We suddenly woke up in the Kafka-esque purgatory of critical American healthcare billing. We’re in our 50s and had been perfectly healthy, then suddenly we got diagnosed with what will be over $500k in treatment over the next 12 months— and multiple millions for the foreseeable future. We have insurance, but many of the required procedures are “out of network” and there’s no way to tell (we have “the best” insurance, supposedly). Even with insurance it will be at least $50k/yr out of pocket
But the raw numbers like $200k for this poor gentleman’s heart attack or $500k aren’t the most alarming. It’s the Terry-Gilliam-level of absurdity of the billing process. Absolutely no one will tell you how much things are, and when you ask, they sass you that it is a ridiculous question. Even though one of my providers just recently started offering estimates, those are off by 100-200% , and completely missing for about half of what has been ordered.
We are both very strong accountants, and despite trying to do audits of these services, it’s impossible. There are 3-4 levels of referred services, bundled codes, nested codes, complication / technical / professional codes , exceptional status codes . Providers overbill, double bill. On accident and on purpose. When we call to get it corrected there is no way to make corrections.
You’ll be asked to take a diagnostic not knowing whether it will cost $10 or $15000 . Even if you try to be responsible and call the provider (who isn’t your doctor, clinic, or hospital ) – they won’t be able to tell you.
The point I’m trying to make isn’t to make you sympathetic. It’s to reinforce in all of the great technical minds here that healthcare billing is the most complicated spaghetti code cluster flock of a system that you’ve ever imagined. It’s far worse than any piece of software you’ve ever seen. And we all just accept the bills and pay them.
Supply and demand and finding a better vendor doesn’t work. There are some rare exceptions like elective MRIs – but those aren’t the norm. Nearly every service is something time sensitive or your disease will get significantly worse. Moreover, signing up a new provider has $1000+ in billing and a few hours in paperwork to make the transfer. is it worth saving $500 for one MRI when $250k worth of services are unaccountable?
The only thing I’m sure of is that there has to be tremendous amounts of incidental and deliberate corruption . Auditing a single patient’s billing is impossible – so a population’s worth is a goldmine .
The stuff you are describing is what bothers me the most. There is a lot of talk about how we should have a free market system. But there is no real market for patients. Most people can't pick an insurance plan for themselves because the employer picks. Then it's extremely hard to get an estimate for anything. And even if you get an estimate, it's most likely wrong. Then the billing is totally opaque. Insurance and providers constantly make mistakes or lose things.
I went through this with my ex after a surgery. It was totally insane to figure out where the numbers are coming from and basically a full time job.
Even if we don't want to go to single player or similar, I don't understand why it's not at least possible to mandate clear and binding estimates and billing a normal person can understand. And let the market work its magic through competition.
America has doubled down on middlemen controlling the prices of medical care and making sure that there is no set price for anything. With the ACA effectively falling apart in the new budget, we do have a chance to move to a different reality, one where medicare prices are the set prices for everything, but that is nearly a political impossibility given the amount that these middlemen spend in keeping politicians who support that from winning primaries. Instead, we are stuck in a situation where companies get to dictate prices and access to care while we get diminishing returns in health quality and longevity.
I’ll look into it. From what I can tell it’s not a simple hero vs villain story. It feels more like an industrial disaster or the AWS outage where there are like a dozen compounding system failures leading to where we are today.
Medical billing is like a massive centuries-old tenement building with a patchwork of legacy plumbing, electrical , framing, sewage all patched together with decades of duct tape, wood shards, and rusty couplings. But in this case there’s massive incentives to keep it all bodged because each pipe and crevice hides billions of un-audited income.
Matt Stoller is properly described as an insane person who thinks every single problem in the world is caused by monopolies (yes, including whatever random problem you're thinking of now).
His most notable attributes on Twitter are he constantly lies about everything and that he spends all his time promoting Republicans who are clearly not going to implement his anti-monopoly agenda.
I haven't paid a lot of attention to Stoller particularly, but the rest of that line of thinking frequently correlates with also believing that monopolies are exclusively a result of active government regulation, a belief which is naturally attracted to Republican deregulatory rhetoric.
Oh, I don't think that applies. He's part of a movement called "neo-Brandesian" aka "hipster antitrust", which basically thinks government should promote small businesses by explicitly bullying large businesses, and that the customer welfare standard was a cop out to give up on this.
So not only would they be against deregulation (they think painful regulations are good because pain for the sake of it is good), but the previous admin actually tried this with Lina Khan and it didn't really work.
The issue here is Democrats are "mainstream" coded, so all populist politics works by fighting them even when they're trying to do your own policy.
> one where medicare prices are the set prices for everything, but that is nearly a political impossibility given the amount that these middlemen spend in keeping politicians who support that from winning primaries.
You're missing the part where the Stated and objective goal of popular politicians from one party is not to let that happen.
They don't get elected because someone scheming to control their funding (though that is a proximal cause of Republican candidates getting more extreme: Align with MAGA or get primaried)
They get elected because a huge portion of the USA are divorced from reality and utterly deny said reality. They say "government is less efficient" as we sit on top of this atrocious system, a system where we already have the government version and it's radically cheaper and we could literally just sign up everyone for that, save everyone time, money, and headache, and then improve service quality.
These people deny that nearly all developed countries and lots of undeveloped countries have vastly better healthcare outcomes than the USA, extremely better healthcare access, and pay way way less overall, taxes included.
These people just consume propaganda, and purposely refuse to engage with any clear or obvious evidence that contradicts said propaganda.
i don't really disagree with you, but i do think it is funny given that the single largest policy targeting medical price transparency came from a republican admin.
i'm potentially on board with signing up everyone for medicare, but only if we actually can get voters to vote for the taxes necessary to fund that. i doubt we will be able to given we can't get voters to vote for the taxes necessary to fund existing medicare consumption.
I feel a great deal of sympathy for you. A medical event wiped out my meager life savings - I’m a tad younger but I worked my whole life for much of it just to go “poof” because of exactly what you are describing. I don’t feel I have a hope at retiring anymore and it makes me really depressed.
thank you for saying that and I share your sadness / anger . A lot of people do. It’s not your fault, or ours. Healthcare is a truly evil bureaucracy staffed with some of the most loving and capable people I’ve seen. So I’ve been able to admire the beauty of the situation while remaining angry at “the system”.
1. There are assistances available for low-net-worth and low income individuals. Have you tried those options?
2. Refuse to pay. Medical debt doesn't count against your credit and, based on my own experience, is almost impossible for the other party to collect, except some annoying phone calls.
I make a good living. I have some of the "best" available health insurance. It's just bordering on scam/fraudulent. Not aware of what programs you're talking about other than medi-cal (medicaid). Which I do not qualify for.
As I alluded in another post I do often let debt go to collections. The issue is often not the collections calls, but that your provider will be even more aggressive about demanding up front payment to continue receiving care. Or stop seeing you. I have a rare neuro muscular disease that only a handful of doctors are even very knowledgeable about where I live.
But you would probably not qualify for something like this due to income. I happened to have a minor accident while unemployed (<$10k income that year) about 10 years ago, and the hospital financial aid forgave most of the cost.
I am sorry to hear that. A friend of mine who moved from US to Canada moved after his mother had cancer on her 60s. She was retired by then after having a very successful career (C level on some manufacture company).
It's probably unsaid that she died with a good credit rating as well.
You don't necessarily need to pay back those loans, and most of the time the hospital has to negotiate a feasible repayment plan.
Medical bills have to lowest life-improvement rating of them all. That is to say paying off someones medical bills will have one of the lowest impacts to their lives compared to another financial intervention.
We had felt invulnerable until we weren’t. I’m sorry about your friend’s mom it’s vile and even more infuriating that there’s no clear “villain”. But you reach a point where you focus on what you have. Good doctors, admirable and compassionate nurses , loving and supportive family. The money is toilet paper really – we conceded that a long time ago. Make the most of it while you can but you can’t hold onto too tightly.
> Absolutely no one will tell you how much things are, and when you ask, they sass you that it is a ridiculous question.
> You’ll be asked to take a diagnostic not knowing whether it will cost $10 or $15000
I feel this in my bones and it makes me irrationally (or maybe it's rational actually) angry. Find me any other industry where you can get away with not telling how much something will cost (or even a realistic range) before services are rendered.
I had a medical procedure a year or so ago and when I asked how much it would cost I got an eye roll, a lengthy and exasperated lecture, and in the end the number they quoted was wildly different. I knew I was going to hit my out-of-pocket maximum so I gave up after a while and moved on but it makes me so mad. I _wish_ I could "vote with my wallet" but good luck doing that unless you have unlimited time and energy. By the time I finally got to asking about the price I had been through multiple appointments that took forever to schedule, were weeks or months in the future, all while I needed relief. After being strung along for 6 months I gave up and rolled the dice even though I disliked how they treated me when I asked for the price.
People talk about how you need to be an informed customer but I have to assume those people are lying snakes, have never used the system, or just too stupid to understand that it's impossible.
"I don't know" should _not_ be a valid answer when asking how much something costs, it's ridiculous.
That’s exactly what we experienced. There is no way to be an informed customer or “vote with your wallet”. For many diagnostics and services, the “provider” is 2 referrals downstream – the patient never elects or engages with them.
Plus, your life is on the line. If they don’t run the test, it means the wrong treatment and your prognosis goes from 80% survival to 80% mortality
> I got an eye roll, a lengthy and exasperated lecture...
This is the part that is galling to me. Apparently no healthcare worker I've ever spoken with about billing has ever had the same considerations I do re: finances. My inquiries have almost always been met with zero empathy and contempt that I would even be so gauche as to ask.
(It's 1000x worse when you're talking to them about your child's medical care. My daughter, at 3 y/o, had a short fall and received a small cut on her face. It bled profusely so we took her to the ER. We ended up with x-rays because I couldn't successful "negotiate" that we didn't want that. The shaming was intense.)
I share the exasperation about the lack of empathy. I know these providers are humans and would ask the same questions. They probably negotiated their car, housekeeper over a few hundred dollars. But when I ask about $10k here or there for critical care suddenly I’m greedy or unrealistic?
A family member had a procedure a few years ago. Provider told the patient that they had contacted their insurer and received confirmation it would be covered. Went ahead with the procedure.
Bill arrives and the insurer denies coverage. Provider says "oh well <shrug> you owe us $$$ now".
Since I am the resident argumentative asshole in the family I dig into the situation a bit. After many phone calls I am eventually told that the hospital routinely records all phone calls with insurance companies and furthermore has found the recording where they gave advance guarantee of coverage for the procedure.
At this point I realized we are being shaken down by a corrupt/criminal enterprise. Even with the recorded phone call the insurer refused to pay and so the patient had to pay off the $$$ over many months.
Similar situation with me and a procedure back in 2014. Practice took me on with my pre-ACA insurance. Post-procedure my insurer decided it was a pre-existing condition and didn't cover the procedure. For the practitioner, who went into the deal expecting the reimbursement rate from my insurer, it was a 10X windfall (and he refused to negotiate, citing that he was within his rights to demand the full fee).
Last time I had blood work done, my doctor and I decided on a set of cholesterol related markers beyond your typical cholesterol assay.
It took me a week and hours of phone calls to figure out what would be covered, and how much the non-covered tests would cost. The doctor pointed at the lab, the lab pointed at insurance, insurance pointed at the doctor.
Finally it was the lab that was able to produce numbers.
And when I was finally billed those numbers were still incorrect! (and thankfully cheaper)
It’s just so insane that the entire industry accepts that no one knows how much things are. Even the “financial services” team will just say “yeah that estimate is wrong” and not blush. What are you guys all doing?
my exact curiosity. They seem to have a rough scope on CPT codes ahead of time, with some buffer. It's baffling that the cost per CPT changes between estimate and billing. Id like to talk to a billing administrator to ask how that process works. Does the admin pad the doctor's figures with additional codes and markup?
I recommend making a good faith effort to negotiate and start a payment plan (reading the fine print on the overall commitment). But bankruptcy is a viable option if you don’t have a ton of assets at risk.
Yes, it is a huge mess. For patients who do have health insurance it's worth checking your health plan's online cost estimator tool before any elective treatments. Most payers are now legally required to offer an estimator to members under federal cost transparency rules. It can be confusing to know what to search for but at least worth a try for something like an MRI.
> We have insurance, but many of the required procedures are “out of network” and there’s no way to tell (we have “the best” insurance, supposedly). Even with insurance it will be at least $50k/yr out of pocket
I can see them being out of network this year, but can't you change insurance in the following year to one where it will be in network?
There are two “provider networks” in our region: BCBS & The United Healthcare network. BCBS is supposed to be better. Were we to switch, let’s say they did cover the 1/10 out of network cases, we risk losing the 9/10 that we currently have . The “whack a mole” is a good example. In this case it’s whack a mole and one could be $50-$100k worth of coverage gone. And more importantly, when you find a good doctor, you need to hold onto them. The difference between a good doctor and a bad one is life or death for this condition.
Is this a somewhat remote location? With all the insurance options I've had from work, the "in-network overlap" was something like 90-95%. People didn't change insurance to get access to providers - it was mostly a better rate, etc.
I can’t help but think there is a huge opportunity here for a health care provider that provides routines scans and such with fixed transparent pricing.
You’re right and there are some provider segments like MRIs that have succeeded with this model.
From our perspective the real blocker is the “lock in” due to timing and the referral process. We’re paying bills to providers like specialized labs that are 2-3 degrees down the chain from our doctor (e.g. radiologist refers pathologist refers lab1 refers lab2 – we only see radiologist) .
Even if there was a “amazon for labs” we wouldn’t be able to order this stuff because the decision is 2 degrees away.
Fun fact is that most such obvious innovative solutions are prohibited by law. There are many layers of turtles the lowest two are: corrupt politicians and, population that doesn't care about corrupt politicians.
That's bad news. Medical billing in the USA is utterly insane. What really gets me is that if they do list the prices they seem quite reasonable, and then after the fact you get hit with a bill that is 10x or even more of what the listed price was due to all of these factors you mention.
>>It’s the Terry-Gilliam-level of absurdity of the billing process. Absolutely no one will tell you how much things are, and when you ask, they sass you that it is a ridiculous question.
Here in India when my dad underwent bypass surgery, I checked the bills the breakdown is insane. This how a charge goes, Nurse comes to see you, so she wears a pair of gloves, that gloves is billed. And often something like 10x the price those are available in the regular pharmacy. Each and everything is billed, and you would be surprised just how many things like these can be be billed.
>>You’ll be asked to take a diagnostic not knowing whether it will cost $10 or $15000 . Even if you try to be responsible and call the provider (who isn’t your doctor, clinic, or hospital ) – they won’t be able to tell you.
Often some 'visiting doctor' comes to see you. Like in the case of my dad we were billed for a diabetic consultation, despite clearly telling them he wasn't diabetic, even more so, the same doctor came in the day before and had to told the same. We didn't need it. But you will see they bill you like 2000 rupees just for the person to enter the room say 'Hi' and exit.
>>The only thing I’m sure of is that there has to be tremendous amounts of incidental and deliberate corruption . Auditing a single patient’s billing is impossible – so a population’s worth is a goldmine .
In these situations most people are so stressed and anxious often people just have no mental bandwidth to fight side battles.
Its really a corrupt system to the core, and I don't see hospitals and doctors giving all this up anytime soon. Or even ever.
For such sums, you're probably better off calling the best private hospitals in France, UK, Germany, whatever, taking the trip, doing whatever treatment there and paying out of pocket, having some holiday, and you're still ahead.
Of course that would only work if you can take the time off from work, have the same treatment available elsewhere, and being able to actually travel with whatever illness you have.
you’re right it’s a great idea for a hip replacement and many other procedures. Our condition doesn’t fit into that model well because of the duration and frequency of treatments.
I’m guessing there has to be a queue on that. Even those countries must be getting backlogged right? I haven’t looked into it besides what I’ve heard on social media.
But the raw numbers like $200k for this poor gentleman’s heart attack or $500k aren’t the most alarming. It’s the Terry-Gilliam-level of absurdity of the billing process. Absolutely no one will tell you how much things are, and when you ask, they sass you that it is a ridiculous question. Even though one of my providers just recently started offering estimates, those are off by 100-200% , and completely missing for about half of what has been ordered.
We are both very strong accountants, and despite trying to do audits of these services, it’s impossible. There are 3-4 levels of referred services, bundled codes, nested codes, complication / technical / professional codes , exceptional status codes . Providers overbill, double bill. On accident and on purpose. When we call to get it corrected there is no way to make corrections.
You’ll be asked to take a diagnostic not knowing whether it will cost $10 or $15000 . Even if you try to be responsible and call the provider (who isn’t your doctor, clinic, or hospital ) – they won’t be able to tell you.
The point I’m trying to make isn’t to make you sympathetic. It’s to reinforce in all of the great technical minds here that healthcare billing is the most complicated spaghetti code cluster flock of a system that you’ve ever imagined. It’s far worse than any piece of software you’ve ever seen. And we all just accept the bills and pay them.
Supply and demand and finding a better vendor doesn’t work. There are some rare exceptions like elective MRIs – but those aren’t the norm. Nearly every service is something time sensitive or your disease will get significantly worse. Moreover, signing up a new provider has $1000+ in billing and a few hours in paperwork to make the transfer. is it worth saving $500 for one MRI when $250k worth of services are unaccountable?
The only thing I’m sure of is that there has to be tremendous amounts of incidental and deliberate corruption . Auditing a single patient’s billing is impossible – so a population’s worth is a goldmine .