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?

I agree, I do, which is why I tried making my statement as much a question as possible. I am unaware that attorney's would fight for cases like this, if they are more common and do not lead to lawsuits.

I agree that an attorney only makes sense if you're facing a significant bill. On a smaller bill I would go to the hospital billing department and negotiate.

You can of course negotiate as well.

If someone bought a car or house, they knew their obligations exactly. If they declare bankruptcy, I would lay some fault with them, if not all.

But with medical billing, you cannot get a straight answer. If they cannot tell you what a simple procedure would cost you, then you don't owe them anything.

Also hopefully if enough people don't pay surprise bills, then medical industry would have motivation to simplify their systems.

I don't get this statement. Not protecting your credit score can cost you real money. Yeah, the whole thing is a racket, and I frickin' hate it, but, pretending like you can ignore your credit score without impact seems counterproductive.

I would really rather see this whole racket of a medical billing system held to account versus advocating that we allow them to punish us in any way for not playing their fraudulent game.

Despite this, I have been able to get a car loan, I got a VA loan for a house, I have opened two credit cards (which I use responsibly) since then, and also was able to get a personal loan for an emergency six years ago. It is absolutely possible to do "normal" things. It's just been a matter of explaining the situation.

Clearing errors involves a byzantine maze and way too much time in an era when everything is digital. There should be stringent regulation around accuracy and we should all have free year-round, real-time access to our credit scores.

But, my point here is not that you can't live a normal life with a few credit dings. It's that those dings represent punishment that can impact you. For instance, you may not have gotten the best interest rate available on your subsequent credit. So, we should be advocating an end to these fraudulent medical billing practices vs accepting punishment from them, then trying to live with it.

BTW, I predict Verizon will soon be the target of some hefty class-action. They are very shady when it comes to contracts. They also have periods wherein substantial numbers of customers report mysterious, frequently dramatic data overages for a time [0] that suddenly disappear. But, they refuse to acknowledge any issues.

And they specialize in making it extremely difficult to achieve resolution, with multiple phone calls, etc.

[0] https://www.wirelessweek.com/news/2016/09/thousands-verizon-...

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.

It only makes sense to at least postulate that the converse is true as well: if you find yourself stuck out-of-network, it's because these regulations created an environment where the insurance companies could do better by eliminating the providers it partners with. So it's reasonable, at a first approximation, to guess that this problem is the result of ACA.

Also: this idea that the "Democrats are the party of the people" and the "Republicans are the party of corporations" is pretty silly.

The Republicans are a conservative political party. The Democrats are a coalition of blacks (~25%), latinos (~10%), women (+10% share), labor unions, and urban (but not suburban) college-educated whites. Liberals are an important component of the Democratic party (and have no home whatsoever in the GOP), but they don't run the table.

Republicans can't win the numbers game so they hammer home on right wing populism. Unfortunately, the last 30-40 years hasn't been kind to the "Main Street" centrist republicans of the past.

Probably the most important realization for the average American in the current political climate is how no party establishment represents you. Both have their sponsors, and none of them are the American people. Individual politicians might have more empathy than others and some might try to help the common man more than another, but they all still have their bosses and despite whatever rhetoric we throw around in almost every election (aside the scant few in contested states and counties) the people are not holding their leash, so they don't work for you.

It is like climate change. It doesn't matter how you want to argue about solving it, it is simply acknowledging the reality that has to happen first and moving on from there on a unified foundation of fact.

A lot of people forget that the GOP does not, as a political party, believe in universal coverage. Moving the country closer to universal coverage is not a GOP political objective. What is a GOP objective is minimizing federal interference and involvement with business. Health care is something like 15-20% of the entire economy, so the GOP's stated objectives run directly counter to universal coverage.

And yet, repeated efforts to eliminate the ACA have all retained policies built around universal coverage, including a massive federal expenditure in Medicaid (block granted or otherwise) and an extremely intrusive regulatory requirement for guaranteed issue insurance, something that only Ted Cruz has tried to push back on.

If that's not a win for the Democrats it's hard to imagine what plausible outcome would be. Nothing that involves 15-20% of the American economy will be simple, or will happen in one legislative session.

Any number of effective cost-saving measures could be passed that would have the effect of increasing your premiums.

If you're paying for your own insurance, you're in the individual market, which is significantly more expensive, and what you're seeing is, in part, the market absorbing the cost of guaranteed issue, something we decisively did not have before the ACA, when health insurers could lock people out of coverage on suspicion of a medical condition, and later rescind care. Pre-ACA and post-ACA insurance is for that reason also not an apples-apples comparison.

Is the actuarial and outcomes data corpus of the health insurance industry so bad that it makes actuarial sense to segment the markets to individual, medium group, large group, etc.? I've always wondered what the explanation is for so many cohorts.

Are state insurance regulations preventing medical insurance providers using more sophisticated risk modeling to create larger pools, or co-marketing with life insurance companies that gather pretty detailed data on individuals before underwriting?

Especially post-ACA, there are very strict limits on what factors can be used to set premiums. Risk-based assessments are basically outlawed except for a few defined variables like age and smoking habits.

Regardless of the cause, it's extremely frustrating to be hit with such a large monthly bill for rather poor coverage. I'm not quite as bad off as 0xbear, but we're at $1550/mo for a family of three for much crappier coverage than we had a few years back.

Here in Phoenix we've seen double digit increases every year for years, and are down to a single provider on the individual market.

Paying $18k/yr before you even use a plan is insane. Use it at all and you're looking at $20 or 25k total, with coverage limits not really kicking in to stop the bleeding until you've shelled out 30k or so.

Somebody making $80k/yr just hits the subsidy payout and is spending 20-40% of income on health care. Unsustainable.

Argue the whys all you want, these sky high rates have to change.

If you don't argue the whys, you're mostly providing a lot of noise that is convenient cover for the next attempt to bilk insured people.

Yes, premiums are way too high. They are not high "because ACA", though. In fact, they'll rise at a much faster rate if we get rid of ACA. (The latest bill had an annual rise of $11.4K for a single male adult >62 years, with an annual income of $12K.)

There's no question ACA is broken, and we need to fix it. But we need to know and understand what is broken to fix it. A repeal won't do that.

There's a good argument to be made that e.g. enforcing cost transparency would do that. (Right now, you have no idea what insane cost your provider will charge you - they make shit up as they go). Single payer is one possible way to do that. Not the only one.

There's another good argument to be made that we need to talk about the right to die. Numerous patients are kept alive at insane costs, even though they would rather live out the last few quiet moments at home, with their family.

There's another good argument that for a decent risk pool, everybody needs to be insured. (This is an argument that stands little chance until being insured is actually somewhat affordable)

There's a good argument to be made that Medicare should be allowed to actually get competitive bids. (Right now it's rejected to "pilot projects" and "test markets").

There's a good argument to be made we need to focus much harder on preventative care. Follow-up costs from acute episodes are much higher than a decent investment in preventative care.

There's a good argument to be made we should talk about our test and prescription obsession. The amount of stuff unnecessarily prescribed "just in case" is ludicrous.

None of these will immediately lower rates. But each day we spend wasting on the theatre that is the junk the current GOP tries to ram down everybody's throats is a day they rise. And should this pass, they'll rise tremendously.

If we don't all inform ourselves as to the why's and then hold our representatives feet to the fire using well-formed arguments, so they can't weasel out, we're stuck with a shitshow. So, while I understand the frustration - I've got health care bills too, after all - an attitude of demanding change without informing ourselves what change to ask for leads to an even worse disaster.

And that feet-to-the-fire thing applies to all parties, in case you were thinking I have a particular partisan view. But it needs to be an informed roasting, or we'll merely end up with the loudest guy making the good sounding promises.

I'm ranting against those who continually tell me "it's not that bad", "suck it up", "you're lucky you have insurance" or some variation of the above.

The first step in fixing the problem is to recognize the problem, and there's many I've talked with that reflexively reject the premise that there is a problem in the first place because of what that means for the ACA.

The foundational issue is that we're stuck in an uncanny valley between single payer and private insurance. Either single payer or private could be viable, but not the unholy menagerie we have now.

The high costs, over prescription and under prevention that are bloating the system all driven by that issue and could be solved with a single arbiter that gets the bill, whether that be the government or the citizen.

The best proposal I've seen is a two-tier system like Germany has, with public healthcare for all and private healthcare available for the rich. That tends to rub Americans the wrong way because fairness, but really solves most of the problems because it gets universal coverage to spread the risk pool while accepting the natural impulse to want to pay for better care if you can rather than rejecting that option out of hand like some single payer systems do.

I lol'ed. Because... we already have private healthcare for the rich, we just don't have public healthcare for all. Because fairness ;)

And I'm very much enamored with the German system as well, but then, I'm biased. I'm from there. (And currently pondering going back there, because as much as I love what the US could be, I hate what it currently is)

The NHS costs about £3,500 a year per person.

As for the increase premiums are up 25% in 2017 alone. At the same time deductibles are also rising, its much more money for much less coverage if you are unlucky enough to make over 50k a year or so.

http://fortune.com/2016/10/25/obamacare-insurance-premiums-2...

https://www.brookings.edu/wp-content/uploads/2016/07/Fall201...

It's remarkable that premiums didn't rise more under the ACA, despite how many new previously-uninsurable people were covered.

But they did during 2009. By July, a number of bills were already approved by committees in the House. And the Fall is usually when the companies get prices for the next year. So it went up sharply then. Then in again in 2010. Price is not always comparable because the level of coverage had also changed. We had to get new plans and while they covered some mandatory free procedures and didn't have lifetime maximum, they had also bigger deductibles and a reduction in options and procedures covered.

That doesn't mean we'll find a larger jump there, I found it for my self, but the KFF study shows there wasn't in general. However discarding date legislation has passed is also dishonest as factcheck did. Companies which are affected by regulations monitor them closely and adjust to them correspondingly.

Without adjusting for inflation, this growth is ~60% growth in 6 years, or a doubling time of ~9 years. After adjusting, it's more like 40% over the same 6 years or a doubling time of ~12 years.

So you could have the impression that you had "cheap insurance" as long as you never need to have significant healthcare paid for.

The very year ACA took effect my health plan was canceled, my doctor went off-network, my new plan had 3x the annual premium and has grown 30% year over year, as have deductibles, and I fight tooth and nail every single charge to make sure it is in network and covered.

Yes, one anecdote is not data. But there is no more validity to the politician's lie that I can "keep my health plan, keep my doctor, and health care costs will go down."

Something like 80,000 Floridans lost that policy because it didn't carry the minimum services under ACA/Obamacare. But it wasn't just losing the policy, they were never able to afford the new blue cross blue sheild policies, having to purchase from a new insurer most of whom had reputations as fly by night operations (many not existing before ACA and shutting down 1 and 2 years in), and finally losing the good BCBS network.

Here is a copy of the actual letter sent out by BCBS when they had to cancel the policy: https://www.floridablue.com/blog/my-policy-being-canceled-no...

Same here, and I hear the same exact story from most people I talk to. Plans dropped, premiums skyrocketing. Here in Phoenix we've got a single insurer left, and we'll see if we have anybody next year.

What I haven't seen is stories of average joes who were substantially helped by ACA. Sure, if you didn't have coverage before by cost or pre-existing condition, or get subsidies now, maybe you're happier. But the vast middle class, not so much.

So there's a face for you, 32 year old, healthy, middle class, white woman who likes cats, rides horses, and has a pet bearded dragon who she talks to in a baby voice can get regular cancer screenings because of ACA.

Post-ACA, I could once again buy health insurance.

I consider no longer being locked out of the US medical system a substantial help.

Consider also the not middle-class recipients of medicaid expansion.

If that's the case, then the difference between Democrats and Republicans is that the Dems want to insure the poor while still ensuring high profits for the industry, while the Republicans want to screw the poor while ensuring high profits for the industry. They differ on one very important issue, but are still mostly the same.

Actually reducing medical costs requires a far more thorough overhaul of the system.

It hasn't been like this since LBJ. Both parties are completely driven by corporate lobbies. All that differ are the excuses why.

We need a single payer system because, at the societal level, it makes sense for government to make sure people get their healthcare needs met for the same reason it makes sense for government to provide police and fire protection. But forcing all Americans to get private health insurance makes no sense and indicates a fundamental misunderstanding of what the insurance industry does.

Direct Primary Care, single payer and wellness programs all have a good track record of genuinely getting people healthier while bringing down costs. Obamacare cannot do any of those things and just runs expenses up.

Source/qualifications: Among other things, I worked in insurance for over five years. I have a certificate from a technical college in life and health insurance, paid for by my former employer.

The provider must set a high sticker price so that they can give the insurer the expected 60-80% discount to get in-network (and still tolerate underpayment and other shenanigans). The consumer is either intentionally misled or confused (usually both) about basically everything cost-related, and often won't learn the true out-of-pocket cost of a service until ~1 year after receiving it, when the billing process has (mostly) finished.

Example: just yesterday I got a new bill for a routine lab test I received in December. It says that the insurance discount applied, but they never sent a payment, and thus I owe a balance of over $200 to the lab company. Now I have to call the insurer to figure out why they denied payment, which is sometimes due to an administrative error, sometimes a paperwork thing like signing a document that verifies there is no other possible insurance carrier whom may have been responsible for the bill, etc.

Obamacare is thus anything but up front, because honestly working to fix the American medical system would involve excising market-breaking, paper-pushing leeches from the marketplace, but Obamacare props up this destructive apparatus by forcing every American to pay in or get fined.

Almost any economist will say this is one of the largest problems with US health care costs and employment mobility.

Every employer outside of the health insurance and drug industries should be furious at the price they pay to pay their employees health benefits. Besides having a distraction that operating businesses in other nations don't have, they're likely paying more than double than what they need to in this area to maintain competitiveness against other nations. It's even worse for startups.

It also probably should have used subsidies instead of Medicaid expansion. Expensive, but a bunch of healthy people would have been good for the exchanges (Medicaid expansion almost by definition was for healthy working people).

Have you been watching anything that's been happening with the healthcare debate over the past, oh, 25 years? The Democrats have been trying with varying degrees of success to inch this country in the direction of a more sensible healthcare system and the Republicans have pitched a generation-long hissy fit about it.

On the coverage side, the two parties have contrasting stances.

Healthcare and Health Insurance are related but distinct topics.

I'm actually not sure the BHCA or AHCA or whatever it's called now has much in it besides slogans and major spending cuts which aren't aimed at making care less expensive -- they're aimed and reducing the overall amount of care provided by shifting costs to those less capable of bearing them.

That's a pretty big contrast.

Cost of healthcare, other than the occasional conversation about drug prices and definitions of necessary care (which continues to be abused by practitioners), continues to take a back seat.

For what it is worth, my personal opinion is that the medical professional lobby is a single issue voting constituency that is just as powerful as the NRA and the teachers unions.

Until then, I will continue to believe democrats and republicans serve the same master and only differ in language to provide an illusion of choice.

It's been that way for decades.

Source: http://voices.washingtonpost.com/ezra-klein/2009/12/the_deat...

By contrast, Lieberman single-handedly killed the public option.

No, as your source accurately states, he was confirmed after a vote to abolish the rule for Supreme Court nominations.

However, it remains the case that in 2009, 59 senators were ready to vote for a public option, but there was no 60th. By contrast, there were nowhere close to even 50 votes for removing the filibuster and changing to a 50 vote threshold.

Please do not miss the fact that Lieberman had no rational justification for opposing the public option and that one of the keenest observers at the time accused him of being "driven more by a pathological dislike of the liberals who dogged him in 2006 than by any remotely rational policy judgment." http://voices.washingtonpost.com/ezra-klein/2009/12/lieberma...

Those are the facts. You are laying emphasis on the one person who wouldn't vote and I'm laying emphasis on the 51+ wouldn't take take stronger action.

I think it's reasonable to give my emphasis given the way the Democratic Party has behaved over time.

I suppose that voters could have hypothetically had a positive reaction to the public option once actually set up, and rewarded Democrats for it in subsequent elections. But I doubt it. Although Medicare already exists, the public option would represent a significant expansion which would probably come with serious growing pains - plenty of material for Republicans to make horror stories out of. Probably fewer actual cases of huge premiums (which are already not that common), but it's not like statistics have ever been much barrier to politicians and their preconceived narratives. I guess the GOP wouldn't have been able to weaken the law through a constitutional challenge, as they did with Medicaid expansion - after all, the public option can't be unconstitutional unless Medicare is. But the Supreme Court is highly political, and I wouldn't be surprised if the law ended up being weakened some other way by a 5-4 majority...

But politically, Republicans would have a stronger alternative to offer: ACA without the public option. Y'know, the thing they currently portray as the root of all evil; I think they'd have ended up seeing it as a good conservative compromise, that preserved universal coverage availability without requiring the government to be involved directly. Arch-conservatives might not like that outcome (then again, they might) - but they'd likely accept it as an intermediate step, that still accomplished the substantive change of repealing a huge government program (the public option). It would be much easier to get consensus on than the repeal-in-name-only bills they're tossing around in the real world.

I suppose I'm getting way too speculative; the last two paragraphs aren't even directly related to the nuclear option, although they're meant to question the upside of Democrats hypothetically having deployed it. There would've been serious downsides, not just in health care; it's quite possible the 60 vote rule would end up being killed entirely rather than only for 'special' bills, so Republicans in the current Congress would've been able to pass a wide variety of their priorities, and repeal a wide variety of Democrats'. (For all I know you might support the Republicans on their other priorities, but the Democrats whose votes we're talking about certainly didn't.)

A suspension is both procedurally (or textually) more complicated (it either requires changing the rules twice, changing the rules to add a suspension provision and then acting separately to exercise it, or changing the rules to include a tailored exception that applied only to the case at issue) and more politically fraught (rather than publicly defending the case that the general rule is outdated, it requires legislators to defend that the rule is generally valid but should not be applied to the immediate case.) It's very much not the same thing as abolishing the filibuster for a well-defined class of cases.

This is particularly true in the Gorsuch case where the recent Democratic action to remove the filibuster from other Presidential appointees made applying the “nuclear option” to Supreme Court justices much less “nuclear” than it had seemed previously when it been considered.

And then watched it get blown away by next congress as soon as the GOP gained 51 seats to do whatever they want. Blowing away the fillibuster is an awful, terrible, no good idea and there is almost no legislative agenda which would validate it.

And to be clear, the GOP senators were and still are slimey bastards for basically everything they did leading up to Gorsuch. It should have never been done. They will almost certainly regret it as soon as they lose the senate.

Public option is a great solution, because it does not prevent the people who prefer (and can afford) to pay for private services from doing so.

And that is counting Lieberman as a D; a person who backed McCain for president and who later personally killed the public option.

I do think we will get to the public option at some point. It just makes too much sense not to and would strengthen the healthcare as a whole while allowing people more choice.

How does single payer fix that? If the hospital gives you a bill and won't negotiate down, how does the government "fix" this? Which is kind of what my question is: were specifics given in the ACA on how that problem will be fixed?

On national health insurance (monthly cost depends on your salary but for an average person it is a few hundred bucks per month) the hospital pays 70% and patient pays 30%.

It means basic visits to the doctor or dentist are very cheap here. Like $20 for consultation + medicine. ER+X-rays and MRI (appendicitis, sigh) was a little bit over $100.

If anything, the billing abuse is a much, much larger problem than lack of insurance. At least, that has generally been true since the ACA/"Obamacare" changes passed.

My thought experiment for some of this. Suppose the US government had a rider on every insurance policy in the US that said the government would pick up the tab for any amount over say $100,000 (think catastrophe insurance). Now, you would make the assumption that looking at the actuarial tables this would reduce the cost of health insurance because no insurance company is on the hook over $100,000 (thus no need to worry about the million $ payout).

I am more and more convinced that hospitals would screw this up with over billing for every damn thing and every visit requiring a stay would get jacked to > $100,000.

We have a solution. It is called "make it a personal criminal liability". Go after individuals. No matter how low they are on a totem pole and no matter how high they are on a totem pole. Committing such fraud should lead to bankruptcy ( all assets wiped out ) and jail time.

You would be amazed how quick those "accidents" and "mistakes" stop happening.

Unfortunately, as the society we do not want to throw Suzi the billing clerk into the slammer, which means that Mike, the Billing Manager, does not get a slap on the wrist, which in turn means that Jack, the VP of Billing Revenue Optimization, does not get Jackie his wife go bananas on him when their bank accounts, house and kids college fund is seized which means that Jack is represented by the public defender and ends up in a slammer together with Suzi, who actually pushed the buttons, Mike, who told Suzi to do it, and Jack, who came up with this wonderful idea.

Socializing this theft turns it into Just Another Crisis among the hundreds of others the US has.

The "true" purpose of the ACA was to do something about spiraling health care costs. What was passed was a "compromise" where the people pushing for a public option got nothing and the most onerous restrictions on the monied interests were rolled back. This has not been an effective solution in many senses. I decline to further characterize the issue, however; this is extremely close to a political discussion, and those are ban-worthy here.

I would not put too much weight on conspiracy theories though. The healthcare system is massively complex. It will take multiple reforms to eat this elephant.

What a terrible industry.

The employees at an insurance company have an ethical responsibility to the company to deny any claims that do not perfectly align with the policy they sold. I don't think every insurance company is the antagonist in The Rainmaker or the car company in Fight Club, but insurance companies will try to reject as many claims as they can, straddling the line of losing reputation with consumers.

the health insurance industry shouldn't exist.

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.

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.

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.

I'm told this came about because historically more people had to pay for dental services out of pocket, so dental offices were used to having standard fees that they could just look up.

Apropos of outliers, this type of attitude is problematic and emblematic of issues in the US.

"Needing healthcare" is not "abusing medical insurance".

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.

He fractures his pelvis into 14 pieces, and broke another dozen major bones including both femurs.

The surgeries are still ongoing although he is mostly himself again. But even two years later, he is facing a daily barrage of calls, being put on hold, no callbacks, paper shuffling, records from hospital to hospital, faxing permission sheets, fighting with the insurance company (who has threatened to drop his insurance multiple times) and on top of it all, his landlord is trying to evict him.

It's been horrible to watch. It's like the insurance company is trying to kill him with stress.

Is it a 'won't happen to me' sentiment? Preferring the freedom of literally landing on the streets with one accident since you're presumably fully in charge? I do not understand, though there must be an understandable reason.

I think the only reason anyone can think it's OK is (1) they haven't had a major medical expense yet and (2) their political tribe tells them capitalism is the answer for everything.

Honestly, healthcare in the US is so broken I don't see how we avoid a crisis in the next few years because of it. Maybe it will somehow pop like a real estate bubble (sad when that's the most optimistic thing you can hope for).

That sounds horrific. What sport was this?

A health insurance company, no less.

If you take an ambulance to the emergency department, see a doctor, they order a scan, the scan shows appendicitis, and your appendix is subsequently removed, this can easily lead to six different bills:

  - Ambulance
  - Facility
  - ED doctor
  - Radiologist
  - Surgeon
  - Anesthesiologist

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.

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.

https://nextshark.com/youll-love-what-this-startup-does-with...

Here are some thoughts:

Fixed takes a percentage of the dollar value of tickets that get dismissed and you pay nothing for the service if it is not fixed.

Trying to get money out of an insurance company is sort of the opposite problem, though it gets monetized essentially the same way. Independent adjusters monetize by taking a cut of claims paid. This is basically the same monetization scheme that lawyers use for things like suing someone over an accident: They take a cut of cases they win, and you pay nothing if they lose. As far as I know, independent adjusters only work on real estate related claims, not health claims.

Last I checked, the only people legally entitled to talk to the insurance company on your behalf are your insurance agent of record, a lawyer or an independent adjuster. So, in practice, you would be talking about independent adjusters for the health insurance space. I am not clear that would even fly, legally.

Health insurance is a pain in part because it is very highly regulated. It has to comply with both federal and state laws in all jurisdictions in which it operates and laws for both health companies and financial services companies. Thus, it is subject to both HIPAA (Health Insurance Portability and Accountability Act) and The Gramm–Leach–Bliley Act (GLBA), also known as the Financial Services Modernization Act of 1999. I got annual training in Gramm-Leach-Bliley when I had an insurance job. Furthermore, claims must be reviewed and paid in accordance with various state laws. The company where I worked kept a database of "state exceptions." If you don't know those state exceptions yourself, good luck arguing the matter with an insurance company.

You are talking about a very challenging problem space.

I have had it cross my mind to offer a service helping people file claims with the company I once worked for. Although I haven't worked there in a while and some things have no doubt changed, I probably could help some people get more money out of their policy. But I have never gotten past the idle thought stage in part because insurance is such a pain of an industry, and in part for other reasons.

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.

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.

My biggest complaint about the medical industry is the cost of prescription drugs. It's ridiculous how much we pay for drugs in this country.

It's not terribly expensive either. I just started COBRA and it is $750 a month or so.

I'm glad I don't have an HMO, as I'm not organized, and tracking down referrals and such would be a nightmare for me. I've never found a doctor that isn't in my network, so I just figure out which doctor is closest to me and isn't a hack and schedule an appointment. I live a couple of miles from Northwestern University Medical, and Rush University Medical Center, and they've got almost any type of doctor you could possibly need to see.

I don't think my PPO is complicated, but I've never found technical documents that hard to understand. Most of the complications seem to be for emergency and urgent care, but office visits are as uncomplicated as I've made them seem. Some types of lab work might cost more, but I've never been charged for any diagnostic tests outside of cat scans and MRIs.

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.)

I am in the opposite camp and don't have the time to write out my position to the extent you did. However, I'd just like to take a moment to point out the ludicrousness of calling something that isn't Fee For Service "Value Based", as if there's anything in the world more "value based" than paying someone for the value rendered in a specific service.

I agree that "value based care" is probably not the best name for a fully capitated system. (Population health might be closer, but still not perfect.) By definition the "value" of something is whatever someone is willing to pay for it. A doctor's reimbursement rate is negotiated with the insurer, so there is an explicit agreement to pay that rate for that service. And by being a member of that health plan, the patient explicitly agrees to pay whatever deductible or copay is required by the plan, based on the rate the insurer negotiated with the doctor. So in a FFS system everyone has actually agreed to pay the price that is charged.

The problem is that as a patient, it is hard to tell how much a medical service will cost before receiving it. In a grocery store, you can look at the price of milk and decide whether it is worth buying. But there are all sorts of reasons why price consciousness is harder with healthcare (for example: emergency care, lack of price transparency, agency issues). And so the idea of value is harder to measure from the patient's perspective, which is why value and price paid may not exactly match.

Mind me asking what kind of work your investment bank does with the healthcare industry?

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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).

Please elaborate. How did that happen?

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.

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.

(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.

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.

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.

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

And it takes a state license for them to operate. The state could require them to provide an accurate and up-to-date price menu in order to remain in business.

I think the problem is also related to the opaque negotiated prices that "in network" providers negotiate with insurance companies, driving up the cost for uninsured or "out of network" consumers.

There are perfectly rational solutions short of single-payer.

The cost side works in every other developed nation? Surely you're aware of how much more expensive health care costs are in the US, so what might you be referring to?

There are other effects as well - nobody is getting away with billing $600 for a 5 minute visit, for instance.

No, we don't. Medicare is not single payer, though it has (for a subset of the services covered by Medicare) a default public option; it also has private, partially-public-subsidized pland; Medicaid, at least in many states, is not single-payer, either, even at the state level, even before considering overlap with Medicare and other insurance.

Apparently, states are unable to restrict entry into state benefit programs such as healthcare. They can't set up a waiting period for people moving into the state before they are eligible; that was declared unconstitutional by a previous Supreme Court. So if states were to do their own single payer system, in theory sick people could move into the state and immediately gain free healthcare simply by virtue of being a resident. Conversely, they could then move back to their home state that doesn't charge higher taxes.

So it wouldn't be feasible on a state-by-state basis unless a future SCOTUS reverses their precedent. This is unlikely in the short term, given the current Court's make up.

Government programs set maximum reimbursement rates and also mandate cost accounting mechanisms to assure that actual reimbursement is not merely within pre-set rates but also justified by actual provider costs. The government isn't buying services with no advance information about what the charges may be.

Private insurers impose similar controls.

So single payer (or even universal coverage through private insurers) eliminates the particular kind of “robbery” from undisclosed charges being discussed.

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.