
Indecipherable Medical Bills Are One Reason Health Care Costs So Much - aaronbrethorst
https://www.nytimes.com/2017/03/29/magazine/those-indecipherable-medical-bills-theyre-one-reason-health-care-costs-so-much.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=photo-spot-region&region=top-news&WT.nav=top-news&_r=0
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drewg123
A few years ago, my wife hurt her back when we were moving. She went to the
local urgent care center, and saw a doctor. We have insurance, and that was
mostly the end of it for us.

We later found out that the urgent care center had coded her visit as
something like "surgical consultation" when it was nothing of the sort. I
think the insurance company actually contacted my wife and inquired about the
visit. We then got curious, and interested in the bill, and discovered that
the codes are copyrighted. My wife actually was able to translate the codes
using something she found in the local university library (which is how we
realized that the visit was upcoded, and suddenly things made sense).

We had thought that urgent care chain was just shady, but after reading this,
I guess that this upcoding is a common practice.

~~~
coldcode
Optimizing coding to maximize income is a major consultancy in the industry.
The key is knowing what an Insurance company will accept without questions
otherwise there will be a delay in getting your money or maybe you get
nothing. Recently the coding system changed to a much more detailed version
(which I think was in use internationally long before the US adopted it). I
don't know if it's better but there are way more ways to code things today.

~~~
awongh
I never realized all this existed!

I'm still not clear from the article why the codes used inside the hospital
are proprietary. copyrighted information- what kind of legal hoop jumping
allows them to claim this?

What kind of domain knowledge do you need to be able to code a procedure? Is
it knowledge just of the insurance system, or is it also deeper medical
knowledge / cultural knowledge of how doctors perceive / deal with one
procedure over another?

~~~
coldcode
The codes are standardized but the interpretation by insurance companies isn't
so clear. For the coding look at
[http://www.medicalbillingandcoding.org/qnas/what-are-the-
dif...](http://www.medicalbillingandcoding.org/qnas/what-are-the-different-
types-of-medical-coding-classification-systems/)

------
patrickg_zill
How to fix USA healthcare IMHO:

1\. Pharma: drugs must be sold to American people at the same price as the
other developed countries such as Canada, Germany, etc.

2\. Prices must be published, and, the lowest paid by any insurer must be
available as a cash option if you pay at the time of service.

That is, an MRI scan with a retail price of $3k but which the insurer pays
only $1100 for, must be available for $1100 if you pay at time of service,
that same $1100.

3\. Repeal EMTALA.

~~~
riahi
#2 is illegal under Medicare/Medicaid rules.

We are required by law to charge the same price to all payers, including
patients. We can't offer a cash discount at the time of service, as it is
Medicare fraud. We can charge you, accept a lower payment, and then write off
the rest as a loss.

In your example, who is this magic insurer? Which reimbursement rate are we
setting as the bar? I hope its not medicare or medicaid, as they often
reimburse below cost.

Is it the highest negotiated reimbursement a given imaging center has
negotiated?

Each of these contracts are negotiated individually between the payers and the
imaging center. Because of the variable reimbursement and the federal
requirement that one price be charged to EVERYONE, you see huge markups lest
you undercharge a payer that would have paid the full amount.

~~~
zimzam
I think you misunderstood. The poster is saying that if the prices are as
follows:

Sticker price (uninsured people pay this): $5000 Insurance A in-network price:
$2100 Insurance B in-network price: $2300 Insurance C in-network price: $1800
Medicare price: $800

That anyone paying without insurance (cash) should be able to pay the $800
Medicare rate since it is the lowest rate. That's not asking for a cash
discount but rather forbidding price discrimination.

~~~
riahi
Medicare and Medicaid often reimburse below cost. Healthcare businesses make
up the difference from private insurance. By forcing people to accept the
lowest rate (which is not negotiated, but effect by decree), you absolutely
destroy the funding for services.

Good luck keeping any healthcare facilities open at those reimbursement rates.

Medicare is allowed to set prices by fiat for physician and hospital services.
It is barred by law from negotiating on medications. Perhaps the ire should be
directed there.

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teslabox
Doctors want to bill insurance for as much as they can. Insurers don't really
care about medical costs either, because the percent they keep as profit grows
as they spend more.

Patients are the victims in the trench warfare between doctors and payers.

~~~
misja111
Isn't there any competition between health insurers in the US? If it's a free
market and consumers care about costs, then you'd expect that at least some
health insurer would start looking for ways to put their insurance premium
down.

~~~
garethsprice
Most health insurance is provided via subsidized employer plans so consumers
can either take the plan they're offered or pay 2-3x as much on the open
market.

The healthcare system in the US is fundamentally broken, overpriced and cruel.
It is one of the worst things about living in this country.

~~~
kgwgk
Employers are the "consumers" in that case, and they do switch plans if they
get a better offer.

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awongh
Wow. Every time I read a story about how the business of health care in
america really works, it makes me really angry.

It seems to me that one of the central issues is, how all these hospitals and
providers can continue to get away with keeping these billing codes
proprietary information- how can the prices for your services be a trade
secret??

If I receive a hospital bill how is it that I, the customer paying that bill,
_not_ receive an itemized list of the procedures done, with prices? I wonder
what the legal reasoning behind keeping them from your customer could possibly
be?

It also strikes me that the companies that aid in coding/billing for providers
are an example of software with unintended evil consequences. If you are a
developer at one of these companies, how can you justify your role in making
healthcare more unaffordable for everyone?

I'm now incredibly curious about how this ecosystem really works and how all
these perverse incentives are setup and perpetuated. Who are all these
software vendors / training course providers / coding specialists / lawyers
who maintain this system?

A while ago I remember reading stories like these:
[http://www.nbcnews.com/health/health-care/u-s-health-care-
pr...](http://www.nbcnews.com/health/health-care/u-s-health-care-prices-are-
all-over-map-new-n563661) which compared costs on a geographical level vs.
this story where the costs are compared system-by-system, and similar
procedure vs. other procedure. Neither makes any sense at all.

~~~
cmurf
It's derived from a perverse combination of cowboy era "git the F away from
me, I will do it myself!" individualism; and classist aristocracy "I am better
than you because of bloodline, family name, and money, I can pay to get better
health care and I'm not waiting in a line with the likes of the rest of you."

A third group genuinely believes an inherently anti-competitive business, with
deeply irrational and price inelastic buyers, can magically squirt out unicorn
poop in a free market. And they've succeeded at getting the above two groups
to use this "choice" and "free markets" nonsense as their messaging, whether
they believe it or not, it gets them what they ultimately want.

And what we have now, is a highly protected industry that whether before or
after ACA, is in no possible way approximating either a free market, or
socialized care. It is a legalized cartel, with a massive economic momentum
such that even if the politics were to turn on a dime, the health care
economic system would resist the changes.

There's also conflation between insurance and payment plans. Insurance is risk
management for random, unpredictable events like cancer. It wouldn't cover
having a baby, that's predictable. Free market health care would mean you pay
out of pocket, or out of savings, or you get a loan and have a payment plan.
What we have from our health care "insurance" industry, is all the peasants
and serfs are on a payment plan.

Adding to the amusement is Medicare, after age 65, covers only 64% of the
bill. You're on the hook for the rest. And it covers 0% dental, and old people
have lots of on-going dental maintenance. If you're dying of a dental related
brain disease, you can just go die if you can't pay. And people do.

It cannot be understated how classist this system is. And it's a box canyon,
near as I can tell.

~~~
awongh
Yeah, and from what I understand the crazy thing is that no one even really
makes that much money, or as much money as a 2-300 percent increase in costs
over other countries would suggest... It's mostly just an unbelievably
inefficient system.

~~~
cmurf
It is the exact opposite of an ant colony. It's almost directionless at a
societal scale, cooperative only at a narrow tribal scale. America has many
tribes. This is a natural consequence of its diversity. The diversity
moderates many things, good and bad mood swings, including efficiency because
we're simply not all on the same page, often not even on the same book.

The county has gotten a lot of rope to hang itself because baby boomers have
charged a massive pile of debt to the country's credit card. That card was
built by the silent generation, who also gave the U.S. the gift of the dollar
being the world's reserve currency.

And in some sense that reserve currency's status is better secured by Brexit,
because it demotes the EU and Euro as being a direct equivalent competitor to
the dollar.

All of the things going on are interrelated, and make complete sense. The way
they're happening is about the only way they could happen because as crazy as
they seem, they're still the path of least resistance forward from where we
are now.

------
1_2__3
We should remember the only reason in many states buying a car is a
transparent process is because the government realized this kind of
billig/invoicing is exploitative and unfair. Almost every argument applied to
the "one page" car buying rules apply to cell phones, medical treatment, you
name it.

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maxerickson
I have this paranoid theory that insurance company coders work a lot harder on
bills that are after the deductible. A sort of gentleman's agreement to inject
as many of those sweet deductible dollars into the system as possible.

~~~
sjg007
Well that or they just deny the claim for some random reason.

------
zelos
Is the situation described for the woman in the article common? It sounds
completely insane, I don't see how anyone could defend it.

Minimum wage is $7.25, so at a guess say $20k/yr net? $800/month insurance is
$9,600, nearly 50% of her income for insurance that would still have left her
with a $70k bill after the haemorrhage?

Edit: I realise that's kind of the point of the article, but seeing those
figures I don't see how _anyone_ below the middle class could get decent
insurance.

~~~
creaghpatr
In theory she's mandated to have insurance to prevent this type of thing from
happening. If she couldn't afford it the government would subsidize her on the
exchanges.

In practice, she paid the ACA penalty to have the privilege of not buying
insurance and then she got screwed for not having it.

~~~
TheAdamAndChe
After the subsidies, chances are good that the amount she would still have to
pay is prohibitively expensive. There is a baseline amount you have to make to
get by, and at minimum wage in the US, chances are good you're hitting that
baseline amount.

------
johan_larson
It sounds like there's a niche for a non-insurance insurer. It wouldn't
actually pay for procedures, but in return for a low monthly membership fee,
it would negotiate on behalf of the members for their bills, just like an
insurance company does.

~~~
creaghpatr
Patient billing advocates are a real service now. For let's say $500 they go
to war with the billing dept of a hospital; the hospital will almost always
knock 50% of the price off because they don't want to fight the battle.

So many patients default on their bills it's a financial crisis for most
hospitals outside of the large major chains. That billing department is going
to take what they can get, even if it's only 20% of the amount the patient
owes. Pretty nuts.

~~~
drewg123
But apparently that strategy doesn't always work. The lady in the article
offered the hospital what her experts said was a reasonable price, including a
profit margin & they turned down the offer.

~~~
creaghpatr
I think the hospitals jack up their list prices with these adjustments
presumed.

Of course, they don't tell the patient to negotiate a discount that's the last
thing they want to deal with.

And you're right, it doesn't always work it depends on the context and
financial health of the provider.

------
moo
A woman's hospital bill for delivering her baby showed "SKIN TO SKIN AFTER
C-SEC $39.35". She could of saved some money if she refused to hold her baby
right after he was born.

~~~
Graham24
What? Is that like normal practice, that women can be charged $40 for holding
their babies immediately after a c-section?

~~~
johan_larson
An ob-gyn had some stuff to say about it here:
[http://www.slate.com/blogs/xx_factor/2016/10/05/hospitals_ch...](http://www.slate.com/blogs/xx_factor/2016/10/05/hospitals_charge_new_parents_for_skin_to_skin_contact.html)

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bluetwo
Transparency in healthcare billing was actually a point Trump ran on but it
disappeared from his website and his agenda as soon as he was elected.

------
nsxwolf
I wonder what groceries would cost if we didn't buy them with cash or credit
but instead a "Foodcare plan". I also wonder what the bills would look like in
that case. If I went to the deli, I imagine there'd be all kinds of
interesting blade sharpening fees and glove disposal fees and whatnot.

~~~
wilde
I mean, Comcast does the same sort of thing without any insurance model
involvement.

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jenkstom
The Republicans are (and have been for almost a decade) trading human
suffering for political gain. Keeping up with medical bills for a serious
illness can be a full-time job. It's tragic, and until everybody after the
baby boomers wakes up and bothers to vote we're stuck with it.

~~~
creaghpatr
Is this a comment about the article? The patient experienced her accident in
2013 after the ACA was in effect, which famously not a single republican voted
for.

Patients are being screwed under the current system right now, regardless of
politics.

Providers are having trouble remaining financially solvent bc most patients
end up not paying their bills; providers rely on private insured or self pay
patients to stay afloat because Medicare/Medicaid don't reimburse enough to
cover costs. If we put everyone on Medicare the system would shut down,
everything else remaining equal- unless we subsidized providers with even more
money from taxpayers to replace the insurance companies.

~~~
maxerickson
If Virginia had taken Medicaid expansion, she likely would have been covered,
or had access to less expensive insurance.

~~~
sjg007
And this is why people should move if at all possible to states that took the
medicare/medicad expansion. You can either vote out the government or move to
a state that offers a better deal. It's almost an impossible choice but it is
your life and your families lives. With respect to health care there are a lot
of Americans leaving the US (who can) for other countries with health care.

~~~
maxerickson
It's really not clear how much it matters. There is a lot of leeway in the ACA
and not much information about how the current administration plans to use it.

[http://www.nbcnews.com/health/health-care/democrats-ask-
hhs-...](http://www.nbcnews.com/health/health-care/democrats-ask-hhs-chief-do-
you-plan-sabotage-obamacare-n740081)

