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I have $6,500 deductable. It's insane how much work I need to do to get healthcare. The biggest issue is price transparency. To get a price, I need the tax-id

I have $6,500 deductable. It's insane how much work I need to do to get healthcare. The biggest issue is price transparency. To get a price, I need the tax-id of the medical office and the procedure code. Often times the procedure code is unknown because I might have any number of different procedures, depending on what the diagnosis is. So, I take my list of codes to the health insurance company with the tax ID and wait while they look everything up. This whole thing can take 2 hours. That's if everyone knows what they're doing. Medical offices are so used to patients not asking about price, their back-office has no idea what to do when someone actually asks how much a procedure will cost. Then there's the insanity of cash price being cheaper than the insurance price. So, I need to decide if I want to pay $600 and have it go towards my deductible or $450 and pay cash. I agreed to pay $450 cash and no one in the office understood how to handle it. I finally get to pay the $450 cash and I still got a bill from my insurance for $600 because they also billed my insurance. You get that? I paid cash and my insurance company still got billed. Then we have billing errors. I got billed for things I never asked for and/or never received. More wasted time addressing that. Of course, back office is not used to patients reviewing their bill, so there's more confusion to deal with. I also have an HSA tax free bank account that lets me pay for this stupidity tax free, yay! Dozens of more hours were thrown away trying to understand how HSA accounts work, what I can charge to the HSA account and picking a bank to handle the HSA account. I spent nearly 100 hours in the last few years dealing with health insurance bullshit. Imagine how many more wasted hours other Americans deal with. Fuck this shit already.

loganwedwards 7y ago
I can't agree more. I also went the self employed route just after ACA went into effect and the level of stress this entire process causes every year is mind boggling. To add insult to injury, my premiums are increasing at astonishing rates - orders of magnitude more than a typical standard of living salary increase.
- tvjunky 7y ago
  I agree with everything here, except the implication that this is only related to the self employed or ACA. Health Insurance companies have been pushing these high deducible + HSA plans for 15 years. They also raised the cost of the older less complicated PPO types plans. This has pushed even the biggest companies to "encourage" employees to "take control of their health care". Oh and each year, the definition of "high" keeps getting bumped. 10 years ago deductibles were $1500.
PaulHoule 7y ago
Medical offices will bill anybody who might pay like the insurance you had 3 years ago...
- MichaelApproved 7y ago
  But I already paid them the agreed price.
  - PaulHoule 7y ago
    You're right, but they will do it anyway.
scroot 7y ago
I once tried to find out how much some blood tests were going to cost me. This entailed a 3-hour ping-pong session between Quest Labs and my insurance company, each claiming the other would be able to tell me. Finally after reaching what sounded like some people in a basement somewhere -- who were baffled at the idea I was calling them, by the way -- I was able to get the "list price" for each individual test and add them up (came to about $1200). When I tried to find out from my insurance company how much I would actually pay, they said "well, it's got to go through claims then we'll know." I asked to speak to someone in claims -- nope. Not possible. The only way to find out what I would be paying is do go through with the tests and get the real price afterwards. Pretty insane stuff. The most insulting part was after all this when the insurance "customer service" guy said to me, "We know what it's like to be unsure of your finances." What? I'm sure about my finances. You aren't -- you can't even tell me the price!
- smsm42 7y ago
  I tried to do the same with an HMO - where everything is inhouse, lab, accounting, insurance, billing, they do everything. The result was the same - nobody knows how much anything costs (or at least nobody will tell me), you'd know when you get the bill. Completely insane system.
linuxftw 7y ago
Literally half the country tried to warn against this exact same thing happening before the ACA passed.
- germinalphrase 7y ago
  This pattern of exploding healthcare costs didn’t begin with the passage of the ACA (though the ACA is also obviously not the solution). The ACA did increase costs as insurance companies couldn’t suddenly refuse service because they are actually sick (preexisting conditions), but what is our healthcare system doing if it’s NOT treating sick people?
  - linuxftw 7y ago
    > ACA did increase costs as insurance companies couldn’t suddenly refuse service because they are actually sick Insurance companies are in business to make a profit. What the ACA did was ensure insurance companies have captive customers. A plan with a $6500 deductible vs pay a fine, nonsense. I should be free to choose between the plan or no fine. If it's all sick people in the plan pool because healthy people opted-out, that's the insurance company's problem, not mine. Now that the individual mandate is gone, we can watch the deductibles climb ever higher and push people out of insurance. For many people $6500 might as well be $50k. I would support a full repeal of ACA and replacement with government payer for all, so long as private insurance is not outlawed and can go back to pre ACA form (I'd like to see more changes, but that's a starting point).
    - germinalphrase 7y ago
      I don’t disagree. That would be a good direction to move.
    - scarface74 7y ago
      I should be free to choose between the plan or no fine That’s fine as long as you support getting rid of laws that force hospitals to treat you whether or not you have insurance and you medical bills are not dischargeable in bankruptcy if you don’t have insurance.
exabrial 7y ago
Hsa's are pretty simple.... Tax free account to pay for health expenses. If we all _exclusively_ had them, I think our insurance rates would drop significantly. Not only would purple be concerned about the price of procedures, but would actively keep a eye on their usage.
- MichaelApproved 7y ago
  It's impossible to properly "keep an eye" on the price of procedures. Call your dermatologist and ask how much it would cost to get a mole removed and checked for cancer. Now, 2 hours later, if they even have you a price, tell me if that's reasonable or overpriced. What are you basing that judgement on?
  - exabrial 7y ago
    Apologies, I wasn't referring to that. I was referring to it's easy to keep an eye on the "total cost you've spent" using an HSA, because it's your money in your account.
snarf21 7y ago
Everything you said is true and part of the problem. I do want to clarify some things though that people may not know. There are several reasons the back-office literally can't tell you what the price will be. First, is that if you have insurance, they don't know. It is up to the payor (insurance company) what the final price will be. Even though there are negotiated rates, most procedures have up to 5 service levels. So depending on the service level, the price will be different. And the service level is based on what service was provided which by definition hasn't happened yet. The only way to actually do it would be to be more like a garage. It is $50 to do a level 2 office examination and then I'll quote you on what we find out then and you can choose to continue or not. Most people would be annoyed by this. Additionally, there are different codes for things like new patient vs existing patient. Seems simple, right? Actually if you haven't been to your doctor in the last two year, you are a new patient regardless of how long they have been your doctor. The service levels mentioned above are why for years, you had do fill out a paper detailing your patient history every visit. This is called taking a family history and allows for higher service levels and higher reimbursement. This is finally changing now that the family history is stored in the EMRs. So, we finally figure this all out. An office visit might be always fine but some procedures require a pre-authorization. The rules for this are unique to your employers specific health plan, not the generic Aetna (e.g.). They may require previous diagnosis codes in your chart to indicate you are a risk before agreeing to pay. For example, a 25 year old with blood in their stool may want a colon cancer screening but that is only approved for people 40+. There is back in forth between the office and the payor to figure this out. Oh, we didn't mention that a lot of employers are now self funded. This means that up to a certain loss threshold X, the company pays the bills, not the payor. This is handled by a company called a TPA (third party administrator). Obviously there are deductibles and other things they control and keep track of as well. This new procedure may now put the employer over their stop loss for the year. The TPA now needs to submit this bill to the re-insurer. They may require even more or different documentation in order for them to process and pay this claim. This is why offices have such huge back office components because a lot of the bills just get bounced back. They have to figure out why and resubmit. So why are the list prices we see on our bill so high when insurance pays so little but the doctor accepts it anyway? It is mostly a hedge against mistakes. Again, since each employer plan may pay out differently even for the same insurance (there can be carve outs), the doctors are incentivized to over price and let the TPA and payor figure it out. If they accidentally charged $150 for something that is reimbursed at $250, they lose money. It is better to charge $900 and just accept whatever they get. They now don't need to constantly update the price of thousands of CPT (current procedural terminology) codes and make sure they are always up to date. And this is just part of it.... The only problem in healthcare is mis-aligned incentives. As long as they are allowed, nothing will change. To your case, I would get a new doctor. Paying cash is not that rare anymore and they should know how to handle it. In addition, they seem to try to overcharge the payor and it got dropped to you in this case. Not sure that I would trust them moving forward. This is the problem but what are the solutions? In my opinion, we need to change three things. Each one would be beneficial separately. 1) Move to national reference based pricing. Said more simply, no one can charge more than Medicare * 1.5 or 2. This gets rid of all the bull crap negotiations and the doctors can still do fine. 2) We need healthcare to move away from employment. This is a relic of WWII labor shortages and its time has come. Besides helping employees be more flexible, it also incentivizes payors to get people healthy. People are lazy and won't switch unless they have to. Today, if a payor pays for a wellness plan, that company is likely to switch to a competitor next year to save 1% and they now benefit from the healthier customer. 3) We need to split health insurance. Most insurance is against a tragedy or massive loss. A yearly physical is planned and not a loss but is managed together. We need health plans that are focused on wellness and prevention and are priced at $X/month. Health insurance moves to being used only for hospital visits, ambulance rides, getting cancer, heart attacks, etc. These now separate health insurance premiums can be tied to user behavior, just like car insurance and life insurance are today. I'm not saying this will make a perfect system but it is more transparent and a step in the right direction. Last point, in the US part of the healthcare cost is our demand for extreme convenience. They put in Urgent Cares all over town. The thought was that a lot of people who use the expensive ER services would be better served with a cheaper option. The hope was that ER usage would drop. It did not, people now just go to the Urgent Care in addition. Sally has a cold and we are at the mall so let's just go triple check she isn't dying. People have the right take their kids to the doctor every day if they want but all actions have consequences. You also can't complain that healthcare is so expensive when you are such a high utilizer. The Urgent Care has to pay a dozen people to sit there all day and someone has to pay for that convenient access.
stult 7y ago
I used to be a lawyer (thankfully have since moved to a more rewarding career). My girlfriend at the time was erroneously billed $2000 for a procedure that the insurance company had pre-approved but later denied the claim for. She had them recorded pre-approving, and they failed to decline her claim within the statutorily specified period anyway so it was a prime facie invalid denial. I had to write several letters, talk on the phone with their legal department for hours, and ultimately get the state insurance commission to initiate an investigation before getting them to back down. It took over 60 hours of work from a qualified attorney to handle a grossly invalid claim denial. Had I charged her at what was then my actual hourly rate, it would have cost $18000 to handle her $2k problem, for which she received no compensation. I honestly don't know how people get healthcare in this country without getting a law degree first.
- Ididntdothis 7y ago
  Interesting to hear that even lawyers can’t manage this better. I can’t think of any other industry with such corrupt and flawed billing practices that doesn’t get forced by law to clean up its practices. My girlfriend has spent months fixing problems that were clearly caused by the insurance. On the way the insurance lied repeatedly but in the end she was still on the hook for 100s of thousand of dollars if she didn’t fix this. Better to deal with a mafia loan shark than with hospitals or insurers. Mobsters probably have stronger ethics.
linuxftw 7y ago
> I agreed to pay $450 cash and no one in the office understood how to handle it. I finally get to pay the $450 cash and I still got a bill from my insurance for $600 because they also billed my insurance. That's not how that works. If a provider submits to insurance, the insurance won't pay it, and the provider will send the unpaid balance to you. The insurance company won't send you a bill. > Then there's the insanity of cash price being cheaper than the insurance price. Not insane. They have to bill higher and the insurance company will have negotiated a 'discount' typically. Also, it costs more money to have people on staff to file with insurance rather than just accept cash. You have to pay for people's time. > I also have an HSA tax free bank account that lets me pay for this stupidity tax free, yay! Dozens of more hours were thrown away trying to understand how HSA accounts work, what I can charge to the HSA account and picking a bank to handle the HSA account. Totally agree with you on this one. It's pretty confusing to say the least.
turk73 7y ago
UnitedHealth Group’s second-quarter 2019 revenues grew $4.5 billion, or 8.0 percent year-over-year, to $60.6 billion, led by double-digit percentage revenue growth at UnitedHealthcare Medicare & Retirement, OptumRx and OptumHealth. Second-quarter earnings from operations grew 12.8 percent, or $540 million year-over-year, to $4.7 billion. Adjusted net earnings of $3.60 per share advanced 14.6 percent.

loganwedwards 7y ago

I can't agree more. I also went the self employed route just after ACA went into effect and the level of stress this entire process causes every year is mind boggling. To add insult to injury, my premiums are increasing at astonishing rates - orders of magnitude more than a typical standard of living salary increase.

tvjunky 7y ago
I agree with everything here, except the implication that this is only related to the self employed or ACA. Health Insurance companies have been pushing these high deducible + HSA plans for 15 years. They also raised the cost of the older less complicated PPO types plans. This has pushed even the biggest companies to "encourage" employees to "take control of their health care". Oh and each year, the definition of "high" keeps getting bumped. 10 years ago deductibles were $1500.

PaulHoule 7y ago

Medical offices will bill anybody who might pay like the insurance you had 3 years ago...

MichaelApproved 7y ago
But I already paid them the agreed price.
- PaulHoule 7y ago
  You're right, but they will do it anyway.

scroot 7y ago

I once tried to find out how much some blood tests were going to cost me. This entailed a 3-hour ping-pong session between Quest Labs and my insurance company, each claiming the other would be able to tell me. Finally after reaching what sounded like some people in a basement somewhere -- who were baffled at the idea I was calling them, by the way -- I was able to get the "list price" for each individual test and add them up (came to about $1200). When I tried to find out from my insurance company how much I would actually pay, they said "well, it's got to go through claims then we'll know." I asked to speak to someone in claims -- nope. Not possible. The only way to find out what I would be paying is do go through with the tests and get the real price afterwards. Pretty insane stuff. The most insulting part was after all this when the insurance "customer service" guy said to me, "We know what it's like to be unsure of your finances." What? I'm sure about my finances. You aren't -- you can't even tell me the price!

smsm42 7y ago
I tried to do the same with an HMO - where everything is inhouse, lab, accounting, insurance, billing, they do everything. The result was the same - nobody knows how much anything costs (or at least nobody will tell me), you'd know when you get the bill. Completely insane system.

linuxftw 7y ago

Literally half the country tried to warn against this exact same thing happening before the ACA passed.

germinalphrase 7y ago
This pattern of exploding healthcare costs didn’t begin with the passage of the ACA (though the ACA is also obviously not the solution). The ACA did increase costs as insurance companies couldn’t suddenly refuse service because they are actually sick (preexisting conditions), but what is our healthcare system doing if it’s NOT treating sick people?
- linuxftw 7y ago
  > ACA did increase costs as insurance companies couldn’t suddenly refuse service because they are actually sick Insurance companies are in business to make a profit. What the ACA did was ensure insurance companies have captive customers. A plan with a $6500 deductible vs pay a fine, nonsense. I should be free to choose between the plan or no fine. If it's all sick people in the plan pool because healthy people opted-out, that's the insurance company's problem, not mine. Now that the individual mandate is gone, we can watch the deductibles climb ever higher and push people out of insurance. For many people $6500 might as well be $50k. I would support a full repeal of ACA and replacement with government payer for all, so long as private insurance is not outlawed and can go back to pre ACA form (I'd like to see more changes, but that's a starting point).
  - germinalphrase 7y ago
    I don’t disagree. That would be a good direction to move.
  - scarface74 7y ago
    I should be free to choose between the plan or no fine That’s fine as long as you support getting rid of laws that force hospitals to treat you whether or not you have insurance and you medical bills are not dischargeable in bankruptcy if you don’t have insurance.

exabrial 7y ago

Hsa's are pretty simple.... Tax free account to pay for health expenses. If we all _exclusively_ had them, I think our insurance rates would drop significantly. Not only would purple be concerned about the price of procedures, but would actively keep a eye on their usage.

MichaelApproved 7y ago
It's impossible to properly "keep an eye" on the price of procedures. Call your dermatologist and ask how much it would cost to get a mole removed and checked for cancer. Now, 2 hours later, if they even have you a price, tell me if that's reasonable or overpriced. What are you basing that judgement on?
- exabrial 7y ago
  Apologies, I wasn't referring to that. I was referring to it's easy to keep an eye on the "total cost you've spent" using an HSA, because it's your money in your account.

snarf21 7y ago

Everything you said is true and part of the problem. I do want to clarify some things though that people may not know. There are several reasons the back-office literally can't tell you what the price will be. First, is that if you have insurance, they don't know. It is up to the payor (insurance company) what the final price will be. Even though there are negotiated rates, most procedures have up to 5 service levels. So depending on the service level, the price will be different. And the service level is based on what service was provided which by definition hasn't happened yet. The only way to actually do it would be to be more like a garage. It is $50 to do a level 2 office examination and then I'll quote you on what we find out then and you can choose to continue or not. Most people would be annoyed by this. Additionally, there are different codes for things like new patient vs existing patient. Seems simple, right? Actually if you haven't been to your doctor in the last two year, you are a new patient regardless of how long they have been your doctor. The service levels mentioned above are why for years, you had do fill out a paper detailing your patient history every visit. This is called taking a family history and allows for higher service levels and higher reimbursement. This is finally changing now that the family history is stored in the EMRs. So, we finally figure this all out. An office visit might be always fine but some procedures require a pre-authorization. The rules for this are unique to your employers specific health plan, not the generic Aetna (e.g.). They may require previous diagnosis codes in your chart to indicate you are a risk before agreeing to pay. For example, a 25 year old with blood in their stool may want a colon cancer screening but that is only approved for people 40+. There is back in forth between the office and the payor to figure this out. Oh, we didn't mention that a lot of employers are now self funded. This means that up to a certain loss threshold X, the company pays the bills, not the payor. This is handled by a company called a TPA (third party administrator). Obviously there are deductibles and other things they control and keep track of as well. This new procedure may now put the employer over their stop loss for the year. The TPA now needs to submit this bill to the re-insurer. They may require even more or different documentation in order for them to process and pay this claim. This is why offices have such huge back office components because a lot of the bills just get bounced back. They have to figure out why and resubmit. So why are the list prices we see on our bill so high when insurance pays so little but the doctor accepts it anyway? It is mostly a hedge against mistakes. Again, since each employer plan may pay out differently even for the same insurance (there can be carve outs), the doctors are incentivized to over price and let the TPA and payor figure it out. If they accidentally charged $150 for something that is reimbursed at $250, they lose money. It is better to charge $900 and just accept whatever they get. They now don't need to constantly update the price of thousands of CPT (current procedural terminology) codes and make sure they are always up to date. And this is just part of it.... The only problem in healthcare is mis-aligned incentives. As long as they are allowed, nothing will change. To your case, I would get a new doctor. Paying cash is not that rare anymore and they should know how to handle it. In addition, they seem to try to overcharge the payor and it got dropped to you in this case. Not sure that I would trust them moving forward. This is the problem but what are the solutions? In my opinion, we need to change three things. Each one would be beneficial separately. 1) Move to national reference based pricing. Said more simply, no one can charge more than Medicare * 1.5 or 2. This gets rid of all the bull crap negotiations and the doctors can still do fine. 2) We need healthcare to move away from employment. This is a relic of WWII labor shortages and its time has come. Besides helping employees be more flexible, it also incentivizes payors to get people healthy. People are lazy and won't switch unless they have to. Today, if a payor pays for a wellness plan, that company is likely to switch to a competitor next year to save 1% and they now benefit from the healthier customer. 3) We need to split health insurance. Most insurance is against a tragedy or massive loss. A yearly physical is planned and not a loss but is managed together. We need health plans that are focused on wellness and prevention and are priced at $X/month. Health insurance moves to being used only for hospital visits, ambulance rides, getting cancer, heart attacks, etc. These now separate health insurance premiums can be tied to user behavior, just like car insurance and life insurance are today. I'm not saying this will make a perfect system but it is more transparent and a step in the right direction. Last point, in the US part of the healthcare cost is our demand for extreme convenience. They put in Urgent Cares all over town. The thought was that a lot of people who use the expensive ER services would be better served with a cheaper option. The hope was that ER usage would drop. It did not, people now just go to the Urgent Care in addition. Sally has a cold and we are at the mall so let's just go triple check she isn't dying. People have the right take their kids to the doctor every day if they want but all actions have consequences. You also can't complain that healthcare is so expensive when you are such a high utilizer. The Urgent Care has to pay a dozen people to sit there all day and someone has to pay for that convenient access.

stult 7y ago

I used to be a lawyer (thankfully have since moved to a more rewarding career). My girlfriend at the time was erroneously billed $2000 for a procedure that the insurance company had pre-approved but later denied the claim for. She had them recorded pre-approving, and they failed to decline her claim within the statutorily specified period anyway so it was a prime facie invalid denial. I had to write several letters, talk on the phone with their legal department for hours, and ultimately get the state insurance commission to initiate an investigation before getting them to back down. It took over 60 hours of work from a qualified attorney to handle a grossly invalid claim denial. Had I charged her at what was then my actual hourly rate, it would have cost $18000 to handle her $2k problem, for which she received no compensation. I honestly don't know how people get healthcare in this country without getting a law degree first.

Ididntdothis 7y ago
Interesting to hear that even lawyers can’t manage this better. I can’t think of any other industry with such corrupt and flawed billing practices that doesn’t get forced by law to clean up its practices. My girlfriend has spent months fixing problems that were clearly caused by the insurance. On the way the insurance lied repeatedly but in the end she was still on the hook for 100s of thousand of dollars if she didn’t fix this. Better to deal with a mafia loan shark than with hospitals or insurers. Mobsters probably have stronger ethics.

linuxftw 7y ago

> I agreed to pay $450 cash and no one in the office understood how to handle it. I finally get to pay the $450 cash and I still got a bill from my insurance for $600 because they also billed my insurance. That's not how that works. If a provider submits to insurance, the insurance won't pay it, and the provider will send the unpaid balance to you. The insurance company won't send you a bill. > Then there's the insanity of cash price being cheaper than the insurance price. Not insane. They have to bill higher and the insurance company will have negotiated a 'discount' typically. Also, it costs more money to have people on staff to file with insurance rather than just accept cash. You have to pay for people's time. > I also have an HSA tax free bank account that lets me pay for this stupidity tax free, yay! Dozens of more hours were thrown away trying to understand how HSA accounts work, what I can charge to the HSA account and picking a bank to handle the HSA account. Totally agree with you on this one. It's pretty confusing to say the least.

turk73 7y ago

UnitedHealth Group’s second-quarter 2019 revenues grew $4.5 billion, or 8.0 percent year-over-year, to $60.6 billion, led by double-digit percentage revenue growth at UnitedHealthcare Medicare & Retirement, OptumRx and OptumHealth. Second-quarter earnings from operations grew 12.8 percent, or $540 million year-over-year, to $4.7 billion. Adjusted net earnings of $3.60 per share advanced 14.6 percent.