Indecipherable Medical Bills Are One Reason Health Care Costs So Much | Hacker News Reader

Indecipherable Medical Bills Are One Reason Health Care Costs So Much

nytimes.com

A few years ago, my wife hurt her back when we were moving. She went to the local urgent care center, and saw a doctor. We have insurance, and that was mostly the end of it for us.

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

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

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

I never realized all this existed!

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

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

The codes are standardized but the interpretation by insurance companies isn't so clear. For the coding look at http://www.medicalbillingandcoding.org/qnas/what-are-the-dif...

I was under impression, that US uses variant of ICD-10 (ICD-9 few years ago) nationally, so WHO browser [1] should more or less work. Not sure if it is copyrighted per se, but most likely official document from CDC or something. It may be a way to milk more money from patients, but at a serious consequences: CDC has biased statistics, changing doctor could be problematic, and probably the doctor risks losing their licence due to document forgery charges. I thought that patients (both inpatients and outpatients) are required to give some form of confirmation (maybe verbal) on both correctness of anamnesis and understanding of discharge summary. One should probably always take copies with themselves to read those carefully.

It would be nice if someone more knowledgeable on actual particulars could expand (I'm from metric land)

[1]: http://apps.who.int/classifications/icd10/browse/2010/en#/Z0...

How to fix USA healthcare IMHO:

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

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

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

3. Repeal EMTALA.

Its a dissapointing thing (usa) that both republicans and democrats cant simply agree to make them declare prices etc.

Its like all these "acts" have no intention of addressing the real issues at all. Then its amazing to see both parties argue over their plans which will never work because none of them address it from bottom up.

A poster on another forum I frequent made the point that "regarding the political parties, there are no actual ideologies, only, different interests they represent" and that does seem to ring true some of the time...

California publishes Medi-Cal rates [1]. Unfortunately, not all codes are explained, e.g., 99282 (according to the NY Times article, E.R. "examination and treatment of a patient with a finger fracture") and 99283 ("a narcotic painkiller was also prescribed") are both described as just "EMERGENCY DEPT VISIT".

California also has a website comparing costs and quality for treatments across hospitals and regions [2].

[1] https://files.medi-cal.ca.gov/pubsdoco/Rates/rates_range_dis...

[2] http://www.cahealthcarecompare.org/cost_detail.jsp?region=16...

If I recall, EMTALA is the law that states that hospitals must provide emergency medical care to someone regardless of their ability to pay.

Do we really want to live in a society where people are refused treatment for medical care just because they can't pay at that time?

The problem with EMTALA, is that it is routinely abused to get non emergency care.

As a result, some hospitals have found that it is better to close ERs; which of course means less emergency care when it is actually needed.

Here's the question though: Why don't ERs have a billing code that is essentially a walk in visit that costs a sane amount?

My vague understanding is that the answer is along the lines of "they don't understand economics" and have worked over time to push lower risk care out of the ER, instead of working to handle it at lower cost inside of the ER, making the typical ER visit more and more expensive to handle...

The architect of the ACA literally said the same thing about hospitals, moving services out of the hospital where possible to save money. But that just means that either the utilization of the hospital goes down (driving up costs) or the complexity of the care delivered goes up (driving up costs).

Because paying people to be there 24/7 is not as cheap as paying people to be in an urgent care from 9-5 or even 9-9.

Precisely because the facility is designed to handle massive emergencies means that your fixed costs are inherently higher.

Just because you intend to use a supercomputer to browse HN doesn't mean the price to buy the supercomputer gets cheaper. If that's your intended use-case, you should buy a cheaper tablet / go to a cheaper level of care.

EMTALA's greatest problem is its unfunded mandate where people are required to provide 24/7 emergency care without regard for ability to pay. Since it's effectively "free", people abuse it and show up at all hours for non-emergent issues because they don't want to wait.

It depends on the utilization rates though.

And the facilities could be designed to handle smaller issues too. The local hospital here runs an ER and an urgent care center about 60 feet away; from a practical standpoint I'm 100% certain that the urgent care could be the same intake as the ER. I'm less certain about it, but I believe the reason it is not is because there are structural incentives in the various reimbursements they get. Those incentives probably do make sense in places where ERs are over used. Here, most of the time, they create redundancy.

Is that so? I have never seen a hospital in my life without an ER. Most hospitals in my area loudly advertise their ER even from the interstate.

That's a symptom of another problem though - lack of accessible and affordable health care outside of the ER or clinic.

What a country needs is a tiered healthcare system, like we have in NL; non-emergency things (the sniffles, complaints, etc) -> GP appointment or walk-in hour. Minor emergency (e.g. pneumonia, etc) -> on-call, night shift GPs (they rotate). Major emergency -> go to ER if possible, else, call ambulance.

Point being, people going to the ER when they don't need to is a symptom of other problems.

#2 is illegal under Medicare/Medicaid rules.

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

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

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

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

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

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

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

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

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

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

My personal view is that most people would be OK with the lowest non-Medicare rate, i.e. "the free market rate".

Why Medicare reimburses at an unprofitable rate is another discussion.

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

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

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

Under the ACA you can't even go out and buy insurance at any point in the year (from a large number of companies) unless you meet a minimal list of conditions that most people won't.

This problem existed far before the ACA so while some stuff in it really needs to be changed I don't think it's fair to blame it for this scenario

The market is riddled with adverse selection problems. The easiest way to reduce costs is to reduce coverage!

Consolidation quickly takes care of any smaller company that tries to compete, in addition to the other issues mentioned here.

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

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

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

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

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

If I receive a hospital bill how is it that I, the customer paying that bill, not receive an itemized list of the procedures done, with prices? I wonder what the legal reasoning behind keeping them from your customer could possibly be?

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

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

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

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

6 figure salary and recession proof employment?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This is why healthcare is such a huge political issue in the US right now. Tons of people are going into bankruptcy over medical bills, and tons of people are dying that shouldn't be. Many democrats want a single-payer system, and many republicans want a free market. Since we have a two-party political system that is behaving more and more partisan with each year, everyone is just yelling at each other and no solution is being found.

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

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

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

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

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

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

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

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

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

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

whoa it already exists: https://disputebills.com/

Thank you for sharing this.

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

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

An ob-gyn had some stuff to say about it here: http://www.slate.com/blogs/xx_factor/2016/10/05/hospitals_ch...

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

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

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

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

The article is discussing the runaway costs of healthcare -- its both a republican and a democrat issue. The current system is unsustainable.

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

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

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

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

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

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

http://www.nbcnews.com/health/health-care/democrats-ask-hhs-...

Sorry but the baby boomers are a huge part of the problem, and they have been voting for a long time. They've gotten exactly what they've been asking for, for decades. They've got the lowest tax burden of any generation. The silent generation had massive taxes, they built massive private and public infrastructure. The baby boomers built next to nothing in comparison to the silent generation. They've gotten Republicans and Democrats to pander to them.

And X and millenials in effect have higher tax through a massive national debt, chosen as policy by baby boomers for us to pay (or be dicks like they are and kick the can down the road to the next generation).

I definitely am in the camp of compulsory suicide by age 65. And I'm also in the camp of 100% inheritance tax.

Millienials have hard choices ahead.

Reply on news.ycombinator.com