The Company Behind Many Surprise Emergency Room Bills

https://www.nytimes.com/2017/07/24/upshot/the-company-behind-many-surprise-emergency-room-bills.html

by petethomas • 9 years ago

337 443 9 years ago

Does anyone know if a lawsuit has been lodged questioning these practices?

I've always thought that my informed consent should also apply to cost of procedure - I have a right to say "NO" to something in the medical establishment. And had I known the price and the success rate, I would have said "No".

Now, I'm not asking "What is my exact rate?", although that would indeed be nice. But given minimal complications, I should be able to get a range of what to expect.

advisedwang• 9 years ago

Price transparency is pretty meaningless for ER care. Anything that is serious enough for an ER visit probably distracts you from making good economic choices, plus it's likely impractical to change ER (plus you'll pay for that ambulance ride!)

Further, it shouldn't be necessary for people to be making financial decisions in the middle of medical emergencies, even if it was easy.

sigstoat• 9 years ago

Anything that is serious enough for an ER visit probably distracts you from making good economic choices, plus it's likely impractical to change ER (plus you'll pay for that ambulance ride!)

there are all sorts of folks using ERs for non-emergency issues, simply because ERs are required to treat everyone.

both of my trips to the ER (subluxed knee; particulate matter lodged in my eye) would've been amenable to at least a few moments of financial consideration, had any information been available to me.

novia• 9 years ago

If the pricing was transparent you could factor in the potential costs when deciding where to live.

maxxxxx9• 9 years ago

The range for most things is somewhere between $0 and $100000, sometimes higher. Is that good enough :-) ?

cortesoft3• 9 years ago

Lots of patients in the ER are incapacited; either unconcious, in severe pain, or under a serious time constraint to get their problem fixed.

They can't just ask about price while unconcious.

vkou4• 9 years ago

And most of them are conscious, in control of their capacities, and may be willing to trade off some time for cheaper treatment. They can't get a quoted price, either.

According to the article, ~50% of hospital admissions today go through the ER.

spinlock5• 9 years ago

I tried to get a doctor to tell me how much they would bill me for an office visit (not ER) and they kicked me out of the office. It was literally, sign this document agreeing to pay any charge we decide to bill or we will not see you. This was a doctor that I went to only because they were recommended by my insurance company as being in network.

They also didn't understand why anyone would even ask the question. They kept saying, "for patients that can't afford to pay we usually work out a payment plan." They didn't understand that I could afford anything and that was the problem. I can write a seven figure check which is why I'm careful not to open myself up to that kind of liability.

deathanatos• 9 years ago

I also tried to ask "how much?" on my last doctor's visit. I was looking for a ballpark estimate, not an exact figure. The person at the desk refused to give me one, citing that insurance plans make that too difficult. I insisted that since I was covered by a major insurer that she must surely deal with regularly given their customer base, and that their office was in-network for my plan, she must have some idea, but again, she refused, saying she didn't know.

It's ridiculous, and it should be illegal. At the time, my reason for visiting was a condition that required treatment, so not going to the doctors really wasn't an option. But the inability to even begin to determine what I'm going to pay is ridiculous.

(I did this after a prior visit to a different doctor stiff'd me something like $3k for the use of what amounts to glorified camera. A camera whose photos I never obtained, despite asking for them — to which the doctor replied "we've never had anyone ever ask for that" — i.e., for their medical records. I could understand that medical-grade cameras might not be cheap, but at $3k per use, my gut says money is raining from the sky.)

pascalxus2• 9 years ago

So, basically, if you visit any emergency room then your handing them a blank Check and they can write whatever number on there they want. That's egregious beyond belief. I'm never one to call for legislation and price controls, but in the face of such adversity, I think it may be our last hope. I think they should either provide a quote before they offer the services or there should be a law limiting the amount that can be billed per service.

sametmax• 9 years ago

The problem is you can't know how healing somebody will turn out. The time and resource require to heal somebody are not fixed.

ajross• 9 years ago

What if there was a group or coop or company somewhere, where people could get together and collectively fund their health care. Then this entity could make deals with providers like EmCare to ensure that the care provided was as efficient as possible.

Sarcasm aside: this problem is solved, and it's called insurance. Private entities sell it. The government does it too. It works. We just need to make sure everyone actually has it.

michaelmrose• 9 years ago

If you had read the article you would know if was about people getting surprise bills for out of network care.

manarth• 9 years ago

The article shows that this issue affects people with insurance.

It's not that the patients don't have insurance, it's not even that they go to a hospital without an agreement in place with their insurer - it's that the ER has a number of people outside that insurance contract, you don't know who they are, you don't get to choose whether they treat you, you just get a bill at the end - despite being insured, and choosing a hospital recognised by your insurer.

Insurance is not the solution for this problem.

madengr8• 9 years ago

Yep. Took my wife to the ER last week for suspect appendicitis or diverticulitis. Last time this happened a CT scan alone was $3k ($11k prior to insurance reduction). My HDP is $4,500 OOP max per family member; $8,500 for family.

What really pisses me off is that the HSA max contribution has not kept up with family OOP max. I contribute the max every year and can't end up with $8,500 saved.

I had a decent insurance plan prior to Obamacare. Now it's 3x as much and a HDP. Don't even have dental insurance anymore; use the HSA for that. Work for a Fortune 100 Company too.

tcbawo2• 9 years ago

It's doubtful we would be in a different situation without Obamacare. Health care costs have been rising faster than inflation for literally decades. There are too many bad actors at every level trying to grab whatever they can, while they can.

e40• 9 years ago

Work for a Fortune 100 Company too.

Your HR department is shit. I manage a 30 person company and our benefits are better than what you've mentioned.

vkou4• 9 years ago

Wouldn't the mandate against dropping coverage for people with pre-existing conditions result in price increases across the board? (Because now insurers can't take your money, and then tell you to fuck off once you get sick.)

You're probably now paying the 'true' cost of healthcare. (Of course, inflated by the peculiarities of the American system.)

EliRivers• 9 years ago

They didn't get to be in the fortune 100 by handing out benefits to their resources. Resources are there to benefit the company; not the other way around.

xenadu02• 9 years ago

If you work for a company with 10,000 employees or more and don't have a gold-plated health plan then it is by deliberate effort on the part of the company to save money.

At that level a company that wants a good plan can demand no exclusions for pre-existing conditions (an issue prior to ACA), same-day partner additions, better drug tiers, lower copays, etc. Often they pay less per person than a 1,000 person company does for a much worse plan.

I know because I looked. Two employers ago we got acquired by a very large company (over 80k employees). They paid ~$800/mo for my family. When I moved to a startup, they were paying ~$1200/mo and the benefits were worse. I'm back at a large company again and it's back to ~900/mo for a better plan.

You are getting screwed because the company has decided to do so.

robocat• 9 years ago

New Zealand example full unsubsidised price list for CT scan:

http://www.riverradiology.co.nz/diagnostic-solutions/price-l...

$500 NZ versus $11000 US - maybe there is something wrong with your health system.

omgtehlion• 9 years ago

Wow.

In Russia fully out-of-pocket (no insurance, no subsidy) CT scan will cost you $50-$200 (depending on body part).

So, this is likely around its prime cost. And the rest of your $(3000-200) is split and pocketed by hospital shareholders and insurance company.

cortesoft3• 9 years ago

This is the fundamental problem of treating healthcare like any other market distributed good; you just don't have the ability to use consumer choice.

People using an emergency room are not in a position to negotiate price or seek an alternative service. An unconcious accident victim can't say, "That price is crazy I am going to the hospital across town."

Single payer is the only viable solution.

maxxxxx9• 9 years ago

"Single payer is the only viable solution. "

That's not true. Plenty of European systems are not single payer and work fine.

Frondo3• 9 years ago

Or if you're dying, literally dying on the spot, and the ER is the only way to save your life, what are you supposed to do? Go try and shop around?

More to the point...is this the America we want to live in?

jghn• 9 years ago

I recently hurt myself and needed an ambulance to take me to an ER. They asked me if the nearest one was ok. Worrying about network was simply not going to be possible, I was in massive pain and wanted it to be helped out asap

Turned out alright, I think. I'm still concerned I'll get an "oh by the way" bill in the mail.

dv_dt5• 9 years ago

Single payer is the only viable solution.

I would say single payer, or a single regulatory arbiter of procedure and drug prices (within a multi payer context).

When you look at the healthcare costs GDP, the single payer systems still tend to come out ahead multi-payer + regulatory oversight (its one more level of abstraction you pay a complexity cost for...).

jseliger• 9 years ago

Single payer is the only viable solution.

This statement is close to the fallacy "Something must be done. This is something. Therefore it must be done."

Consider counterexamples: http://marginalrevolution.com/marginalrevolution/2013/08/a-f...

Frondo3• 9 years ago

The thing is, if you're in an emergency room, for the most part, you're there because of a medical emergency. (I know this isn't universally true, etc.)

If you're bleeding, and someone hands you a price quote, what are you going to do?

Or if you're unconscious, they can't even hand you a price quote. (I guess they could shove it in your pocket.)

I know the one time I needed to go to the ER, for emergency surgery, I'd have done it if they'd said it was a million billion dollars, because my life was literally on the line. I wasn't going to go shopping around, because leaving that ER would've meant death.

What's a price quote supposed to do in those situations?

We just need universal coverage, whether single payer or actually universal insurance.

godot2• 9 years ago

Your text is grey and you may be getting downvoted and I'm not sure why. You are absolutely right and anyone who has ever been to ER will agree. I was in ER a couple of months ago, and it wasn't even a life-threatening issue, but I felt terrible. I went to the closest hospital with ER department (thankfully, it was in-network), and I was going to get their treatment no matter what price quote they hand me (not that I asked). When you're deeply, physically unwell, nothing else matters to your mind.

I think you may be getting downvoted for your last sentence, but the points you're making are very real.

ballenf2• 9 years ago

Another approach would be that a hospital actually has to take responsibility for the doctors and all other care teams working inside. Legislation to this effect would work, but in some cities there is enough competition that a marketing campaign along the lines of "guaranteed no out of network bills!" would catch my attention. I'd happily drive an extra hour for that piece of mind. And the reality is that a large number of ER visits are not true time-critical emergencies. Many times the standard admission procedure starts with reporting to the ER.

I spent 4+ hours before a small outpatient procedure at a local hospital trying to find out if the anesthesia group and surgeons were in-network. I never got a straight answer -- no one knew the answer and I was forced to roll the dice.

Hospitals are currently more like co-working spaces where each room (ORs, radiology, etc.) is rented out. The support staff is included, but everyone else is their own small business.

tcbawo2• 9 years ago

I learned about these independent groups during a jury stint on a medical malpractice trial. This was actually a four way fingerprinting exercise (plaintiff's family, hospital, nurse, physician's group). The incentives in the system are perverse and corrupting. I think the system will need to be reinvented from the ground up.

Tempest19812• 9 years ago

That was a weird concept for me to learn as well. When your surgeon is in-network, you kind of expect the anesthesiologist to also be in-network. But surprise! $3500 for anesthesia. Not sure how the average person would know to expect this... http://consumersunion.org/2014/08/surprise-your-anesthesiolo...

snuxoll4• 9 years ago

Cost control right now in the medical industry is all up to your insurance provider, from the article it looks like EmCare is skirting this by simply not participating in any (or very few) provider networks.

I work for a medical billing company owned by a competitor to EmCare, we participate it a large number of insurance networks at each site we staff because it's the best way to get reimbursed - I'm rather shocked the hospital didn't investigate how their contracted providers handled insurance contracts and billing.

The problem with trying to provide quotes for emergency services is you don't know ahead of time what E&M code will apply to the visit, what labs will be run, what procedures may be required for treatment, and since physician and facility billing are separate the right hand doesn't know what the left is doing.

I also have some suspicions about the jump from 6% to 28% rates for billing what I assume is a 99285 (highest level non-trauma ED E&M code) and why it may explain the lack of their participation in insurance networks, but I don't want to tread into libel territory so I'll keep my mouth shut.

Disclaimer: I work for MedAmerica Billing Services, Inc. a subsidiary of CEP America - these views, opinions and statements are my own and don't necessarily reflect those of my employer.

acranox• 9 years ago

I'm never one to call for legislation and price controls, but in the face of such adversity, I think it may be our last hope.

I'm always one to call for legislation and price controls, because time and time again, without the legislation in place, situations like this arise. It's the sad reality. Regulating companies is apparently our only hope to keep people from constantly being stepped on.

spinlock5• 9 years ago

It's not just the emergency room. When you go to any doctor they make you sign a blank check before they will see you.

mapster2• 9 years ago

sinks the whole 'the free market will self-police' fallacy. esp re: health and environment, finance, and worker safety, corporations need regulation, badly.

pascalxus2• 9 years ago

this is a unique situation. Customers can't shop around for the best price because there are laws in place that prevent insurance companies from offering plans that are sufficiently cost effective in such emergency room visits (and a host of other conditions as well). Otherwise, I'm sure someone would have recognized these problems and offered an insurance plan that protects you from this. Free-market can't do anything when it's hands are tied behind it's back.

chasing5• 9 years ago

If we had an ounce of common sense in this country we would've moved to single payer decades ago.

rwmj• 9 years ago

Over here (in Europe) we get the impression that US has such a crazy healthcare system. Why aren't people marching in the streets? Is it not as crazy as it sounds for most users? If you're taken to ER how are you supposed to know if the doctors are all part of "your network" (whatever that even means)?

madengr8• 9 years ago

Too sick.

istorical• 9 years ago

Because those in the middle and upper class have employer-paid health insurance which protects from the worst of bills. You only go bankrupt if you're uninsured and usually only those in the lower-middle or lower class are uninsured.

And those in the lower echelon of society economically are those least able to have the time or money to march or lobby for change.

maxxxxx9• 9 years ago

"You only go bankrupt if you're uninsured"

With copays and out of network stuff a lot of people will go bankrupt in case of a serious illness.

muninn_• 9 years ago

I just logged in to say this (trying to comment less and read more) but this needed said.

Even with a vanishing middle class, the middle and upper class that remains still have largely great healthcare and healthcare plans, it's the poor who are largely being screwed. Even then, they don't support universal healthcare (it's mostly us hipsters or whatever) because they are still weary of the government and we're still dealing with post-mccarthyism where any sort of government service for the public benefit is socialism.

ProAm2• 9 years ago

You only go bankrupt if you're uninsured

This is absolutely not true [1]

[1] http://www.cnbc.com/id/100840148

empath75• 9 years ago

I just spent over a year and countless phone calls arguing with the hospital over bills for the birth of my son. We had two employer paid insurance companies and HRA, and they still managed to send us to collections until we threatened to take them to court. They eventually sent us a refund of $600.

godot2• 9 years ago

I went to ER a couple of months ago for a relatively minor issue and stayed for a few hours total. This was in-network hospital, doctors and so on. Purely by co-pays this ended up being a ~$800 bill after all the insurance kicked in.

If I didn't have a comfy software engineer salary, and instead lived paycheck to paycheck, this would've been devastating, even with insurance.

frgtpsswrdlame• 9 years ago

The people who need to march the most are the ones who can't, the ill. And when they do it's not exactly pretty:

http://time.com/4829103/mitch-mcconnell-protest-senate-healt...

maxxxxx9• 9 years ago

There is a lot of propaganda how bad systems in other countries are. Plus, this is the only system most people ever have seen so they think this is just the way things are and have to be.

abalone• 9 years ago

Additionally, the U.S. working class (who are most affected) is disorganized and politically weak. Other democracies often have "labor" parties; that doesn't exist in the U.S. Labor unions have been under attack for decades. There is a saying that the U.S. has one political party, the Business Party, with two factions. Elements of the working class are so desperate and underserved by establishment Democrats that some are turning to Trump-ian false promises and easy answers. Remember Trump (falsely) promised to fix their health care and offer cheap, quality plans.

wnevets• 9 years ago

socialism is bad, most americans stop thinking at the point until it affects them directly.

getemback2• 9 years ago

Most Americans repeat "socialism is bad" while driving down their toll-free interstate highways.

occultist_throw2• 9 years ago

Unfortunately, We've tried. It does little good.

This last Saturday, there was a peaceful protest of around 200 people held in DC in front of Congress. One of my friends attended this protest. Around 150 of them were arrested, and then given bullshit charges, like crowding, obstructing, incommoding, or resisting arrest (of what charge were they being arrested for, angering Trump...).*

When you try to "peacably protest", and "redress the government for a redress of grievances" and are arrested, detained for 6 hours, and then given a $25 citation of 'crowding' - what else do you do? Molotov Cocktails? AR-15's?

The answer, unfortunately, is nothing. You keep your job, eat decent food, and live a life under whomever the current 'king' is. And hope to the gods that nothing knocks you down to a lower socioeconomic ladder rung.

* https://www.washingtonpost.com/local/public-safety/police-ar...

purple-again• 9 years ago

We have rules in place that allow the population to peacefully protest without interfering with the business of others. These people didn't follow the rules and were punished accordingly just like every other law on the books.

If you are unable to enact the change you want from within the system it's because not enough people agree with the change you are proposing.

Welcome to the complexities of Society.

If you don't want to participate you don't have to. Abandon the laws of man and return to the laws of nature. Just remember the law of nature demands conflict be resolved in the favor of the more powerful will. I doubt very much you would fair well.

liveoneggs2• 9 years ago

in europe a $50/year increase in public university tuition results in 500 burned police cars. In france you can legally kidnap your CEO as long as you feed him.

jaymzcampbell3• 9 years ago

Fellow European (UK) here. From what I understand one argument often given, is that there's a mistrust of the government for anything like this and people prefer to "shop" for it themselves. By making their own choice (even if all that actually means is picking from 1 or 2 options given to them by their employer) - they feel empowered and in control of it. There is a general feeling of "if you want it, pay for it".

This StackExchange answer sums up it up succinctly: https://politics.stackexchange.com/a/16372. I find it immensely saddening; the same goes with the general population's attitude to education (in many countries) or providing housing.

For what it's worth I know a lot of people with private healthcare in the UK with the attitude that the NHS is complete trash (something I very much disagree with) - I fear this sort of mindset is spreading. "Pull the ladder up jack" as they say.

chimeracoder16• 9 years ago

From what I understand one argument often given, is that there's a mistrust of the government for anything like this and people prefer to "shop" for it themselves

As a data point: the patient satisfaction scores for Original Medicare (government-run) are drastically lower than every single major provider of Medicare Advantage (privately-run).

As much as people dislike insurance companies, people in the US are even less happy with the government-run programs, compared to their private counterparts.

richthegeek• 9 years ago

Unfortunately the NHS is, in many ways, pretty bad. They're pretty good at dealing with pregnancies, cancers, and emergencies but try getting seen for a chronic pain and you'll follow this rough timeline:

- Try see your GP. Wait 2 weeks until your appointment.

- GP will give a cursory examination and recommend a dietary change, taking ibuprofen/paracetamol, and to come back if problem persists.

- Problem persists. Book in with your GP and wait another 2 weeks.

- GP will actually examine you this time. They may then refer you to the local hospital, and so you should await a letter.

- about 2 weeks later, the a will arrive saying that you should phone up to make an appointment.

- within 8 weeks you should get another letter telling you when your appointment is, which will be within 4 weeks.

At this point you have spent 20 weeks just to get seen by a specialist. And that's assuming everything goes ok. Admin may not update your details, so the letters go to an old (or wrong) address. They may just entirely forget to make an appointment for you. Probably if you try phone them they just won't pick up the phone.

There's a fetishisation of the NHS in this country that protects it from a lot of criticism. Some will say "well you should put up with that because it's free" or some similar rubbish, ignoring that it costs £2200 per person.

None of these issues are restricted to the NHS. Any large organisation will have such issues. But it's utterly frustrating stuff like this that makes me consider going private - I shouldn't have to spend hours on the phone figuring out why I haven't been assigned an appointment despite being referred 3 months ago.

Shivetya• 9 years ago

Not that I think the our system (US resident) is all that great but our government runs two of the worst systems that exist in the country, the Veterans Administration which nearly everyone hears about but also the Indian Health Service which sadly flies under the RADAR.

so it is a very hard sell to get more Federal involvement when we have constant stories of VA issues and more available just by searching. throw in rules that actively prevented insurers from making multi state offers and the system was bound to be a mess.

however one of the problems not discussed is that many receive their health insurance from their employers and while this has been going away slowly, this idea like income taxes, tends to remove the cost component from people's minds. you don't see the cost in whole or in large lump sums so its easy to not think about it.

the big hurdle will be convincing people there will be limits of what can be treated. the US infant mortality statistics are one area of exaggeration to the bad simply because to the extent money will be spent to save a newborn that many other system won't

astockwell4• 9 years ago

It is exactly as crazy as it sounds, unfortunately. But due to many years (decades!) of pre-meditated political maneuvering, one of our political parties has managed to inextricably relate any kind of desire for "single-payer" or "socialized" medical system with effectively being a communist USSR apologist. No exaggeration.

sehugg• 9 years ago

Except for Medicare.

JustSomeNobody2• 9 years ago

Because, literally, one side of the street would be the Republicans and the other side of the street would be the Democrats. Nothing would get done as neither side feels the need to concede anything.

JackFr• 9 years ago

For an explanation of how the bizarre US system came to be I would recommend the following episode of EconTalk:

http://www.econtalk.org/archives/2017/06/christy_ford_ch.htm...

The guest is an economic historian who details the historical forces which led us to where we are right now. She also describes a few different, more effective and rational models (not just single payer) which could potentially have existed, but which sadly are, for all practical purposes, impossible to get to now.

mikeash3• 9 years ago

Decades of propaganda has convinced half our electorate that the US's system is the best in the world, and that countries with socialized medicine are hellholes where you have to wait months to get a broken bone looked at.

mistermann15• 9 years ago

Similarly, decades of propaganda in Canada has convinced far beyond half our electorate that the Canadian system is the best in the world even though you actually do have to wait several months for treatment if your issue is not "urgent", the definition of urgent being unknown.

spinlock5• 9 years ago

Because people don't get sick every day. Most people don't run into these bad situations and, in general, americans lack empathy for others who do wind up in bad situations. We have a media that tells us -- and religion before -- that you get what you deserve. So, if you're rich, you deserve it. If you're sick, you deserve it.

The idea that life is unfair and random is not accepted by america.

getemback2• 9 years ago

Essentially, poor white Americans oppose any kind of social service that might benefit black Americans. Virtually every problem that America faces is complicated by this one simple fact, which is an echo of the fact that half the country literally went to war over their preference to enslave black people. Despite this glaring and obvious reality, most commentators are afraid to mention it.

doubt_me• 9 years ago

poor white americans oppose any kind of social service that might benefit anybody but themselves including other white people.

Black americans oppose any kind of social service that might benefit anybody but themselves including other black americans.

People are people and ignorance doesn't have a color. It has always been like this. Blaming one or the other doesn't actually fix anything and it is also why nobody brings it up any longer not because they are afraid to mention it.

Houshalter• 9 years ago

Because it didn't used to be like this. Healthcare in the US was 5 times cheaper in 1970. The cost has been ballooning up since then and no one can explain why or how to stop it.

We don't necessarily need socialized medicine. If we just went back to the way things were done in 1970 everything would be solved. The money the government currently spends on healthcare subsidies could buy free healthcare for everyone at 1970 prices.

Life expectancy was a bit shorter in 1970, but not by that much. And most of the increase is due to other factors than healthcare (e.g. the smoking rate has dropped a lot, cars are much safer, air pollution is reduced, etc.) And there have been studies done that show increased spending on health care doesn't really correlate with increased life expectancy.

ugh1232• 9 years ago

Your impression is reality. And its more f'cked up then you think.

breischl• 9 years ago

It's at least as crazy as you think.

I don't think that anybody really believes that the mess we've made of billing/paying-for services via insurance + government + hospital/doctor is a good idea. At least nobody who has dealt with it for more than 5 minutes, which is most people over 25.

The problem is that nobody can agree on how to fix it. One side wants to socialize the whole thing, the other side wants to do... something else, I guess. Regardless, neither side has enough power to just do what they want, so we're stuck with this bizarre Frankenstein's monster instead.

Meanwhile it's almost impossible to escape from the mess. You can't just have no insurance and pay for yourself, because they've made the prices for most things ludicrously high and then basically rebated them to the insurance companies.

Actually, it reminds me just a bit of that paraphrase of the Laws of Thermodynamics: you can't win, you can't break even, and you can't get out of the game.

abritinthebay2• 9 years ago

UK but live in the US now - simply because to them this is always how it has been.

The UK cried and moaned when the NHS was introduced but now (aside from Conservative efforts to "starve the beast" on it) most wouldn't go back for the world (though it could be improved, obviously).

The US has a mentality that it's the best in the world for everything. Even when it's objectively not true (like in healthcare) this colors the debate.

ionised2• 9 years ago

The US has a mentality that it's the best in the world for everything.

Fundamentalism, basically.

Or maybe fanaticism is a better word.

Danihan• 9 years ago

What would marching in the streets accomplish, exactly?

thephyber5• 9 years ago

Is it not as crazy as it sounds for most users?

It's primarily lots of Byzantine rules in small print buried in long policies that few people read and even fewer memorize. If you are lucky and are conscious when you need to use a policy to visit a health care provider, you can bring your policy with you to ensure you follow it, but it's not always that easy. The health insurance company claims they told you how to follow the policy, but they don't make it any easier than they legally have to.

If you skip a rule (like calling your health insurance company before you visit an emergency room), that might violate your policy. If you visit an "out of network" hospital when you should have visited an "in network" hospital, you may be liable for the difference in cost (which is huge due to health insurance distortions in the medical market). If you try to go to a medical specialist without first going to your primary provider (as defined by your health insurance company), they likely won't cover it. There are usually dozens or hundreds of pages of these rules in booklets that you get when you join an insurance policy. If you don't know about / forget about a rule, you are responsible for the costs associated with the violation.

It's easy to unwittingly ask a health insurance question about your policy to the office manager at a doctor's office (who isn't qualified to speak about specific health insurance policies) and getting bad information that you then assume is good.

Why aren't people marching in the streets?

I think most people see this as a "free market" problem (since 60%+ are covered by their employer-sponsored health insurance), not a political one. ~20% of Americans are covered by Medicare (the retirement-aged national health coverage) or have military veteran benefits, which are generally considered pretty good (unless you listen to political arguments). How would "marching in the street" fix a problem that people have with the "free market"?

The remaining 20% are among the most politically apathetic. We are lucky to get 50% participation of the voting-eligible electorate, even in presidential elections (which have higher turnout than other elections).

I think lots of Americans pride themselves on being stubborn and pretending like painful things aren't painful, then trying to ignore them.

Lastly, I think most Americans simply don't think that marching works. Rural America doesn't march. Urban America only seems to march for generic social justice causes, not for specific policy improvements.

ciconia• 9 years ago

Why aren't people marching in the streets?

Americans seem to have always preferred so-called "freedom" to social solidarity. It's every man for himself over there in the land of the free.

Merad• 9 years ago

Basically, events like TFA where someone gets shafted even with insurance are fairly rare. The system is bad, but many (most?) people aren't exposed to just how bad it really is. The elderly, who require the most healthcare, have Medicare helping them. Working adults often get insurance subsidized by their employer, and young adults/kids under age 26 can stay on their parents insurance plans. With insurance, especially "good" insurance, you don't see all the insanity unless you dig into the itemized details of your medical bills... even then most people will shake their heads, pay their (relatively small) portion of the bill, and move on.

ams6110• 9 years ago

Yes, it is not as crazy as it sounds for most users.

Media outlets like to publish horror stories because it attracts eyeballs.

Yes they can happen and there are bad actors in the system. But most ER patients either don't pay a dime because they don't have a dime, or their insurance picks up the tab subject to deductible. "In Network" rules specifically don't apply in true emergencies under most plans. Of course if you go to the ER for a runny nose, there may be some pushback.

chasing5• 9 years ago

Propaganda. Pure and simple. People have been lied to about how healthcare should and could work for so long that they hold political beliefs that are completely at odds with their best interests.

We have the resources to fix many of these problems. But we won't. The powers that be would prefer lower taxes.

chrismealy• 9 years ago

A lot of white Americans would rather be fucked over than risk helping non-whites.

Fej2• 9 years ago

Some are beginning to march in the streets, actually. Especially those who stand to lose their lives or a relative's should a Republican repeal bill pass. (Ironically, many of these people votes for those Republicans in the first place.)

For the rest who aren't, there's a simple reason: services operated by the government tend to suck (or are at least perceived to be so). It is an American tradition to stand in long lines at the Department of Motor Vehicles to renew your driver's license, or to get your vehicle inspected. The TSA exists to inconvenience travelers. Public schools are perceived to be failing (they are in some places; I was lucky enough to get a very good education in public schools) even if they are not necessarily. The Postal Service is not profitable (even if it doesn't need to be...) and there are always lines at post offices. And so on. (typing on mobile, could give more examples but I'm sure others have their own)

Whether these problems are real or not is irrelevant. Americans distrust the government, especially the federal one. You could call it indoctrination, to a degree. Those who benefit from the system are allowed to persuade the populace, even from birth, and are supported by both major parties. (Drug and other healthcare advertising is legal.)

It is also part of our history. The tradition of the US is a distrust of big government. Before the US Constitution was written, we had a federal government under the Articles of Confederation. It was meant to be permanent. The federal government was extremely weak, gave too much power to the states, and ultimately did not work. So the Founders had to go back and try a second time and gave the federal government more power. And that's where we are today...but that feeling of distrust has persisted through the centuries.

So to sum it up: many like the idea of private healthcare not because they have a choice, but because they believe that the government(s) will screw it up worse.

rconti• 9 years ago

At least the hospital in Newport took back their coding/billing into their own hands.

bdamm4• 9 years ago

What was the result?

coreyp_1• 9 years ago

I am having problems with my insurer at this very moment. I went to an in-network hospital for an ER visit, which turned into an 8-day stay (yes, it was serious). Evidently, none of the doctors at the hospital are in-network, however, (claims from various technicians are still "in processing", so I don't know how they will turn out) despite the fact that the hospital itself is definitely in-network. I had no choice as to what doctors came in, and, yes, I can now see them billing $600 for a 1-minute visit ($600 per visit, & they came every morning).

This is ludicrous! I have insurance, & still this will completely drain me financially. I'm at the point where I almost think it would be easier to declare bankruptcy and start over!

JustSomeNobody2• 9 years ago

First, hope you're feeling better.

This is exactly why Congress should not be exempt from any health care legislation. They need to go through this also, so it can be fixed.

maxerickson7• 9 years ago

At the moment they get payments from the government to purchase ACA gold plans from the Washington DC exchange.

(the Gold plans are closest to other federal government provided health insurance...)

Of course, many members of Congress are quite wealthy and wouldn't be much more than annoyed by a bill in the tens of thousands of dollars.

benmarten• 9 years ago

This sounds like fraud to me. Fight it legally! A co-worker told me that this happened to her, and that made me not take the in-network only plan, but I got the PPO instead. I still think it's illegal or morally not right what they are doing, so we should all fight this practice!!!

myke_cameron3• 9 years ago

Sadly this is how hospital stays are conventionally billed. The cost of being admitted covers only the bed and routine nursing, literally everything else is billed separately. As unfair as it is, the best patients can do is vehemently question the necessity of any interaction with a physician, or else get billed for it. And good luck with that if your case is complicated and you're getting referrals to a wide range of specialists.

jetcata• 9 years ago

Also experiencing something similar right now - pathology for a day procedure ended up being out of network and I have a $3500 bill. This is insane.

astockwell4• 9 years ago

You may have some recourse with the insurance company because for emergency care that leads to an admission, the hospital being in-network is supposed to be what counts. Individual doctors being out-of-network should only come into play if you have a procedure done at their practice's office. I sincerely hope it works out for you. It might not hurt to get a 1-hr consult with a lawyer and send the insurance company a nasty letter?

vkou4• 9 years ago

That depends on the state. Most states have no laws against this.

Also, if you read your insurer's fine print, you'll find that they will only pay out-of-network providers to some limit that they and the provider agreed to. Even in an emergency situation, you will foot the bill for the delta.

sbov• 9 years ago

We had a similar experience about 8 months ago, but only one night in the hospital. Raise hell with everyone.

The out of network doctors were resolved the fastest for us, and the longest was the hospital stay itself, which our insurance didn't agree to pay until 8 months after the stay. It was a seriously draining experience, and luckily my wife doesn't work so I didn't have to take time off for all the phone calls and following up that was required.

I don't fault our insurer. The hospital charged more for our one night stay than another slightly further hospital recently charged us for three nights stay. It was completely ridiculous. But completely out of our hands.

I've had to deal with that and more in the last couple years. In my experience there are no "good" or "bad" guys in this fight. It's a bunch of individually rational entities that when taken as a whole are completely fucking over the rest of us.

astockwell4• 9 years ago

luckily my wife doesn't work so I didn't have to take time off for all the phone calls and following up that was required

This.

This is so horrifically true, it takes call after call after call (and emails, and faxes, and snail-mail claims forms that take "30 days" to "process") to get anything changed, and by then you have collections companies harassing you and your credit goes down the drain. Meanwhile you must keep working and taking care of family and dealing with the actual illness/issue that led to the medical visit in the first place. It is insane.

spinlock5• 9 years ago

I think there are "bad" guys. I've pointed out to a doctor that their agreement said that I would agree to pay any charge they decided to bill me for. I pointed out that I was in their office because they were in network for my insurance and that I couldn't agree to pay literally anything they decided to bill. So, I asked them to tell me what the maximum they might bill would be. And, they kicked me out of the office.

So, yes, if you refuse to be transparent in your billing and you extort money from your patients by refusing them treatment unless they agree to pay literally anything for service, you are a "bad" person.

jackmott• 9 years ago

vote for candidates who will support single payer.

theandrewbailey• 9 years ago

It seems like we already have single payer healthcare: the patient. The patient pays up the ass. All the way.

mistermann15• 9 years ago

Changing things so all taxpayers are getting robbed rather than just the individual being treated seems like a sub-optimal solution.

rgbrenner• 9 years ago

Completely agree.

There's no free market in healthcare. They are selling services without providing prices... it completely breaks any market that might exist.

ydt2• 9 years ago

I had this same thing happen. My daughter was admitted via ER and it turned into a 6 day stay. At the end we received a bill for 40k for being out of network. Luckily I have friends in the industry and it turns out if they fail to inform you within 48 hours that you're not in network you don't have to pay the out of network cost. We ended up paying just our deductible after a letter was drafted. Do not take what the hospital/insurance Co say at face value. Call an attorney.

eatbitseveryday2• 9 years ago

Luckily I have friends in the industry and it turns out if they fail to inform you within 48 hours that you're not in network you don't have to pay the out of network cost.

Curious, can you perhaps provide evidence of this? Seems like a good thing to know.

Call an attorney.

This is itself a cost, and maybe only makes sense if you owe ≥ $10k but for procedures billed as $1k when they should be $400 I don't think warrants the cost and time of an attorney; what other recourse is there except to pay?

mistermann15• 9 years ago

Can someone knowledgeable on the subject comment on whether the "Obamacare movement" has been up front in acknowledging this aspect of the problem with health care in the US?

My perception is that the problem is typically framed as a lack of insurance problem for financially challenged people, but the "abuse" on the billing side to me seems like at least as big of a problem. And if this is being conveniently ignored, it feeds my conspiracy thinking that the Democrats are actually largely indistinguishable from Republicans - they may wear a different mask, but their actions are only slightly different, in this case altering who is getting robbed.

seppin2• 9 years ago

Do not take what the hospital/insurance Co say at face value. Call an attorney.

What a terrible industry.

sjg007• 9 years ago

ER + hospitalization visit should be covered no matter what.

narrator• 9 years ago

When I had back surgery, there were all these therapists coming in the moment I got out of surgery trying to get their 1 minute in. It was throughly ridiculous. One of them was attempting to do physical therapy and pulled on my leg a little and put me into so much pain I went into shock. She probably got her $600 bucks.

I am with Kaiser now and it is the most BS free medical experience I have ever had. To fix healthcare without single payer the government should just make a law that medical insurance can only be offered by hospital chains and the doctors and specialists cannot bill insurance separately, but must be paid by the hospitals. This is how Kaiser works. That way the hospitals can pay a fair market rate to doctors and not have them demanding a surprise emergency room rate from distressed patients.

et-al2• 9 years ago

Everyone in the Bay Area loves talking down on Kaiser, but financially they've been the most worry-free experience. Had ringing in my ear for a week, went to the doctor, and she referred me to both an audiologist and MRI. Paid $20 for both of those other visits.

If I had been on Blue Cross Blue Shield, I probably would've sucked it up given my super high deductible and navigating the in-network maze.

Cerium• 9 years ago

I choose Kaiser as well because it is worry free. I've been admitted to the emergency room and still confidently paid with the cash in my wallet.

amalcon2• 9 years ago

While this sounds nice, I've heard too many Kaiser horror stories from family in the DC area to ever consider them even if it were an option. They've nearly killed at least three relatives of mine. If your current doctor's approach is not working, there's usually nothing you can do about it. You are only allowed two opinions, both of whom work for the same people.

parmta3• 9 years ago

I work in investment banking and cover hospital facilities (i.e. the "hospital chains"). You are right that the Kaiser model, or what the industry calls fully integrated systems, can often produce more efficient healthcare. For people that aren't as familiar with the healthcare system, I thought it might be helpful to provide a brief overview of why that is the case.

Since the ACA, there has been an emphasis on shifting from a fee-for-service model (FFS) to a value-based care model (VBC). Under a FFS model, doctors and hospitals are paid for each service they provide and make their profit from the margins built into the prices they charge for their services. In an ideal VBC world, doctors and hospitals are paid a certain amount for each patient they cover, and don't make additional revenue when they provide services to patients.

You can immediately see the incentives in each model. In a FFS world, doctors and hospitals are incentivized to give you the most care possible at the highest possible prices. For example, you could see how a doctor could be motivated to give a patient an unnecessary MRI. In a VBC world, the best-case scenario for the doctor is that he never sees you, and that you never enter the hospital. Each time you receive care, he spends time and money providing that care, but doesn't get paid any additional money for it. In other words, his margins decrease when he provides care (or, as those in the industry think about it, his medical loss ratio increases). When you become sick, the doctor would prefer that you seek care in a setting that is as low-cost as possible - via telemedicine, an urgent care center, or his office. That way, he keeps more of the monthly premium.

Practically, though, in the VBC world, the doctor probably wants to see you once or twice a year, to make sure you are healthy and that you are taking preventative measures to avoid becoming sick and utilizing healthcare. That investment of resources can help reduce your need for healthcare in the future, protecting his profit margin going forward.

So in a perfect VBC world, everyone's incentives line up. You spend as little time in the hospital or at the doctor as possible, and check in every once in a while to make sure you are healthy. Doctors and hospitals make more money when they don't have to treat you, and want to keep you out of the healthcare system.

The problem is, the current system is a mix of FFS and VBC. Most hospitals and doctors aren't compensated on a fully capitated basis (capitation is a concept that, in layman's terms, measures how close the system is to VBC vs FFS - more highly capitated = closer to VBC). Under FFS, doctors don't make much money providing preventative care, so there is no incentive to keep people away from the hospital. Unless you are a member of a system like Kaiser, you are most likely covered by a plan that is partially capitated - your insurer may share profits over a certain % with your doctor as a reward for keeping you healthy, but still pays for services on a FFS basis. Often, this profit sharing does not compare with the potential revenue from providing additional acute care services, so the old FFS incentives are still at play. (Hence the $600 1-minute consultation.)

Now, wouldn't it be great if every health system operated like Kaiser, where all the incentives are aligned and the objective is to keep people out of the healthcare system? Yes, but the answer is not as simple as requiring healthcare systems to provide insurance. In fact, Kaiser is one of the only success stories involving provider-sponsored health plans (Presbyterian in New Mexico is another).

The reason why many of these provider-sponsored health plans fail is twofold:

First, most healthcare in the US (70% I believe - but that is from memory) is provided by regional or community healthcare systems. These systems only serve certain communities (their primary service area, or PSA) and therefore certain populations. These populations are often not of significant enough size to provide adequate risk diversification for healthcare systems that provide insurance plans. One of the key reasons insurance works is risk diversification - but these hospitals can't diversify their coverage beyond their community's population. In fact, one of the most common criticisms of Kaiser from the investor community is that its membership is too concentrated in California - and Kaiser has over 10 million members on the East and West coasts.

Second, these systems often don't have the capability to price their insurance and healthcare services correctly to account for the levels of risk embedded in their insurance plans. Sometimes that is due to lack of actuarial experience, sometimes that is due to lack of risk diversification causing risk to exceed estimates, and sometimes that is due to existing healthcare prices driving up costs to a level beyond where they can reasonably charge premiums. Also, it is hard for these systems to predict who will enroll in their health plan, and what their overall risk level will be after enrollment season. There are companies dedicated to helping systems operate provider-sponsored health plans (e.g. Evolent), but this has proved to be a difficult problem. For examples of premier systems getting this wrong, look up Partners (they own Mass Gen), Catholic Health Initiatives, Northwell, Banner Health.

While this is a hard problem to solve, and I don't have the answer, you are right that the Kaiser model has in many ways proven to be more cost effective than FFS or other capitated models. It might be a good intermediate step for some of the larger systems. But there is still a lot of work to do to fix the system, and even solutions that sound good on paper have unintended consequences (for example, if you move to a single payer system to reduce prices, would lower drug prices disincentivize pharma R&D, hurting development in the US and the rest of the world? Would medical device companies making prosthetics go out of business if prices decreased below their cost levels? etc.).

Hopefully this was helpful to people who aren't as familiar with the way the system works. A less-than-perfect analogy I often use is:

The old FFS model is a "supermarket" model: the supermarket makes money by selling you as many gallons of milk as possible, and pricing the milk at a premium to their cost. The higher they can price the milk, or the more milk they can convince you to buy, the better off they are.

The current model is a "Costco" model: you pay a recurring membership fee to Costco, and can buy their products at a lower price, but (let's assume) you still pay a slight margin on those products to Costco. So, Costco would love to have as many members as possible paying membership fees - and, in fact, could offer its products close to cost if there were enough members who didn't use the store. But, they would still prefer that members use the store as much as possible, and buy as much product as possible at the highest allowable margin for Costco.

The "ideal" VBC model is a "Netflix" model: you pay a recurring membership fee to Netflix, and can stream any of their videos for free. Netflix starts out the month with its $10 of revenue from your membership, and each video you stream causes them to incur streaming costs and royalty payments, reducing their margin on your $10 throughout the month. From a pure profit perspective, Netflix would love to have millions of members who never used the service, allowing Netflix to keep 100% of their membership fees. However, in order to grow and be successful, Netflix needs members to use and love the service, so it "invests" some of its membership fee by streaming videos to users. If users are going to stream, Netflix would prefer that users stream its proprietary content, which is lower-cost for them to provide. (That last part of the analogy is stretching it a bit, but meant to demonstrate that for the health of the system, some utilization is required, and the provider would prefer that utilization to be as low-cost as possible.)

softawre• 9 years ago

Do you not have some max out of pocket for the year? Mine is 4000$, or 6000$ out of network.

msoucy• 9 years ago

And heaven forbid you have to take an ambulance to the hospital - ambulances might not be in network, in which case you're looking at a $800 charge for a ten minute drive (that you can't make yourself due to a variety of reasons). I wasn't even in bad enough health that they would turn on the lights, so I didn't even get that small silver lining.

Then you get to sit in an "emergency room" for hours, when you're physically unable to move, and with your phone dead so you can't even let anyone know where you are. When you're finally wheeled to where you need to be, you're basically dumped in a hallway facing a wall for half an hour, and you're in a wheelchair and so weak that you can't even turn to face anything interesting. I paid about $1000 for that luxury. At that price I'd expect a decent waiting room...

Yes I just needed to vent about that situation. It sucked, especially for a college student. I was hounded for months afterward to pay those bills, because of course when you're throwing up you can pick which ambulance gives you a ride.

ugh1232• 9 years ago

Wait it out until things settle (in processing, and until actual bills come in). I was in a similar situation and claimed this was news to me and inappropriate (others have said they have a window to notify you). Keep pestering them and they'll likely drop it.

will_brown2• 9 years ago

Here is a nice article about that practice: https://fairhealthconsumer.org/reimbursementseries.php?terms...

Most importantly, most states have laws mandating insurers use in network rates for certain instances of using out of network providers, including in factual instances like you described (i.e. in network hostitals and out of network providers). Seperately, most states have statutes awarding attorneys fees to the insured when claims have been denied in bad faith, like refusing to adjust bills to in network rates when mandated by law.

specialist2• 9 years ago

I'm sorry for your current struggles. I too was recently bitten; billed $4500 for a $40 blood test, with no recourse.

My state's bad ass Insurance Commissioner is trying to mitigate this problem:

Surprise billing legislation passes state House of Representatives

https://www.insurance.wa.gov/news/surprise-billing-legislati...

Be sure to call and voice support. Public pressure matters.

Long-term fix is single payer, universal coverage. Remove the (worst) profiteering from our healthcare system (racket).

jrs235• 9 years ago

billed $4500 for a $40 blood test

Please elaborate. How did that happen?

laydn• 9 years ago

How do they get away with charging $FULL_RATE for a 2 minute visit is a mystery to me. How is that not criminal?

copperred• 9 years ago

I had a similar experience with some nurses that showed up during my daughter's birth. It was an in-network hospital, pre-approved by the insurance company. The provider that sent the out-of-network bills included a letter with word-for-word what to say to the insurance company (along the lines of "no in-network option was available to me"). I called and opened a grievance because my plan had no out-of-network coverage. Strangely, the insurance company accepted one out of two bills from the same provider. The second bill they passed through against the deductible which I was able to get reimbursed from my employers HRA. Needless to say, this year I moved back to a plan that included out-of-network benefits.

Mz3• 9 years ago

This is ludicrous! I have insurance, & still this will completely drain me financially. I'm at the point where I almost think it would be easier to declare bankruptcy and start over!

I worked in insurance for over five years. Not this kind of insurance, but it was a kind of health insurance.

a) Get a letter of "medical necessity" drafted by your primary care physician.

b) Call the insurance company and ask about the policies concerning emergency treatment. Don't accuse them of anything. They get cussed out all the time and it will not help you. Be nice and start from the assumption that there must be some mistake.

c) If you make no progress with that, have a lawyer send the insurance company a letter requesting a copy of your records. This sometimes makes them look very carefully at the bill and sometimes is enough to get you whatever benefits you are legally due. Which may not be your wildest dreams of avarice, but may stave off your desire to declare bankruptcy.

If you do have a lawyer request your medical records, expect the insurance company to come back with a form letter stating they need a third party auth. Yes, a lawyer will need a third party authorization to get your medical records, but I wouldn't bother supplying them with one at the start. Just make the request without it and supply it if you really need to. If you get your bill paid because a lawyer wrote them, your lawyer doesn't really need your records. The initial inquiry sometimes gets the claim looked over more thoroughly. I am basically recommending this as a scare tactic.

There are actually a lot of errors made in paying complex medical bills at insurance companies for the simple reason that the claims processor may not see an 8 day hospital stay all that often and may have about 10 minutes in which to look your bill over and decide what is payable before moving on. I had to process 60 claims a day to keep my job. This meant I had minutes to decide what the benefits were and people who were very fast were actively rewarded for it. I often cleaned up their messes and, no, this did not get me promoted or anything, even though it sometimes kept the company out of court because the people were threatening to lawyer up.

Best.

rtpg• 9 years ago

sounds a lot like there's a startup like that parking ticket startup, but for medical bills.

erroneousfunk• 9 years ago

Insurance companies and hospitals "accidentally" bill you for the wrong thing all the time, even for the little stuff.

I went to the ER for a broken hand a couple years ago, got a $450 bill in the mail when I should have just had a co-pay. Called the hospital, they said I had to pay. Called my insurance, insurance company said I didn't have to pay. Got in a three way call with the insurance company and the hospital... The billing specialist at the hospital literally said "Sorry, that's a known billing error!"

I'm generally not a conspiracy theorist, but I've never heard of a medical billing error that was in favor of the patient... If you see something alarmingly high or out of whack (especially if you've done your due diligence, read and understood your policy, and researched covered hospitals) you'd be silly not to fight it.

Waterluvian• 9 years ago

My wife and I had a mid-pregnancy scare last year (all is fine). We spent a week as petrified maybe-first-time parents waiting for our turn to get some genetic tests done. I kept returning to the thought about how we had to wait a week, but that people in less fortunate countries might end up facing a massive financial decision. I felt a mix of national pride, relief, and terrible anger for my friends who are forced to intermingle medicine and money.

isostatic4• 9 years ago

"This is ludicrous!"

When US citizens en mass realise they pay three times as much as a country for healthcare that other western countries do, maybe it will change.

liveoneggs2• 9 years ago

this situation is illegal in new york. I know that doesn't help you.

dingo_bat• 9 years ago

$600 per visit

Is this considered normal? I honestly think I'll take my chances than pay that much per minute. Of course I'm thinking in ₹ and my current salary in ₹, which must be vastly lower in absolute terms than the average American.

aaronbrethorst• 9 years ago

Best lifehack on health insurance: get your government to move to single payer.

sixdimensional4• 9 years ago

In a past life, I worked in health insurance fraud detection.

Everybody should know, the health insurance system in the US is fundamentally broken and has been almost since its inception in the early 20th century. The lack of adequate consumer protection, transparency, health systems and appropriate government regulation, in addition to organizational oversight, has lead to a situation where we have poor systems that can easily be exploited. And they are exploited.

What the third party care outsourcing/billing company mentioned in the article (Emcare) was doing sounds like upcoding. They bill the highest cost service they legitimately can to maximize profit. In this case, as a third party billing organization, they both want to maximize the profit for their customer (the hospital system), but also for themselves, as they surely take a cut as a middle man.

Likely, they were operating within the gray area where illegal upcoding has to be proven in a court of law. It is an expensive process, that requires review and comparison of huge amounts of medical records with claims to determine whether the more expensive procedure billed was medically necessary/appropriate, or if it was egregious. That legal process does pan out sometimes in the end, but it can take years and just adds even more overhead.

Coding correctly, fairly and getting reimbursed correctly and fairly is incredibly complex. There are an enormous number of combinations of services (usually represented by codes called HCPCs and CPT codes) and diagnoses (ICD-10... which has 100,000s of codes), as well as all different regulations and scenarios for settings of care (inpatient, outpatient, doctor's office, etc.).

Props go to the hospital system for taking back their coding after they realized what the third party was doing, but the reality is, it was probably financially benefiting the hospital system too.

Every technology that I know of has been tried to address these issues, such as data mining, machine learning, rule-based expert systems, etc. and none of them has addressed the root cause, which is the basic system is fundamentally flawed.

All the politics you see about US healthcare in the news are, in a way, representative of the root problem - how big and complex the systems are now, how much money they represent, and how many interests are involved. We have a tangled web.

I don't know the solution (and many have been proposed).

snuxoll4• 9 years ago

Props go to the hospital system for taking back their coding after they realized what the third party was doing, but the reality is, it was probably financially benefiting the hospital system too.

I doubt the hospital system got anything from it, physician groups usually keep all their revenue from professional services claims - the hospital gets paid whatever they do for their facility claim regardless of what the professional claim pays.

sixdimensional4• 9 years ago

It's possible you're right. Without knowing the details of the relationship, you never know.

The reason I say that is the article points out another glaring issue - the shortage of ER docs that we are currently facing. I know this first-hand, as I have a family member who is one and is working harder than ever.

Some of these arrangements are to make up for the shortage, and the hospital systems and physician groups are often working in partnership... so it could be there was benefit for both since the hospital system needed coverage for their ER (due to physician shortages), and Emcare is providing the physicians. Without the physicians doing the services in the hospital, there would be no facility claim either...

AngeloAnolin• 9 years ago

Every technology that I know of has been tried to address these issues, such as data mining, machine learning, rule-based expert systems, etc. and none of them has addressed the root cause, which is the basic system is fundamentally flawed.

There's no technology cure for the insatiable greed of a few. Sad reality.

AndrewKemendo2• 9 years ago

how big and complex the systems are now, how much money they represent, and how many interests are involved

I don't follow what you're saying. Are you proposing that the root of the problem is that it's a huge, expensive, complex industry, where a lot of people work?

sixdimensional4• 9 years ago

Yes, I'm proposing that the high level of complexity and ambiguity involved (which originates from the intersection of the technology, organizations, politics, finances and people) in the US healthcare and health insurance system is the root cause of the problem. It is another giant machine, like the military industrial complex, for example.

I don't want to go so far as to say all huge institutions have problems like this, but I am thinking along those lines.

Some have proposed simplifying health insurance greatly by running a "single payor" system, where the emphasis is on a single health insurance entity that covers claims for every person in the US. While that might seem like a simplification in terms of process, procedure and organizations, it is very unlikely to happen in the US, and I'm not sure we could even administer that well either.

If you look at other countries that are closer to single payor, maybe say, the British NHS system - even in those countries, private insurance still exists and competes. The NHS does provide care for everyone and eliminates some issues by having a stricter control system, but the quality, availability and timeliness of that care is often called into question.

In the end, being able to dictate quality, access, and affordability (and preventing fraud) comes down to control vs. morals/ethics. Many are vying for control, for many different reasons and this often tears apart the basic industry, while morals/ethics are difficult to maintain.

xenihn• 9 years ago

This really sucks. I don't even see how an overhaul could be done.

rmmw• 9 years ago

Hi sixdimensional, thank you for the insightful comment here. I've been researching this area, and I'd love to chat more with you, would you be open to that? My email is on my profile page, feel free to email me on that address and I'll follow up.

zippergz• 9 years ago

I feel like there must be something I'm missing here. Isn't providing health care the core purpose of a hospital? Why are they outsourcing that? Outsourcing might make sense for ancillary stuff (e.g. running the cafeteria), but I'm confused why they'd look to outsource their core job. And if the outsourcing company can do it so much more efficiently, why don't they just open their own hospitals and take all of the profit?

adolph• 9 years ago

Think of a doctor as being an specialist independent contractor affiliated with the primary business.

Imagine if you would, a small hospital. They probably don't see enough patients with diagnosis X to keep staff specialized for X busy year round. There is a doctor in town that specializes in X. This doctor needs a place to get their patients stabilized and where the doctor can see the patients periodically. When one of the patients needs hospitalization, the doctor can write an admission order telling the hospital to take care of a patient in a certain way. When somebody comes into the ER and the generalist/hospitalist discovers that person has condition X, then the hospital knows they can call on the doctor to consult with them on how to treat X.

A historical artifact of the hospital/physician relationship is that there are separate billing streams for each side. There is just enough information sharing so that the doctor's billing system knows who the patient is and it is up to the doctor to claim that certain actions were performed for a valid medical reason and documented.

The current state ranges from very arms length relationships to total economic integration, which is rare enough to have a term for it, Single Billing Office.

http://healthaffairs.org/blog/2016/05/09/the-tangled-hospita...

toss12• 9 years ago

Start with the fact that even the hospitals themselves do not even know the cost/price of their procedures and goods.

Notice here, in 2013, an article about how "For the very first time, the federal government is publicly releasing the "rate card" (the full charge before insurance company discounts) prices hospitals throughout the nation charge for the one hundred most common procedures and services." https://www.forbes.com/sites/rickungar/2013/05/08/the-great-...

Yet two years later, a CEO of a hospital cannot even get the costs at the hospital of which she is CEO: https://www.nytimes.com/2015/09/08/health/what-are-a-hospita...

Price discovery, the most basic element of a free market, is literally impossible, even for expert executives within their own organizations. Vast price discrepancies exist for procedures just a few towns apart. Discovery for consumers in advance is impossible, and of course absurd in the situation where you are being rushed to the nearest hospital in an emergency.

Do not let anyone get away with claiming that this is somehow a "Free Market" until reliable prices, and outcome rates (with case difficulty information) are as easily available as prices and reviews on Amazon.

chimeracoder16• 9 years ago

If you want to understand how medical billing works and why these ridiculously high bills get created, there's a lot of important context that this article unfortunately leaves out.

Large hospital systems accept patients who have a range of payers (Original Medicare, Medicare Advantage, various Medicaid plans, private insurance, and uninsured patients). On the aggregate, they want to make sure that their entire system is cashflow-positive - however, they do that in a rather roundabout way, because they only have the ability to negotiate with some of their payers, whereas the others are able to set their rates at whatever price they want.

Medicare and Medicaid set their reimbursement rates by fiat, and providers have essentially no ability to negotiate those. Except in critical access areas, Medicare actually reimburses much less than the marginal costs of care for its patients (7% in the aggregate)[0]. These rates are so low that Medicare actually has a separate program to pay extra money to hospitals that treat a lot of Medicare patients - otherwise, they would literally go under. The reason they provide this money as a separate program and don't count it in claims is entirely political.

As a result, providers present very large bills to everyone else (privately insured and uninsured patients) to make up for this loss - you can't stay in business if you're literally making a loss on every patient! Uninsured patients see the large bill and assume they have to pay the entire amount (they don't!), and private insurers end up negotiating that down to some multiple of what Medicare pays.

A typical insurer will negotiate an agreement like, "we'll pay 350% of what Medicare pays for this category of services".

[0] This is not looking at any markup that the hospital provides - we're talking about how much the hospital has to pay its suppliers. So, for a hypothetical vaccine that costs $100 wholesale, Medicare might reimburse $93, which doesn't even cover the cost of the equipment, let alone the entire hospital infrastructure (wages, etc.).

joe_the_user8• 9 years ago

We're talking about how much the hospital has to pay its suppliers

Except suppliers can engage in their own fiat prices, as the OP demonstrates.

But your narrative does show the basic situation - where you have an elaborate digraph of buyers and sellers, most of which have a more or less monopolistic position. These monopolistic suppliers initially/formally set their prices based on "what they could possibly imagine getting", expecting regulators/down-stream-buyer to be the ones who will push things back into sanity (or not).

American health care, of course, has bounced from regulatory regime to another, with all of the players having to adjust. And moreover, all the players are now adept at adjusting, able to switch gears to leverage whatever ad-hoc cost reductions might go with any new system (cautious enough to lay-low when the new system comes since they know the politicians need to point to gains but will move on - see the way Obamacare worker great for two years, etc, etc).

And with all the bouncing, the situation has gotten only broadly more catastrophic. Health care was ~18% of GDP a year or two ago and no doubt is higher still.

Not only does health care have a problem but the four or eight cycle of ad-hoc fixes to health care has itself broken. Which might relate to the general breakdown of the countries political system, and so-on. I assume when (part of) Rome fell apart, no had seen an empire disintegrate on quite those terms (where a lot of civilization still remained on higher terms than Rome's neighbors). Perhaps our descendants will look back on this era in similar terms.

chimeracoder16• 9 years ago

Except suppliers can engage in their own fiat prices, as the OP demonstrates.

Those aren't fiat prices by any stretch. Aside from the fact that there is a competitive market of providers, patients don't have the obligation to pay the entire billed price (a key point which this article does not mention). That's neither a monopsony nor a monopoly.

Medicare, on the other hand, is a legal monopsony over its patient population and does set its prices by fiat. (There is no competitive market; patients can opt to receive their Medicare benefits privately, but they cannot opt out of Original Medicare entirely. Similarly, most providers cannot legally opt out of accepting Medicare, in practice).

blfr• 9 years ago

Why is a clear, insightful comment like this being downvoted? Is it not true?

throwrow2• 9 years ago

For surgery centers, the Affordable Care Act has limited a lot of plans to daily center maxes (on the facility side) so in theory the doctors are being paid market rates for their services. But the differences in prices between Medicare rates and out of network are significant.

maxerickson7• 9 years ago

A bit more than 1/4 of hospitals (with emergency departments) are designated as critical access hospitals. They are in most states:

http://www.flexmonitoring.org/wp-content/uploads/2013/06/CAH...

(in high population areas it doesn't make sense to comply with the limits imposed by the program, for instance, only having 25 beds, that's why there aren't any in Connecticut and such)

(Just adding a bit of info, I think CAHs are pretty high jargon)

notadoc2• 9 years ago

What are the specific benefits to having an immensely expensive administrative bureaucracy lodged between the actual patient and actual health care provider?

This should be easy to answer and explain.

Chardok• 9 years ago

Shifting costs from the hospitals and insurance to the patients, plain and simple.

This is merely the tip of the iceberg for what for-profit healthcare is developing into. You cannot have sound medical decisions being made when money is so deeply intertwined in the process.

notadoc2• 9 years ago

I would highly recommend every patient asks their doctor(s) about health insurance and their opinions of it. You will get an interesting earful.

dsfyu404ed3• 9 years ago

Every time I read a story about ER-billing I have to fight the urge to spend a few hundred bucks on the materials and equipment required to produce "official enough looking" forms of ID.

Seems like getting a hospital to think they treated someone who doesn't exist is a better bet and no more stressful than getting your insurance to cover things to the extent you are lead to believe they would be covered

mahyarm5• 9 years ago

They do check IDs at hospitals. I remember sitting in one and the person next door having a conversation about how their ID was fake / not theirs.

vladgur• 9 years ago

This is no longer legal in some states, including California... http://www.huffingtonpost.com/entry/surprise-no-more-balance...

Im curious how many supporters of GOP's free market rhetoric would support regulations around these practices once they are hit with a surprise bill like that

canhe2• 9 years ago

Canadian here. Had a pain in my right side for about 3 weeks (thinking muscle pull). Called Doctor's office at 10am had appointment at 11am, had exam and referred electronically to local hospital for X-Ray, had X-Ray at 11:45am, out the door at 12pm. Doctor called me personally the next day to say it's probably a muscle pull and call back in a couple of weeks if still sore.

$0 out of pocket, just showed my government issued card everywhere.

Couple of years ago my father was in an ICU for two weeks with Parkinson's related complications. That one had a $0 out of pocket bill as well. The ICU was in a world class university teaching hospital.

System works here. Sure people can cite edge cases, but they are relatively rare. The single payer, $0 out of pocket system also encourages pro-active care as opposed to waiting until the problem is severe, which in turn keeps costs down.

Wouldn't trade our single payer, socialized medicine for anything. There's reason why Tommy Douglas, the father of Canadian socialized medicare, was voted the greatest Canadian of all time by the public in a recent CBC poll.

(Shameless plug: software industry is booming in Toronto and there's lots of jobs. Just sayin'...)

vkou4• 9 years ago

My family lives in Canada. My grandfather had a heart attack when he was 84. My dad drove him to the ER, he got surgery, a stent implanted, a prescription, and follow-up appointments and care.

$0 out of pocket for the hospital work, a small co-pay for the prescription.

He also spent a few months on a waiting list for surgery. Cataracts surgery. They fixed him, he can now see better. Out of pocket cost? $0.

The system works. If the trade-off for free life-saving treatment is waiting on non-critical surgery, it's a good trade-off. When you're ill, the last thing you want to weigh is whether you will put pay the heating bill, or the ER bill, or whether you should go to some other hospital, because this one will gouge you, even though you're in-network.

The whole point of health insurance is that the healthy pay for the sick. We will all eventually be sick.

refurb2• 9 years ago

System works here. Sure people can cite edge cases, but they are relatively rare.

Not sure these are just "edge cases"...

http://www.cbc.ca/news/canada/british-columbia/patients-live...

mahyarm5• 9 years ago

Lets compare the 'horrible edge case' rate of the USA compared to Canada now.

toomanybeersies• 9 years ago

Kiwi here. Had a mate drop a ladder on my head and had to get my head stitched together.

Total cost: $0, 9 stitches, and a lecture from the nurse on the dangers of drinking.

RyanMcGreal• 9 years ago

Seriously, America: how is ANYONE still arguing against universal, single-payer health care?

Tempest19812• 9 years ago

Healthcare is 1/6 of the US GDP, and they have good lobbyists.

hermitdev• 9 years ago

Dear NYT, Spokane is not rural. It may not be the metropolis you're accustomed to, but rural it is not.

thingschanged• 9 years ago

In any other field all of these billing scams would be a federal crimes.

Congress could solve this issue overnight by passing a 1 line law:

If a patient is using services that is not covered by their insurance, or if they have no insurance, no medical service provider can change more than the official medicare standard rate for any services rendered.

Problem solved.

mahyarm5• 9 years ago

That quickly becomes single payer, since prices will be set to a price ceiling of whatever medicare (the gov't) sets it at. Good luck!

sol82• 9 years ago

The entire pricing scheme is an elaborate sham if you ask me. My wife had to have surgery. A outpatient laparoscopic procedure that required cutting a tendon. The time she spent at the facility (from the when they took her back and discharged her) was about 3 hours. A month later we got a statement showing they tried to charge $67k and were denied… followed by a separate bill for $7.5k We ignored the bill and contacted Anthem who said the hospital didn’t code it correctly. Anthem said they would resolve it. A month later… another attempt to charge $67k another separate bill for $7.5k. Again we repeated the same process. This time it appears it went through. Final total when they “coded it correctly” was $74k.

I have a friend who had to have an emergency appendectomy this year. She paid $1500 for it after insurance. My father had knee surgery he says they tried to charge the insurance company $64k for it.

At this point I think the pricing is all arbitrary. It’s about them trying to charge what they think they can get away with and sticking you for the rest. Kind of like raising the price so you can offer a deep discount later on. I think the real price of the surgery (without insurance) was probably the $7.5k.

I can think of no other business where you agree to have work done without an agreed upon price. The insurance company will tell you it’s covered but the hospital you go to may decide to play games with you. At the very least I suppose they are just hopping you pay so they can collect interest on your money on it before sending it back.

21• 9 years ago

I can think of no other business where you agree to have work done without an agreed upon price.

You can't really compare this with other businesses. Unless you want the doctors to stop the moment they hit your negotiated price (like lets say a building constructor would).

However you should be able to get a rough quote for the procedure (assuming no unexpected complications).

And I agree with you in general, US health care is a total scam (very high-quality to be fair).

sol82• 9 years ago

That's good point. I wouldn't expect pricing to function like that, especially in life or death situations. In our case, this was a surgery that was planned and scheduled a month in advance and at no time was a price ever mentioned. Just a letter from Anthem saying it was covered. We didn't start to see anything on the monetary side until after it was all said and done with. In advance of the procedure I tried to find some pricing data on the surgery but struck out. Apart from some articles about hospitals in California publishing prices for procedures, I could find nothing for the east cost.

throwrow2• 9 years ago

Some out of network providers send bills to patients but don't collect. Some even tell the patients not to worry about it, although I believe this may be illegal.

In theory, the high reimbursements are so out of network doctors can get paid market rates. There's also a fair amount of propaganda from insurance companies on this issue which makes the reality hard to discern. Yet they pay 10-20% on average of the bills they receive, so it's just another way to punish the patient while both the insurance company and doctor are taken care of.

siliconc0w• 9 years ago

Similar experience where I went to an ER and like six people interacted with me for less than 1-2 minutes apiece plus scans and an unneeded IV which came with a generous offer of Opioid pain meds when I specifically said, multiple times, I wasn't in pain. I got like seven different bills, each for randomint(0,1000). Worse, after wasting a day there - all they could do is just refer me to a specialist. The bills didn't even really explain what they were for, they just kept coming for almost a year after - apparently one for every person who may have looked in my direction plus each scan or test.

So I switched to Kaiser which is slightly better from the billing side but feels pretty mediocre care-wise. I don't hear back from the GP about questions/tests ordered and I've waited literally all night just to get something for a bad cough.

Healthcare in America is truly and thoroughly fucked.

todd8• 9 years ago

I have learned, directly from people that would know, that even in affluent cities in the US one-third of the people having surgery do not have insurance and simply refuse to pay any of their hospital bills. In some cities, hospitals have virtually no paying patients.

This surprised me, but I suppose it makes sense that cost have to be born by those of us that have the means to do so.

Fej2• 9 years ago

We will have our universal healthcare, eventually. More and more people are scorned every day by the perils of our system. The Democrats couldn't manage to pass a public option during Obama's honeymoon period but the country might be ready for it once the pendulum swings back in 2020. Even my somewhat economically-conservative father admits that it is inevitable.

These next two to four years are going to suck, though.

I am a New Jerseyan and the medical industry is going to fight tooth and nail on this. My district swung (!) and even the Democrat won't endorse single-player.

Hopefully we can effect change as the Boomer leaders die off, at the very latest.

nfriedly• 9 years ago

One thing to keep in mind: when you go to the emergency room as a relatively well-off individual who has insurance and pays their bills, you're not only paying for your emergency room visit - you're also paying for the visits of people who don't have insurance and can't afford to pay their medical bills.

Ricky789• 9 years ago

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The Company Behind Many Surprise Emergency Room Bills

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