
For Her Head Cold, Insurer Coughed Up $25,865 - the_mitsuhiko
https://www.npr.org/sections/health-shots/2019/12/23/787403509/for-her-head-cold-insurer-coughed-up-25-865?t=1577125419719
======
rayhendricks
How is this different than the scam where they charge you $300 for what would
usually be a $30 dinner?

We need to socialize the healthcare in the USA and put a stop to this crazy
billing practices. (Maybe send a few execs to jail too) Canada really has the
right idea here, as even if you are making $bank here, you can be fired for
any reason/no reason and health insurance will end. IMO this is by design, as
it is much more difficult to leave a job if insurance will end.

~~~
sillysaurusx
Why is that a good thing?

That sounds similar to indentured servitude.

EDIT: I misread the “here” as “Canada”. The US healthcare system has caused me
some personal hardships, so I was surprised Canada had something similar.
Luckily it’s more sensible.

~~~
ska
Why is what a good thing?

~~~
bufferoverflow
He is asking why is it good for the workers. You're basically advocating for
price controls on one field. How would you like if you were only allowed to
make $30/hr for writing code?

We already have massive shortages of doctors (and nurses, I think). This will
only make it worse.

~~~
shantly
AFAIK _every single other_ OECD state has explicit or de-facto (via monopsony)
price controls for much of the healthcare sector. Hell, even non-OECD free-
marketer-beloved Singapore does.

I would, no kidding, love to see any example of a successful, modern
healthcare system that doesn't employ price controls to keep costs from
getting out of hand. Allowing "successful" and "modern" to describe the system
in the US, it's the _only_ one I know of that doesn't.

~~~
bufferoverflow
You didn't answer the question though. You just went with "well, everyone else
does that".

~~~
shantly
... which means you can go look at them to see how it's working out. Again, I
am _legitimately_ interested in learning about any healthcare system in a
state with an advanced economy that _doesn 't_ employ price controls in one
form or another, but in the meantime, instead of spitballing about what a
disaster it might be, we can just look at, AFAIK, literally any other such
state to see how it works out. Dozens of examples.

------
imgabe
> The third reason for the high bill may be the connection between the lab and
> Kasdan's doctor. Kasdan's bill shows that the lab service was provided by
> Manhattan Gastroenterology, which has the same phone number and locations as
> her doctor's office.

They really buried the lede there. This sounds like fraud. She went to her
doctor, who, I'm guessing, is in-network since the article says he was her
primary care physician. The doctor operates a lab that is not in same network
he operates his practice in? Is that some kind of coincidence? Is there any
other reason for that except to bilk money out of the insurance company?

------
jonplackett
It’s weird how the argument in America is always socialised healthcare VS
private healthcare. Rather than people just demanding non-insane private
healthcare. I have private healthcare here in the UK through work and it costs
£150 a month to add my wife too, for one of the best plans around.

~~~
tux1968
Could it be because it has to compete with the public option, or at least
stand up to comparison with it?

~~~
jonplackett
Exactly! Competition is what makes capitalism work, otherwise you just have a
monopoly and then everything turns to crap real quick.

We have a similar problem in a way with our trains. They’ve all been
‘privatised’ but if only one train company runs your route there can’t be any
competition, so our trains suck big time and are really expensive.

~~~
lordnacho
Not only that, there's also only one Network Rail doing the maintenance. So
the local monopoly on passengers relies on another monopoly.

End result is it costs upwards of £4k for an annual pass for a half hour train
journey.

Add to that the fact that nobody would ever allow the trains to cease
operating, and you have a really big question mark over what the point of
privatizing was?

~~~
hogFeast
Do you understand what they were like when they were public? Costs have fallen
dramatically, prices are actually way down, the govt subsidy is down (although
will rise again with HS2), and service quality/output is up.

We know this doesn't work because we tried it and it didn't work.

~~~
jonplackett
This is the usual argument.

But it doesn’t hold water. France, Germany, Spain all have cheap, really good
government-owned trains - in fact they also operate some of our trains in the
UK and use the profit to fund their own trains.

Prices have gone up by the maximum operators are allowed to increase them
every year (there’s a 1 year exception where I think they were frozen for
political reasons)
[https://www.bbc.co.uk/news/business-49331238](https://www.bbc.co.uk/news/business-49331238)

Just because we tried something before and did it badly doesn’t mean it won’t
work in future if done well. Execution is everything, right?

~~~
hogFeast
Left out is the specific reason why you think it will work well in the future.

Define really good? They are less safe, the prices charged to consumers may be
lower but what is the overall subsidy (I understand that you want other people
to subsidise your commute...other people tend not to be happy about this), and
it is fair to say that UK trains are less punctual but the difference is not
massive (and we do come ahead of the nations you mention some years too).

The discussion on this in the UK is pathetically weak, and largely a function
of trade union lobbying (if you didn't know, the TUC pours money into this
cause like nothing else...presumably they just really really care about
commuters).

------
EamonnMR
This is fraud, they where fleecing the insurance company and the patient just
went along for the ride. The whole point of insurance companies is that they
are supposed to be motivated by their own financial interest to fight against
schemes like this, so it's shocking that they paid up.

~~~
lsaferite
Did you read the full article by chance? Saying 'the patient just went along
for the ride' insinuates that the patient was complicit when in reality the
patient reported the whole incident themselves after they received the bills.
They did this even though _they_ didn't have to pay anything. And they told
the provider they were going to report them.

> "I made it very clear [to the doctor's office] that I was unhappy about it,"
> Kasdan says. In fact, she told them she would report the doctor to New York
> state's Office of Professional Medical Conduct.

> Kasdan says she was not told that the throat swab was being sent out of
> network at the time of her appointment, though it's possible one of the many
> papers she signed included a broad caveat that some services might not be in
> network.

~~~
EamonnMR
By "patient just went along for the ride" I meant to say that her bills where
collateral damage.

------
peter303
The largest HMO in the US billed medicare $90 for a flu shot. A drug store
would have done so for $19 without insurance.

~~~
cmpolis
The system is broken. I think a fundamental issue is that insurance is not
really insurance - it is used to cover routine, expected things such as a flu
shot (while increasing cost for these and adding complexity, bureaucracy,
middlemen). E.g. car insurance does not cover oil changes and home insurance
does not cover getting the gutters cleaned - they're there for major events.

------
wyldfire
NPR has to be responsible journalists but we can call a spade a spade: this is
insurance fraud, plain and simple.

All of the noise in this thread about healthcare system in the US is a good
discussion but arguably unrelated to the bill in question. Single payer
government run plans can be defrauded too.

------
Gatsky
By way of comparison, that exact same throat swab test - which some professor
was trying to say was excessive - is available at no charge to the patient in
Australia, and there are no 'out of network' labs.

I don't know how this nonsense isn't the number one election issue in the USA.
Instead everyone just puts up with it.

~~~
AdrianB1
The comparison is meaningless: the patient did not pay anything in this case,
but the cost is astronomical, the problem is with the cost not with who is
paying. By the way of comparison, I just paid approximately $25 for a bit
simple test (bacteria, not virii, but it included sensibility to antibiotics)
in Europe last week. Out of the pocket, waiting weeks for the free public
system was too much to be effective.

~~~
Gatsky
The article tries to make the sub-point that the swab was somehow an excessive
test - I was trying to highlight that this is not the case, which makes the
overcharging even more egregious.

Also to clarify, in Australia there is no cost to anyone with permanent
residency status, whether they are insured or not.

~~~
AdrianB1
I now understand what was your point.

Also to clarify, there is no cost for anyone (EU residents) here too if you
use the public health system, but if you cannot wait till you're dead then you
can use the (optional) private system and pay for that.

------
xenospn
Can you imagine if Amazon never let you choose how they deliver your orders
and purposely decided to charter a commercial jet to route your package though
Antarctica? Because thats basically what happened here.

~~~
shantly
No part of medical billing whatsoever would fly most anywhere else. It's
batshit crazy, top to bottom. Go get service at one place, get fifteen damn
bills from five people & companies spread out over three months plus a pile of
mail that looks like bills but may say it's not a bill, and then several will
have errors requiring back & forth to correct, you'll get a refund then have
to pay more, pay more then get a refund, all kinds of nonsense, you're acting
as a go-between for insurance and the providers because they're all friggin'
incompetent and that means hours and hours on hold, finally six months later
it's all settled but you're guaranteed to have missed something in all that
mess and now you've got a letter from a collection agency for a $48 bill out
of thousands paid.

Fuck the whole thing, I hope it all burns to the ground. It makes me so very
unhappy every time I have to deal with it.

~~~
OnlineCourage
Sir, you are choking and dying would you like the premium $500 intubation tube
or the discount $10 one? Oh thats riiiight he cant talk lets just assume he
values his life and give him the good one.

Oh, sincere apologies about not trying to save you money.

~~~
shantly
Yes this is exactly what dealing with medical billing is like and why it's
awful, and not a non-sequitur.

~~~
OnlineCourage
It's awful that you have access to a premium life saving service which gets
better every year, beyond the immagination of years prior? Or is it awful that
the price for said service is high? What exactly is awful to you?

~~~
shantly
All the stuff I wrote about in the first comment, which is zero of the things
you just strawmanned?

------
seibelj
> _Jim McManus, director of public relations for BCBS of Minnesota, says the
> company has a process to flag excessive charges. "Unfortunately, those
> necessary reviews did not happen in this case," he wrote in an email._

The reason it wasn't flagged is that both the insurer and the provider are
incentivized to make this as expensive as possible. Insurers cannot make more
than 10% in profit, so if they want to make an extra $1000, they need to take
in $10,000. Next, providers are paid fee-for-service, so they want to bill as
many services as possible and charge the highest rate for each one. Ultimately
our insurance premiums go up to cover this, but the whole thing is a racket.

And single payer _will not_ solve this. All we do is subsidize demand and
decrease supply in a never ending fashion in the medical industry. We need to
1) Make it easier to supply services (allow doctors to be imported from other
countries, easier to start facilities, allow people with less credentials than
an MD to perform services) and 2) Stop subsidizing demand (Medicare for All =
Use as much as you want).

My ideal health insurance model is catastrophic insurance provided by the
government for any bills over $50,000, Health Savings Accounts to allow you to
save for procedures beneath 50k, and a total free-for-all of insurance
companies beneath the 50k mark. This would radically reduce insurance rates
while preventing people from becoming bankrupt. Catastrophic insurance covers
you from cancer and being hit by a bus, but for 99% of all health issues the
bill would not exceed that.

~~~
burkaman
> And single payer will not solve this.

If there is only one payer, and they refuse to pay your outrageous prices, you
either lower your prices or you go out of business. Since a government-run
payer does not have to make a profit, it is very easy to incentivize it to
keep costs low.

~~~
seibelj
If you don’t forcibly ban doctors from opening up private, non-governmental
clinics - and that means radically restricting individual freedom through the
threat of violent force, which I assume would be unconstitutional - then
doctors (or at least the good doctors) will decamp to the private sector only.

~~~
burkaman
Private sector medicine is legal in the UK. Why isn't this a problem there?

------
arbitrage
This is insurance fraud and abuse. Over-billing is very common in the American
medical world. As long as there is no oversite, nor competition, it will
continue and grow worse over time.

~~~
tcbawo
Speaking of competition, it would be interesting if the major political
parties competed on improving results instead of sabotaging results or
preventing the other side from getting a win.

Both parties have symbiotic relationships with profiteers that stifle progress
and innovation.

~~~
saas_sam
Trump signed an exec order* (thx for correction folks!) requiring hospitals to
dramatically improve price transparency for patients. A huge win. But of
course you'll never hear much about it for obvious reasons.

~~~
tptacek
First, no he didn't. He issued an EO directing CMS to implement the rule,
which doesn't go into effect until 2021 and is facing pretty significant legal
challenges. The fact that it's an EO and _not_ a bill is likely part of the
reason why its vulnerable to lawsuits.

Second, health care experts don't seem to think much of the new rules, since
there's little evidence anyone price shops for care, especially since,
regardless of published prices, they're not the ones paying for them; they pay
indirectly, through premiums. I think price transparency is a good thing and
the rule is a good thing, but I don't think this is "huge".

Third, the "obvious reasons" snark at the end of your comment poisons what
would otherwise have been a valuable contribution to the thread.

------
nickik
The US healthcare system is just fundamentally broken. Its not even about
private or public. Even if they made it public, it would probably still be far
and a away the most expensive system in the world.

People who believe that making it public will massively lower the cost because
other socialized systems are cheaper are up for a rude awakening.

No matter in what direction the US system evolved those problems need some
amount of addressing and those questions are more practically important then
the question about public or not.

~~~
OnlineCourage
That's a hypothesis and you have presented zero evidence to back up your very
abstract claim.

------
Meekro
Writing good rules to prevent this stuff is hard.

Insurers have to create networks so they can negotiate fair rates with doctors
and hospitals. These rates often end up being more than medicare would have
paid, but not _wildly_ more. Sounds pretty fair. But what to do if the patient
goes to an out-of-network doctor? Insurance might say "we won't pay unless it
was an emergency," but then the patient gets stuck with a $30k bill. He'll get
angry, tell the media, write his Congressman, etc. Somehow the blame will
always fall on the insurer (who had no way to prevent this from happening) and
not the doctor (who was engaged in price gouging.)

Or maybe the insurer can say "we'll only pay the same rate we would have paid
an in-network provider." No problem, says the doctor-- we have the patient's
signature on this huge contract that says we can bill them for the remainder.
Now the patient gets a $29.5k bill instead of a $30k bill. Still no good.

I'd love to say "just socialize medicine and be done with it", but this
worries me too. The US already runs two 100% socialized healthcare systems:
the VA for veterans, and IHS for Native Americans. Both are absolute
nightmares where people sometimes wait years to see a barely-competent doctor.
Many IHS doctors only work there because no private hospital would hire
them[1].

I'm not sure what a good solution looks like.

[1] [https://www.pbs.org/wgbh/frontline/article/u-s-indian-
health...](https://www.pbs.org/wgbh/frontline/article/u-s-indian-health-
service-gave-troubled-doctors-second-chance-patients-paid-price/)

~~~
imgabe
Is it hard? Just eliminate insurance networks. Healthcare providers can set
whatever prices they want for procedures. But, they must offer the same price
to all customers. Insurance, medicare, cash, whatever. They must also publish
the prices publicly. That would put a swift end to this nonsense.

------
jmpman
Why isn’t the doctor disbarred for this? It’s an ethics violation, and likely
not the first.

------
jonplackett
But socialised medicine is insane, right?

It says that the bill was 20X more expensive than it shouldn’t have been. I
can’t even imagine having to pay that when I go to the doctor. The NHS isn’t
perfect, but it’s damn good.

~~~
sp332
Why would this be different under socialized medicine? A doctor can lie to a
government agency as easily as lying to a private company.

~~~
BookmarkSaver
Reading the article, the trick here is exploiting a loophole that exists
specifically within private healthcare.

The doctor part owns/is associated with an "out-of-network" lab where the
tests were sent. Healthcare providers have default listings which are
typically outrageously high, and negotiate with insurers for their "actual"
rates. But by the in-network doctor quietly sending the tests "out-of-
network", the insurer could be charged the outrageous fee.

With single payer, the price is the price. No bullshit, shady multilateral
private negotiations in a marketplace where people's health is what is being
wagered.

------
pbreit
It's not always clear to be in these types of stories if the money actually
changed hands. Just because it was invoiced, doesn't mean that's actually what
was transacted.

------
TYPE_FASTER
I’ve been wondering why coverage costs to employers have been increasing, this
could be an example of a cause if it happens frequently.

------
annoyingnoob
And rates are going up for everyone.

------
avocado4
Remember folks, physicians are the root of the problem. Don't let anybody fool
you into thinking otherwise.

It's easier politically to blame corporations and whatnot. And it's true -
there's plenty of leeching downstream by pharmas, PBMs, hospital admins,
device makers, insurance companies, vendors, labs, and many others. But at the
base of the supply funnel sit the doctors (and numerous associations like AMA,
ACR, ABP, AHA, AAMC, etc) who control the entire supply through licensing and
state-level regulations, and are entirely responsible for all of the
atrocities. It's effectively a cartel.

There's a reason why any time there's a talk about pro-consumer regulation on
the Hill like anti-surprise billing, pro-price transparency, and Medicare for
All, each of these association is blasting their members with calls to contact
their representatives and resist at all cost. Their argument is easy to
understand emotionally - doctors will protect you from the harm, and hence
there should be more licensing and supply restrictions. But this is the root
of all problems in US healthcare.

~~~
avocado4
Here's a couple sources

[https://www.usnews.com/news/health-
news/articles/2019-07-03/...](https://www.usnews.com/news/health-
news/articles/2019-07-03/california-doctors-oppose-expanding-nurse-
practitioner-authorities)

Amid Provider Shortage, California Doctors Oppose Expanding Nurse Practitioner
Abilities

[https://thedo.osteopathic.org/2018/10/dos-help-defeat-
bills-...](https://thedo.osteopathic.org/2018/10/dos-help-defeat-bills-that-
seek-to-cut-doctors-out-of-health-care/)

As APRNs and nurse-midwives ramp up their efforts to practice independently,
DOs are fighting back.

[https://www.kcur.org/post/nurse-practitioners-try-shake-
free...](https://www.kcur.org/post/nurse-practitioners-try-shake-free-doctors-
kansas-physicians-resist#stream/0)

As Nurse Practitioners Try To Shake Free Of Doctors, Kansas Physicians Resist

[https://www.wabe.org/bid-to-loosen-rules-on-mid-level-
provid...](https://www.wabe.org/bid-to-loosen-rules-on-mid-level-providers-
draws-legislative-debate/)

But the vote for recommending the imaging change was 3-2 in favor, with two
physicians on the panel, Sens. Ben Watson (R-Savannah) and Kay Kirkpatrick
(R-Marietta), voting against.

[https://www.aei.org/carpe-diem/whod-a-thunk-it-a-medical-
car...](https://www.aei.org/carpe-diem/whod-a-thunk-it-a-medical-cartel-
doesnt-like-competition/)

the American Academy of Pediatrics declared that retail health clinics are “an
inappropriate source of primary care for pediatric patients, as they fragment
medical care and are detrimental to the medical home concept of longitudinal
and coordinated care.”

[https://www.politico.com/agenda/story/2017/10/25/doctors-
sal...](https://www.politico.com/agenda/story/2017/10/25/doctors-salaries-pay-
disparities-000557)

[https://fee.org/articles/the-medical-cartel-is-keeping-
healt...](https://fee.org/articles/the-medical-cartel-is-keeping-health-care-
costs-high/)

[https://www.modernhealthcare.com/patients/surprise-
medical-b...](https://www.modernhealthcare.com/patients/surprise-medical-
bills-becoming-more-frequent-and-costly)

Stanford University researchers found that from 2010 through 2016, 39% of 13.6
million trips to the ED at an in-network hospital by privately insured
patients resulted in an out-of-network bill. That figure increased during the
study period from about a third of ED visits nationwide in 2010 to 42.8% in
2016.

[https://www.npr.org/sections/health-
shots/2019/12/23/7874035...](https://www.npr.org/sections/health-
shots/2019/12/23/787403509/for-her-head-cold-insurer-coughed-up-25-865)

[https://www.medscape.com/viewarticle/922816](https://www.medscape.com/viewarticle/922816)

More Than Half of Doctors Get Industry Payments/Meals: Poll

[https://revcycleintelligence.com/news/aha-others-to-sue-
hhs-...](https://revcycleintelligence.com/news/aha-others-to-sue-hhs-over-new-
hospital-price-transparency-rule)

AHA, Others to Sue HHS Over New Hospital Price Transparency Rule

------
avocado4
All non-emergency medical bills should be legally null.

That is, if you go to a doctor's office, they can try to collect payment
upfront, but if they send you a random bill after the fact without your
explicit price consent, it doesn't have to be paid. Similarly to how I can
send a bill to y'all for the privilege of reading my post (and justify by
saying it took me years of expensive training to obtain this knowledge), but
you shouldn't be required to actually pay me, of course.

Emergency medicine OTOH should be socialized - everybody is covered in the US
by Medicare. For every emergency admission facility can charge Medicare for
all up to $X (say $300 in Kansas and $500 in San Francisco) and have to make
do with that money. Patient gets between 0% and 30% copay depending on whether
they are trying to abuse the system or came with a legit reason. This is the
same as Kaiser today, but on a National scale.

~~~
akvadrako
The problem with emergency care being free and non-emergency being paid is
that people will try to make things into emergencies and it discourages
preventative care.

But we do need upfront pricing. It should be mandatory in non-emergency
situations.

------
avocado4
[https://www.manhattanspecialtycare.com/doctors/internist/](https://www.manhattanspecialtycare.com/doctors/internist/)

Roya Fathollahi, MD

Report her to the NY Medical Board and Department of Financial Services

[https://www.health.ny.gov/professionals/doctors/conduct/file...](https://www.health.ny.gov/professionals/doctors/conduct/file_a_complaint.htm)

[https://www.dfs.ny.gov/consumers/health_insurance/surprise_m...](https://www.dfs.ny.gov/consumers/health_insurance/surprise_medical_bills)

