "negotiated" with the hospital for the service, and exactly "what the insurance company would pay".

It was in network. I don't believe it though. I did say I was speculating, because I don't have any evidence. I would love to see what they actually pay, assertions that they must pay the allowed amount don't really make me any less skeptical about it.

The comments from those in India are interesting. Here in Thailand it is similar. Prices for standard procedures are published and you get an estimate in advance if it is a complex procedure. This is true for private hospitals. It is also true for public hospitals that offer "special clinic hours" which is when foreigners must go since they are not covered by the national health insurance scheme. To top it off, quality of care is better here than what I experienced in the U.S. at a fraction of the price. It drives me nuts to be reminded of the U.S. health care mess.

It's not just the billing codes that are insane, it's also the differences in prices. I recently filled a prescription at CVS. CVS billed my insurance company nearly $200 for 90 days. I found out that you can get the same prescription at Target for $10 for 90 days. (I'm not sure that the insurance company will actually pay $200 - I'll have to wait to see what the claim says).

> 1. 25030731 HC RT OXYGEN DAILY CHARGE — $2,132.25.”;

>The supplemental oxygen delivered into the nose after surgery, a routine precaution at many hospitals.

What is wrong with US healthcare in one sentence. two thousand dollars for oxygen is beyond ludicrous. There is no way this cost could be justified.

This is a completely rational price given that none of the prices are published, and that the prices tend to be set more on who is doing the paying than anything related to the actual cost.

Do an experiment sometime. Pretend that you need an MRI of your head. Call around to the various places that provide MRIs and see if you can get (a) the price, (b) a description of the equipment that will be used so that you will know if it will be a good MRI or an ancient one.

It's pretty laughable that we just had a major "reform" of our health insurance system, with lots of lip service paid to cost, and yet there is still no information available to allow people to make decisions based on cost and quality, and this appears to be by design.

Rational ... way more oxygen than a person can consume costs a couple of bucks ... you need a valve and a drinking straw ...

"Your medical care would be paid for by others. And therefore you would gratefully accept, on bended knee, what was offered to you as a privilege. Your role being responsible for your own care would be diminished."

I've paid (either directly, or by an employer having paid money that otherwise could have gone to me) about $60,000 into the medical insurance system since leaving college. (That's 10 years times $500 per month, which is a low estimate.) I've also paid several hundred thousand dollars in taxes to a government that prioritized blowing up Iraq over protecting us from things that might actually kill us, like cancer and heart disease.

Given the amount paid, I see health care as a right, not a privilege. We already have high taxes and high insurance premiums. Yet we live in a society where it's pretty much random whether your insurance even covers you when you get sick.

They always give me direct, flat prices beforehand, once I tell them that I don't have insurance, and after they pull out their "other" price chart.

Where is the startup helping me to decode my medical bills?

How would knowing the meaning and even the average cost for a given code change your behavior? It's still basically impossible to get even an estimate of cost for even the most basic medical procedures before having one.

Also, the bills are much more complicated than what they print out and mail to you. The amounts can vary based on many different factors, such as BMI, alcohol/nicotine dependency, and other risk factors that make you more risky to provide care for.

Why would it need to change your behaviour - if your paying for something surely you have a right to have the bill explained to you and for you to be able to challenge individual items?

[NB I'm from the UK so I have no idea how medical billing works. But I do have plenty experience with lawyers and I know that getting a details breakdown of work charged is a really good idea.]

Well, at the point that you have a bill, you are kinda beholden to the people that sent it. You can't easily dispute a charge with our system. It would definitely be useful to understand the bill later on, if you could actually do something about it. My point is not being able to know the estimated charge before you choose a provider makes it impossible for the market to work, because competition can't happen, at least not with costs.

You sound like an insurance company talking.

Not exactly, but I am quite familiar with the issues involved. My point is that we need to make shopping and selection easier and better, instead of focusing on what all you were billed for. If we fix that problem, the most important part aspect of the bills is that they are close to the estimate. The health system as a whole is moving away from billing from individual services anyways, hopefully that will continue.

Exactly what I was thinking. It could be a simple app that you take a photo of your itemised medical bill and it decodes it for you. Although after reading this, I think an app that does this automatically would fail as itemised bills do not seem to be the norm and even when you ask for one, nothing makes sense and there appears to be a lack of standardisation.

I think insurance companies should offer this as a value-add. A broken down, item-by-item explanation of what you were charged for and what it means.

I don't think its that simple, the myriad of billing formats would be problematic. That said, a credit karma like service to connect with your insurance company could be a lot less problematic IMO to implement.

It's because the myriad formats are problematic that this would make for a good startup. And you could initially schlep it: as new formats come in, do just-in-time research to figure it all out.

Here: https://www.copatient.com

I have no affiliation with the company; I'm just a fan of their work.

Sometimes I wonder if I sent an incomprehensible bill to the hospital for services rendered if they would pay it.

I just received a bill for some SEO that I never ordered. I explained to my mother that it was a common scam, then pitched it into the recycling bin.

If my company were larger than just myself, that bill would have gone to Accounts Payable, with a good chance that it would get paid. Accounts Payable staff at big companies don't have the headspace to chase down whether someone really ordered $85.00 worth of SEO service; such a small amount would not require managerial signoff.

I worked for a company that bought about £100,000 of electronic components (plus other stuff) per month. They knew where every single item was - down to the paperclips.

I'm kind of surprised to hear that tech companies might not know where their money is going, especially when it's $85.

See also "Cuckoos Egg" where a few cents difference in billing leads to uncovering hackers intruding on the network.

I expect your former employer was quite successful. Many aren't.

My full name is Michael David Crawford. I had a classmate in high school named Michael Dwayne Crawford who often skipped out of school. High school truancy before the age of sixteen is a criminal offense in California. Whenever Mike Dwayne would skip out, the police department's truant office would call my father at work, who then had to take leave from his important work of fighting the cold war then ride his motorcycle twenty miles - sometimes in the driving rain - then visit the principal, all to say "This is not my son".

This because the school's MIS system only recorded our middle initials.

One minor, pathetic quibble:

> “The baby boomers have tolerated the current system,” she said. “But 20-somethings and millennials are not used to this and they won’t.”

So as a Generation Xer, what am I, chopped liver?

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