
The Medical Bill Mystery - prostoalex
http://www.nytimes.com/2015/05/03/sunday-review/the-medical-bill-mystery.html?smid=fb-nytopinion&smtyp=cur
======
codegeek
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.

~~~
acveilleux
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.

~~~
yummyfajitas
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.

------
noonespecial
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.

~~~
acveilleux
Basically, Oracle pricing.

------
yummyfajitas
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](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.

~~~
solutionyogi
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.

~~~
gkop
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.

~~~
solutionyogi
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.

------
tomohawk
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.

------
bachmeier
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.

~~~
fluidcruft
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.

~~~
pcurve
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.

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

------
mirimir
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.

~~~
maxerickson
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).)

~~~
mirimir
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.

~~~
maxerickson
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).

------
geomark
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.

------
GabrielF00
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).

------
venomsnake
> 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.

~~~
tomohawk
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.

~~~
mplscoder
"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."

~~~
michaelochurch
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.

------
strathmeyer
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.

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

~~~
oomkiller
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.

~~~
arethuza
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.]

~~~
oomkiller
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.

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

------
MichaelCrawford
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.

~~~
DanBC
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.

~~~
MichaelCrawford
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.

------
twic
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?

