10 ms·

For Her Head Cold, Insurer Coughed Up $25,865

98 points by the_mitsuhiko 7y ago

arbitrage 7y ago
This is insurance fraud and abuse. Over-billing is very common in the American medical world. As long as there is no oversite, nor competition, it will continue and grow worse over time.
- tcbawo 7y ago
  Speaking of competition, it would be interesting if the major political parties competed on improving results instead of sabotaging results or preventing the other side from getting a win. Both parties have symbiotic relationships with profiteers that stifle progress and innovation.
  - saas_sam 7y ago
    Trump signed an exec order* (thx for correction folks!) requiring hospitals to dramatically improve price transparency for patients. A huge win. But of course you'll never hear much about it for obvious reasons.
    - Operyl 7y ago
      Because I wouldn't call that bill something Trump "made." It was something both parties in Congress worked on, all Trump did was sign it.
    - everdrive 7y ago
      >But of course you'll never hear much about it for obvious reasons. I heard all about this, and so did lots of people. It was as well covered as anything is these days.
    - tptacek 7y ago
      First, no he didn't. He issued an EO directing CMS to implement the rule, which doesn't go into effect until 2021 and is facing pretty significant legal challenges. The fact that it's an EO and not a bill is likely part of the reason why its vulnerable to lawsuits. Second, health care experts don't seem to think much of the new rules, since there's little evidence anyone price shops for care, especially since, regardless of published prices, they're not the ones paying for them; they pay indirectly, through premiums. I think price transparency is a good thing and the rule is a good thing, but I don't think this is "huge". Third, the "obvious reasons" snark at the end of your comment poisons what would otherwise have been a valuable contribution to the thread.
      - saas_sam 7y ago
        It wasn't snark it was a direct agreement with the comment I was replying to. That last bit ruined your otherwise okay contribution. (Have you had a lot of coffee today? Have less.)
    - sykick 7y ago
      It is neither a big win nor a great improvement. At the time of need of essential goods/services price transparency is not as helpful as you make it seem. The American health system is so complex, has so many competing interests, and so many negative externalities that I doubt any one new regulation can be anything more than superficially beneficial to patients. I suggest the obvious reason this new regulation doesn’t get as much press attention as you’d like has less to do with Trump and more to do with its futility.
- shantly 7y ago
  Are insurance companies' take of the pie still defined as a percentage of total spending? If so, they have little reason not to look the other way, especially if fighting the problem in a systemic fashion (rather than just every now and then, or when someone notices and says something) would be tough and expensive and wouldn't be likely to capture its benefits for them in particular (rather than spreading out the benefits over "defector" insurers who don't bother to work on enforcement, too).
  - OnlineCourage 7y ago
    No, the ACA maxes out total profit payers can take home at 15% for large groups and 20% for small groups respectively throughout a year, so it's not a commission based system like you are imagining. There are severe penalties for improper billing including prison. No one likes insurance, but HMOs are not at fault here, it was due to overcomplexity and lack of regulation within private practice.
    - shantly 7y ago
      So higher medical spending does not let them make greater profits?
      - OnlineCourage 7y ago
        No, because there are extreme penalties and disincentives to overbill. Also, payers are not strictly payers in the US, they are what is known as HMOs, they are incentivized to bring healthcare costs down or at least slow the rise. Healthcare costs will inevitably rise in the US however, as labor is scarce, practioners are scarce, people are increasingly unhealthy and older...we are in for a massive healthcare cost spike due to economic conditions and blaming HMOs is emotional and politician inspired at best. Its like blaming insurance companies for a rise in car crashes.
        shantly 7y ago
        Ah, pretty sure I've never been under nor been close to anyone under an HMO so I'm not familiar with how those operate. Given how common stuff like in TFA is, plus so much more on smaller and less eye-popping scales, and seeming endless ability for providers to say "oops our bad now it's fixed" when caught and avoid punishment, I'm skeptical that these extreme penalties kick in often enough to counteract incentives to let prices creep higher. [EDIT] from my personal experience, it's mostly up to individuals to burn tons of time investigating irregularities and escalate them to elected officials & regulators when insurers or providers dig in their heels, to which the officials' and regulators' response is usually a strongly worded letter that makes your particular problem go away, with no follow up, presumably because pursuing it will be difficult, expensive, and unlikely to yield results that help anyone with their next election or promotion. That's kinda how it looks like this one's going, in fact, though maybe there'll be some regulatory follow-up with something resembling teeth, since it got press. It's like the Twitter-complaint model of customer support, but way worse.
- FireBeyond 7y ago
  Similar to Diagnostic Imaging - firms will aggressively market MRI/CT/PET ownership/co-ownership schemes to physicians, which become a license to print money very quickly. Such doctors who participate in schemes, entirely unsurprisingly, order multiple standard deviations above their expected imaging needs.
- cabaalis 7y ago
  I think you should assume incompetence instead of malice. > Fathollahi, the Manhattan Specialty Care physician, didn't answer our questions about the bill. Neither did Dr. Shawn Khodadadian, listed in state records as the CEO of Manhattan Gastroenterology. Because they CAN'T. Why didn't NPR publish their response, which is likely along the lines of how they are forbidden to discuss patient charges and procedures? It's far more likely this was a mistake that will end up costing the doctor 25k when the insurance company hires someone who checks for things like this, which they will.
  - deleted 7y ago
    [deleted]
xenospn 7y ago
Can you imagine if Amazon never let you choose how they deliver your orders and purposely decided to charter a commercial jet to route your package though Antarctica? Because thats basically what happened here.
- shantly 7y ago
  No part of medical billing whatsoever would fly most anywhere else. It's batshit crazy, top to bottom. Go get service at one place, get fifteen damn bills from five people & companies spread out over three months plus a pile of mail that looks like bills but may say it's not a bill, and then several will have errors requiring back & forth to correct, you'll get a refund then have to pay more, pay more then get a refund, all kinds of nonsense, you're acting as a go-between for insurance and the providers because they're all friggin' incompetent and that means hours and hours on hold, finally six months later it's all settled but you're guaranteed to have missed something in all that mess and now you've got a letter from a collection agency for a $48 bill out of thousands paid. Fuck the whole thing, I hope it all burns to the ground. It makes me so very unhappy every time I have to deal with it.
  - OnlineCourage 7y ago
    Sir, you are choking and dying would you like the premium $500 intubation tube or the discount $10 one? Oh thats riiiight he cant talk lets just assume he values his life and give him the good one. Oh, sincere apologies about not trying to save you money.
    - shantly 7y ago
      Yes this is exactly what dealing with medical billing is like and why it's awful, and not a non-sequitur.
      - OnlineCourage 7y ago
        It's awful that you have access to a premium life saving service which gets better every year, beyond the immagination of years prior? Or is it awful that the price for said service is high? What exactly is awful to you?
peter303 7y ago
The largest HMO in the US billed medicare $90 for a flu shot. A drug store would have done so for $19 without insurance.
- cmpolis 7y ago
  The system is broken. I think a fundamental issue is that insurance is not really insurance - it is used to cover routine, expected things such as a flu shot (while increasing cost for these and adding complexity, bureaucracy, middlemen). E.g. car insurance does not cover oil changes and home insurance does not cover getting the gutters cleaned - they're there for major events.
- michael_j_ward 7y ago
  Whenever you fill a prescription at your pharmacy, ask what that cash price for the drugs would be. Frequently at my local CVS, they have "coupons" available to cash buyers that makes the cost less than my copayment.
seibelj 7y ago
> Jim McManus, director of public relations for BCBS of Minnesota, says the company has a process to flag excessive charges. "Unfortunately, those necessary reviews did not happen in this case," he wrote in an email. The reason it wasn't flagged is that both the insurer and the provider are incentivized to make this as expensive as possible. Insurers cannot make more than 10% in profit, so if they want to make an extra $1000, they need to take in $10,000. Next, providers are paid fee-for-service, so they want to bill as many services as possible and charge the highest rate for each one. Ultimately our insurance premiums go up to cover this, but the whole thing is a racket. And single payer will not solve this. All we do is subsidize demand and decrease supply in a never ending fashion in the medical industry. We need to 1) Make it easier to supply services (allow doctors to be imported from other countries, easier to start facilities, allow people with less credentials than an MD to perform services) and 2) Stop subsidizing demand (Medicare for All = Use as much as you want). My ideal health insurance model is catastrophic insurance provided by the government for any bills over $50,000, Health Savings Accounts to allow you to save for procedures beneath 50k, and a total free-for-all of insurance companies beneath the 50k mark. This would radically reduce insurance rates while preventing people from becoming bankrupt. Catastrophic insurance covers you from cancer and being hit by a bus, but for 99% of all health issues the bill would not exceed that.
- sharkmerry 7y ago
  Doesnt single payer "solve" this by having negotiating power. As a provider, You can choose not to take it but you are keeping yourself out of 95% of the market.
  - seibelj 7y ago
    Medical care is a product like any other. When it's 100% free, you have no disincentive to use it. Unfortunately, there is not a single thing in the economy that is immune from the laws of supply and demand. So if you want to have the government pay 100% of all medical bills and do nothing to prevent using it, you'll have never-ending increases is costs.
    - 7y ago
rayhendricks 7y ago
How is this different than the scam where they charge you $300 for what would usually be a $30 dinner? We need to socialize the healthcare in the USA and put a stop to this crazy billing practices. (Maybe send a few execs to jail too) Canada really has the right idea here, as even if you are making $bank here, you can be fired for any reason/no reason and health insurance will end. IMO this is by design, as it is much more difficult to leave a job if insurance will end.
- sillysaurusx 7y ago
  Why is that a good thing? That sounds similar to indentured servitude. EDIT: I misread the “here” as “Canada”. The US healthcare system has caused me some personal hardships, so I was surprised Canada had something similar. Luckily it’s more sensible.
  - ska 7y ago
    Why is what a good thing?
    - rayhendricks 7y ago
      I was referring to the non-transferability of health insurance in the USA; e.g. you get fired at Microsoft or anywhere with great healthcare and that is only extendable temporarily via COBRA. Then you either have to find another job or get insurance through one of the Obamacare exchanges. What I am arguing is that this reduces the mobility of labor. Also as someone who has switched jobs in the last year setting up new insurance/dentist/optometrist multiple times is a absolute waste of my time and would be entirely eliminated if we stopped tying insurance to the employer.
      - shantly 7y ago
        Our current system puts a huge time burden on healthcare "consumers" despite being vastly more expensive than any remotely similarly-effective system. This time burden falls largely, though not entirely, on the sick and their families. It's straight-up inhumane, given it's clearly not necessary.
jonplackett 7y ago
But socialised medicine is insane, right? It says that the bill was 20X more expensive than it shouldn’t have been. I can’t even imagine having to pay that when I go to the doctor. The NHS isn’t perfect, but it’s damn good.
- sp332 7y ago
  Why would this be different under socialized medicine? A doctor can lie to a government agency as easily as lying to a private company.
  - BookmarkSaver 7y ago
    Reading the article, the trick here is exploiting a loophole that exists specifically within private healthcare. The doctor part owns/is associated with an "out-of-network" lab where the tests were sent. Healthcare providers have default listings which are typically outrageously high, and negotiate with insurers for their "actual" rates. But by the in-network doctor quietly sending the tests "out-of-network", the insurer could be charged the outrageous fee. With single payer, the price is the price. No bullshit, shady multilateral private negotiations in a marketplace where people's health is what is being wagered.
- OnlineCourage 7y ago
  We already have socialized medicine in the US and you can go ahead and compare average billing rates to calculate the insanity ratio by using Medicare and VA.
EamonnMR 7y ago
This is fraud, they where fleecing the insurance company and the patient just went along for the ride. The whole point of insurance companies is that they are supposed to be motivated by their own financial interest to fight against schemes like this, so it's shocking that they paid up.
- OnlineCourage 7y ago
  Billing is done largely manually, there is a lot of room for human error.
  - wyldfire 7y ago
    No way, this was totally deliberate fraud. The physician likely included all of the accompanying diagnostic codes for ultra rare/serious symptoms/history so it wouldn't get rejected by the insurer. Plus when asked for an explanation by the reporter they didn't opt to fessing up to a mistake or explain why the charge was necessary: they offered no comment whatsoever. Their fraud relies on insured patients not reading EOBs (because many of us don't).
    - OnlineCourage 7y ago
      Fraud on the part of the practice, yes possible. The parent comment seems to imply the payer is at fault or committing fraud.
      - EamonnMR 7y ago
        I thought it was obvious so I didn't spell it out, but yes this is the practice defrauding the insurer.
- lsaferite 7y ago
  Did you read the full article by chance? Saying 'the patient just went along for the ride' insinuates that the patient was complicit when in reality the patient reported the whole incident themselves after they received the bills. They did this even though they didn't have to pay anything. And they told the provider they were going to report them. > "I made it very clear [to the doctor's office] that I was unhappy about it," Kasdan says. In fact, she told them she would report the doctor to New York state's Office of Professional Medical Conduct. > Kasdan says she was not told that the throat swab was being sent out of network at the time of her appointment, though it's possible one of the many papers she signed included a broad caveat that some services might not be in network.
avocado4 7y ago
All non-emergency medical bills should be legally null. That is, if you go to a doctor's office, they can try to collect payment upfront, but if they send you a random bill after the fact without your explicit price consent, it doesn't have to be paid. Similarly to how I can send a bill to y'all for the privilege of reading my post (and justify by saying it took me years of expensive training to obtain this knowledge), but you shouldn't be required to actually pay me, of course. Emergency medicine OTOH should be socialized - everybody is covered in the US by Medicare. For every emergency admission facility can charge Medicare for all up to $X (say $300 in Kansas and $500 in San Francisco) and have to make do with that money. Patient gets between 0% and 30% copay depending on whether they are trying to abuse the system or came with a legit reason. This is the same as Kaiser today, but on a National scale.
- akvadrako 7y ago
  The problem with emergency care being free and non-emergency being paid is that people will try to make things into emergencies and it discourages preventative care. But we do need upfront pricing. It should be mandatory in non-emergency situations.
jonplackett 7y ago
It’s weird how the argument in America is always socialised healthcare VS private healthcare. Rather than people just demanding non-insane private healthcare. I have private healthcare here in the UK through work and it costs £150 a month to add my wife too, for one of the best plans around.
- tux1968 7y ago
  Could it be because it has to compete with the public option, or at least stand up to comparison with it?
  - jonplackett 7y ago
    Exactly! Competition is what makes capitalism work, otherwise you just have a monopoly and then everything turns to crap real quick. We have a similar problem in a way with our trains. They’ve all been ‘privatised’ but if only one train company runs your route there can’t be any competition, so our trains suck big time and are really expensive.
    - lordnacho 7y ago
      Not only that, there's also only one Network Rail doing the maintenance. So the local monopoly on passengers relies on another monopoly. End result is it costs upwards of £4k for an annual pass for a half hour train journey. Add to that the fact that nobody would ever allow the trains to cease operating, and you have a really big question mark over what the point of privatizing was?
      - hogFeast 7y ago
        Do you understand what they were like when they were public? Costs have fallen dramatically, prices are actually way down, the govt subsidy is down (although will rise again with HS2), and service quality/output is up. We know this doesn't work because we tried it and it didn't work.
TYPE_FASTER 7y ago
I’ve been wondering why coverage costs to employers have been increasing, this could be an example of a cause if it happens frequently.
vladletter 7y ago
Ha. America.
- deleted 7y ago
vladletter 7y ago
Ha. American Health Care. :(
annoyingnoob 7y ago
And rates are going up for everyone.
pbreit 7y ago
It's not always clear to be in these types of stories if the money actually changed hands. Just because it was invoiced, doesn't mean that's actually what was transacted.
nickik 7y ago
The US healthcare system is just fundamentally broken. Its not even about private or public. Even if they made it public, it would probably still be far and a away the most expensive system in the world. People who believe that making it public will massively lower the cost because other socialized systems are cheaper are up for a rude awakening. No matter in what direction the US system evolved those problems need some amount of addressing and those questions are more practically important then the question about public or not.
- OnlineCourage 7y ago
  That's a hypothesis and you have presented zero evidence to back up your very abstract claim.
avocado4 7y ago
Remember folks, physicians are the root of the problem. Don't let anybody fool you into thinking otherwise. It's easier politically to blame corporations and whatnot. And it's true - there's plenty of leeching downstream by pharmas, PBMs, hospital admins, device makers, insurance companies, vendors, labs, and many others. But at the base of the supply funnel sit the doctors (and numerous associations like AMA, ACR, ABP, AHA, AAMC, etc) who control the entire supply through licensing and state-level regulations, and are entirely responsible for all of the atrocities. It's effectively a cartel. There's a reason why any time there's a talk about pro-consumer regulation on the Hill like anti-surprise billing, pro-price transparency, and Medicare for All, each of these association is blasting their members with calls to contact their representatives and resist at all cost. Their argument is easy to understand emotionally - doctors will protect you from the harm, and hence there should be more licensing and supply restrictions. But this is the root of all problems in US healthcare.
- avocado4 7y ago
  Here's a couple sources https://www.usnews.com/news/health-news/articles/2019-07-03/california-doctors-oppose-expanding-nurse-practitioner-authorities https://www.usnews.com/news/health-news/articles/2019-07-03/... Amid Provider Shortage, California Doctors Oppose Expanding Nurse Practitioner Abilities https://thedo.osteopathic.org/2018/10/dos-help-defeat-bills-that-seek-to-cut-doctors-out-of-health-care/ https://thedo.osteopathic.org/2018/10/dos-help-defeat-bills-... As APRNs and nurse-midwives ramp up their efforts to practice independently, DOs are fighting back. https://www.kcur.org/post/nurse-practitioners-try-shake-free-doctors-kansas-physicians-resist#stream/0 https://www.kcur.org/post/nurse-practitioners-try-shake-free... As Nurse Practitioners Try To Shake Free Of Doctors, Kansas Physicians Resist https://www.wabe.org/bid-to-loosen-rules-on-mid-level-providers-draws-legislative-debate/ https://www.wabe.org/bid-to-loosen-rules-on-mid-level-provid... But the vote for recommending the imaging change was 3-2 in favor, with two physicians on the panel, Sens. Ben Watson (R-Savannah) and Kay Kirkpatrick (R-Marietta), voting against. https://www.aei.org/carpe-diem/whod-a-thunk-it-a-medical-cartel-doesnt-like-competition/ https://www.aei.org/carpe-diem/whod-a-thunk-it-a-medical-car... the American Academy of Pediatrics declared that retail health clinics are “an inappropriate source of primary care for pediatric patients, as they fragment medical care and are detrimental to the medical home concept of longitudinal and coordinated care.” https://www.politico.com/agenda/story/2017/10/25/doctors-salaries-pay-disparities-000557 https://www.politico.com/agenda/story/2017/10/25/doctors-sal... https://fee.org/articles/the-medical-cartel-is-keeping-health-care-costs-high/ https://fee.org/articles/the-medical-cartel-is-keeping-healt... https://www.modernhealthcare.com/patients/surprise-medical-bills-becoming-more-frequent-and-costly https://www.modernhealthcare.com/patients/surprise-medical-b... Stanford University researchers found that from 2010 through 2016, 39% of 13.6 million trips to the ED at an in-network hospital by privately insured patients resulted in an out-of-network bill. That figure increased during the study period from about a third of ED visits nationwide in 2010 to 42.8% in 2016. https://www.npr.org/sections/health-shots/2019/12/23/787403509/for-her-head-cold-insurer-coughed-up-25-865 https://www.npr.org/sections/health-shots/2019/12/23/7874035... https://www.medscape.com/viewarticle/922816 https://www.medscape.com/viewarticle/922816 More Than Half of Doctors Get Industry Payments/Meals: Poll https://revcycleintelligence.com/news/aha-others-to-sue-hhs-over-new-hospital-price-transparency-rule https://revcycleintelligence.com/news/aha-others-to-sue-hhs-... AHA, Others to Sue HHS Over New Hospital Price Transparency Rule
Gatsky 7y ago
By way of comparison, that exact same throat swab test - which some professor was trying to say was excessive - is available at no charge to the patient in Australia, and there are no 'out of network' labs. I don't know how this nonsense isn't the number one election issue in the USA. Instead everyone just puts up with it.
- wyldfire 7y ago
  It's a good point but the amount and payer for coverage is independent of the fraud that happened here.
- AdrianB1 7y ago
  The comparison is meaningless: the patient did not pay anything in this case, but the cost is astronomical, the problem is with the cost not with who is paying. By the way of comparison, I just paid approximately $25 for a bit simple test (bacteria, not virii, but it included sensibility to antibiotics) in Europe last week. Out of the pocket, waiting weeks for the free public system was too much to be effective.
  - Gatsky 7y ago
    The article tries to make the sub-point that the swab was somehow an excessive test - I was trying to highlight that this is not the case, which makes the overcharging even more egregious. Also to clarify, in Australia there is no cost to anyone with permanent residency status, whether they are insured or not.
    - AdrianB1 7y ago
      I now understand what was your point. Also to clarify, there is no cost for anyone (EU residents) here too if you use the public health system, but if you cannot wait till you're dead then you can use the (optional) private system and pay for that.
  - xenospn 7y ago
    Last time I went to Slovenia I got strep throat. I went to the public doctor, on a Sunday, waited about 25 minutes and got a throat swab and a prescription for $14. And I was a tourist!
imgabe 7y ago
> The third reason for the high bill may be the connection between the lab and Kasdan's doctor. Kasdan's bill shows that the lab service was provided by Manhattan Gastroenterology, which has the same phone number and locations as her doctor's office. They really buried the lede there. This sounds like fraud. She went to her doctor, who, I'm guessing, is in-network since the article says he was her primary care physician. The doctor operates a lab that is not in same network he operates his practice in? Is that some kind of coincidence? Is there any other reason for that except to bilk money out of the insurance company?
avocado4 7y ago
https://www.manhattanspecialtycare.com/doctors/internist/ https://www.manhattanspecialtycare.com/doctors/internist/ Roya Fathollahi, MD Report her to the NY Medical Board and Department of Financial Services https://www.health.ny.gov/professionals/doctors/conduct/file_a_complaint.htm https://www.health.ny.gov/professionals/doctors/conduct/file... https://www.dfs.ny.gov/consumers/health_insurance/surprise_medical_bills https://www.dfs.ny.gov/consumers/health_insurance/surprise_m...
Meekro 7y ago
Writing good rules to prevent this stuff is hard. Insurers have to create networks so they can negotiate fair rates with doctors and hospitals. These rates often end up being more than medicare would have paid, but not wildly more. Sounds pretty fair. But what to do if the patient goes to an out-of-network doctor? Insurance might say "we won't pay unless it was an emergency," but then the patient gets stuck with a $30k bill. He'll get angry, tell the media, write his Congressman, etc. Somehow the blame will always fall on the insurer (who had no way to prevent this from happening) and not the doctor (who was engaged in price gouging.) Or maybe the insurer can say "we'll only pay the same rate we would have paid an in-network provider." No problem, says the doctor-- we have the patient's signature on this huge contract that says we can bill them for the remainder. Now the patient gets a $29.5k bill instead of a $30k bill. Still no good. I'd love to say "just socialize medicine and be done with it", but this worries me too. The US already runs two 100% socialized healthcare systems: the VA for veterans, and IHS for Native Americans. Both are absolute nightmares where people sometimes wait years to see a barely-competent doctor. Many IHS doctors only work there because no private hospital would hire them[1]. I'm not sure what a good solution looks like. [1] https://www.pbs.org/wgbh/frontline/article/u-s-indian-health-service-gave-troubled-doctors-second-chance-patients-paid-price/ https://www.pbs.org/wgbh/frontline/article/u-s-indian-health...
- imgabe 7y ago
  Is it hard? Just eliminate insurance networks. Healthcare providers can set whatever prices they want for procedures. But, they must offer the same price to all customers. Insurance, medicare, cash, whatever. They must also publish the prices publicly. That would put a swift end to this nonsense.
wyldfire 7y ago
NPR has to be responsible journalists but we can call a spade a spade: this is insurance fraud, plain and simple. All of the noise in this thread about healthcare system in the US is a good discussion but arguably unrelated to the bill in question. Single payer government run plans can be defrauded too.
jmpman 7y ago
Why isn’t the doctor disbarred for this? It’s an ethics violation, and likely not the first.
hc91 7y ago
US people, you might already be fully aware of this but your medical system is completely totally utterly fucked if shit like this is even possible. Sort your shit out and come back amongst the civilised countries [from the healthcare services point of view]!
- dang 7y ago
  Could you please stop posting unsubstantive comments to Hacker News? You've been doing it repeatedly, and we ban such accounts. The site guidelines explain the intended use of the site: https://news.ycombinator.com/newsguidelines.html https://news.ycombinator.com/newsguidelines.html.

98 points by the_mitsuhiko 7y ago

This is insurance fraud and abuse. Over-billing is very common in the American medical world. As long as there is no oversite, nor competition, it will continue and grow worse over time.

tcbawo 7y ago
Speaking of competition, it would be interesting if the major political parties competed on improving results instead of sabotaging results or preventing the other side from getting a win. Both parties have symbiotic relationships with profiteers that stifle progress and innovation.
- saas_sam 7y ago
  Trump signed an exec order* (thx for correction folks!) requiring hospitals to dramatically improve price transparency for patients. A huge win. But of course you'll never hear much about it for obvious reasons.
  - Operyl 7y ago
    Because I wouldn't call that bill something Trump "made." It was something both parties in Congress worked on, all Trump did was sign it.
  - everdrive 7y ago
    >But of course you'll never hear much about it for obvious reasons. I heard all about this, and so did lots of people. It was as well covered as anything is these days.
  - tptacek 7y ago
    First, no he didn't. He issued an EO directing CMS to implement the rule, which doesn't go into effect until 2021 and is facing pretty significant legal challenges. The fact that it's an EO and not a bill is likely part of the reason why its vulnerable to lawsuits. Second, health care experts don't seem to think much of the new rules, since there's little evidence anyone price shops for care, especially since, regardless of published prices, they're not the ones paying for them; they pay indirectly, through premiums. I think price transparency is a good thing and the rule is a good thing, but I don't think this is "huge". Third, the "obvious reasons" snark at the end of your comment poisons what would otherwise have been a valuable contribution to the thread.
    - saas_sam 7y ago
      It wasn't snark it was a direct agreement with the comment I was replying to. That last bit ruined your otherwise okay contribution. (Have you had a lot of coffee today? Have less.)
  - sykick 7y ago
    It is neither a big win nor a great improvement. At the time of need of essential goods/services price transparency is not as helpful as you make it seem. The American health system is so complex, has so many competing interests, and so many negative externalities that I doubt any one new regulation can be anything more than superficially beneficial to patients. I suggest the obvious reason this new regulation doesn’t get as much press attention as you’d like has less to do with Trump and more to do with its futility.
shantly 7y ago
Are insurance companies' take of the pie still defined as a percentage of total spending? If so, they have little reason not to look the other way, especially if fighting the problem in a systemic fashion (rather than just every now and then, or when someone notices and says something) would be tough and expensive and wouldn't be likely to capture its benefits for them in particular (rather than spreading out the benefits over "defector" insurers who don't bother to work on enforcement, too).
- OnlineCourage 7y ago
  No, the ACA maxes out total profit payers can take home at 15% for large groups and 20% for small groups respectively throughout a year, so it's not a commission based system like you are imagining. There are severe penalties for improper billing including prison. No one likes insurance, but HMOs are not at fault here, it was due to overcomplexity and lack of regulation within private practice.
  - shantly 7y ago
    So higher medical spending does not let them make greater profits?
    - OnlineCourage 7y ago
      No, because there are extreme penalties and disincentives to overbill. Also, payers are not strictly payers in the US, they are what is known as HMOs, they are incentivized to bring healthcare costs down or at least slow the rise. Healthcare costs will inevitably rise in the US however, as labor is scarce, practioners are scarce, people are increasingly unhealthy and older...we are in for a massive healthcare cost spike due to economic conditions and blaming HMOs is emotional and politician inspired at best. Its like blaming insurance companies for a rise in car crashes.
      - shantly 7y ago
        Ah, pretty sure I've never been under nor been close to anyone under an HMO so I'm not familiar with how those operate. Given how common stuff like in TFA is, plus so much more on smaller and less eye-popping scales, and seeming endless ability for providers to say "oops our bad now it's fixed" when caught and avoid punishment, I'm skeptical that these extreme penalties kick in often enough to counteract incentives to let prices creep higher. [EDIT] from my personal experience, it's mostly up to individuals to burn tons of time investigating irregularities and escalate them to elected officials & regulators when insurers or providers dig in their heels, to which the officials' and regulators' response is usually a strongly worded letter that makes your particular problem go away, with no follow up, presumably because pursuing it will be difficult, expensive, and unlikely to yield results that help anyone with their next election or promotion. That's kinda how it looks like this one's going, in fact, though maybe there'll be some regulatory follow-up with something resembling teeth, since it got press. It's like the Twitter-complaint model of customer support, but way worse.
FireBeyond 7y ago
Similar to Diagnostic Imaging - firms will aggressively market MRI/CT/PET ownership/co-ownership schemes to physicians, which become a license to print money very quickly. Such doctors who participate in schemes, entirely unsurprisingly, order multiple standard deviations above their expected imaging needs.
cabaalis 7y ago
I think you should assume incompetence instead of malice. > Fathollahi, the Manhattan Specialty Care physician, didn't answer our questions about the bill. Neither did Dr. Shawn Khodadadian, listed in state records as the CEO of Manhattan Gastroenterology. Because they CAN'T. Why didn't NPR publish their response, which is likely along the lines of how they are forbidden to discuss patient charges and procedures? It's far more likely this was a mistake that will end up costing the doctor 25k when the insurance company hires someone who checks for things like this, which they will.
- deleted 7y ago
  [deleted]

xenospn 7y ago

Can you imagine if Amazon never let you choose how they deliver your orders and purposely decided to charter a commercial jet to route your package though Antarctica? Because thats basically what happened here.

shantly 7y ago
No part of medical billing whatsoever would fly most anywhere else. It's batshit crazy, top to bottom. Go get service at one place, get fifteen damn bills from five people & companies spread out over three months plus a pile of mail that looks like bills but may say it's not a bill, and then several will have errors requiring back & forth to correct, you'll get a refund then have to pay more, pay more then get a refund, all kinds of nonsense, you're acting as a go-between for insurance and the providers because they're all friggin' incompetent and that means hours and hours on hold, finally six months later it's all settled but you're guaranteed to have missed something in all that mess and now you've got a letter from a collection agency for a $48 bill out of thousands paid. Fuck the whole thing, I hope it all burns to the ground. It makes me so very unhappy every time I have to deal with it.
- OnlineCourage 7y ago
  Sir, you are choking and dying would you like the premium $500 intubation tube or the discount $10 one? Oh thats riiiight he cant talk lets just assume he values his life and give him the good one. Oh, sincere apologies about not trying to save you money.
  - shantly 7y ago
    Yes this is exactly what dealing with medical billing is like and why it's awful, and not a non-sequitur.
    - OnlineCourage 7y ago
      It's awful that you have access to a premium life saving service which gets better every year, beyond the immagination of years prior? Or is it awful that the price for said service is high? What exactly is awful to you?

peter303 7y ago

The largest HMO in the US billed medicare $90 for a flu shot. A drug store would have done so for $19 without insurance.

cmpolis 7y ago
The system is broken. I think a fundamental issue is that insurance is not really insurance - it is used to cover routine, expected things such as a flu shot (while increasing cost for these and adding complexity, bureaucracy, middlemen). E.g. car insurance does not cover oil changes and home insurance does not cover getting the gutters cleaned - they're there for major events.
michael_j_ward 7y ago
Whenever you fill a prescription at your pharmacy, ask what that cash price for the drugs would be. Frequently at my local CVS, they have "coupons" available to cash buyers that makes the cost less than my copayment.

seibelj 7y ago

> Jim McManus, director of public relations for BCBS of Minnesota, says the company has a process to flag excessive charges. "Unfortunately, those necessary reviews did not happen in this case," he wrote in an email. The reason it wasn't flagged is that both the insurer and the provider are incentivized to make this as expensive as possible. Insurers cannot make more than 10% in profit, so if they want to make an extra $1000, they need to take in $10,000. Next, providers are paid fee-for-service, so they want to bill as many services as possible and charge the highest rate for each one. Ultimately our insurance premiums go up to cover this, but the whole thing is a racket. And single payer will not solve this. All we do is subsidize demand and decrease supply in a never ending fashion in the medical industry. We need to 1) Make it easier to supply services (allow doctors to be imported from other countries, easier to start facilities, allow people with less credentials than an MD to perform services) and 2) Stop subsidizing demand (Medicare for All = Use as much as you want). My ideal health insurance model is catastrophic insurance provided by the government for any bills over $50,000, Health Savings Accounts to allow you to save for procedures beneath 50k, and a total free-for-all of insurance companies beneath the 50k mark. This would radically reduce insurance rates while preventing people from becoming bankrupt. Catastrophic insurance covers you from cancer and being hit by a bus, but for 99% of all health issues the bill would not exceed that.

sharkmerry 7y ago
Doesnt single payer "solve" this by having negotiating power. As a provider, You can choose not to take it but you are keeping yourself out of 95% of the market.
- seibelj 7y ago
  Medical care is a product like any other. When it's 100% free, you have no disincentive to use it. Unfortunately, there is not a single thing in the economy that is immune from the laws of supply and demand. So if you want to have the government pay 100% of all medical bills and do nothing to prevent using it, you'll have never-ending increases is costs.
  - 7y ago

rayhendricks 7y ago

How is this different than the scam where they charge you $300 for what would usually be a $30 dinner? We need to socialize the healthcare in the USA and put a stop to this crazy billing practices. (Maybe send a few execs to jail too) Canada really has the right idea here, as even if you are making $bank here, you can be fired for any reason/no reason and health insurance will end. IMO this is by design, as it is much more difficult to leave a job if insurance will end.

sillysaurusx 7y ago
Why is that a good thing? That sounds similar to indentured servitude. EDIT: I misread the “here” as “Canada”. The US healthcare system has caused me some personal hardships, so I was surprised Canada had something similar. Luckily it’s more sensible.
- ska 7y ago
  Why is what a good thing?
  - rayhendricks 7y ago
    I was referring to the non-transferability of health insurance in the USA; e.g. you get fired at Microsoft or anywhere with great healthcare and that is only extendable temporarily via COBRA. Then you either have to find another job or get insurance through one of the Obamacare exchanges. What I am arguing is that this reduces the mobility of labor. Also as someone who has switched jobs in the last year setting up new insurance/dentist/optometrist multiple times is a absolute waste of my time and would be entirely eliminated if we stopped tying insurance to the employer.
    - shantly 7y ago
      Our current system puts a huge time burden on healthcare "consumers" despite being vastly more expensive than any remotely similarly-effective system. This time burden falls largely, though not entirely, on the sick and their families. It's straight-up inhumane, given it's clearly not necessary.

jonplackett 7y ago

But socialised medicine is insane, right? It says that the bill was 20X more expensive than it shouldn’t have been. I can’t even imagine having to pay that when I go to the doctor. The NHS isn’t perfect, but it’s damn good.

sp332 7y ago
Why would this be different under socialized medicine? A doctor can lie to a government agency as easily as lying to a private company.
- BookmarkSaver 7y ago
  Reading the article, the trick here is exploiting a loophole that exists specifically within private healthcare. The doctor part owns/is associated with an "out-of-network" lab where the tests were sent. Healthcare providers have default listings which are typically outrageously high, and negotiate with insurers for their "actual" rates. But by the in-network doctor quietly sending the tests "out-of-network", the insurer could be charged the outrageous fee. With single payer, the price is the price. No bullshit, shady multilateral private negotiations in a marketplace where people's health is what is being wagered.
OnlineCourage 7y ago
We already have socialized medicine in the US and you can go ahead and compare average billing rates to calculate the insanity ratio by using Medicare and VA.

EamonnMR 7y ago

This is fraud, they where fleecing the insurance company and the patient just went along for the ride. The whole point of insurance companies is that they are supposed to be motivated by their own financial interest to fight against schemes like this, so it's shocking that they paid up.

OnlineCourage 7y ago
Billing is done largely manually, there is a lot of room for human error.
- wyldfire 7y ago
  No way, this was totally deliberate fraud. The physician likely included all of the accompanying diagnostic codes for ultra rare/serious symptoms/history so it wouldn't get rejected by the insurer. Plus when asked for an explanation by the reporter they didn't opt to fessing up to a mistake or explain why the charge was necessary: they offered no comment whatsoever. Their fraud relies on insured patients not reading EOBs (because many of us don't).
  - OnlineCourage 7y ago
    Fraud on the part of the practice, yes possible. The parent comment seems to imply the payer is at fault or committing fraud.
    - EamonnMR 7y ago
      I thought it was obvious so I didn't spell it out, but yes this is the practice defrauding the insurer.
lsaferite 7y ago
Did you read the full article by chance? Saying 'the patient just went along for the ride' insinuates that the patient was complicit when in reality the patient reported the whole incident themselves after they received the bills. They did this even though they didn't have to pay anything. And they told the provider they were going to report them. > "I made it very clear [to the doctor's office] that I was unhappy about it," Kasdan says. In fact, she told them she would report the doctor to New York state's Office of Professional Medical Conduct. > Kasdan says she was not told that the throat swab was being sent out of network at the time of her appointment, though it's possible one of the many papers she signed included a broad caveat that some services might not be in network.

avocado4 7y ago

All non-emergency medical bills should be legally null. That is, if you go to a doctor's office, they can try to collect payment upfront, but if they send you a random bill after the fact without your explicit price consent, it doesn't have to be paid. Similarly to how I can send a bill to y'all for the privilege of reading my post (and justify by saying it took me years of expensive training to obtain this knowledge), but you shouldn't be required to actually pay me, of course. Emergency medicine OTOH should be socialized - everybody is covered in the US by Medicare. For every emergency admission facility can charge Medicare for all up to $X (say $300 in Kansas and $500 in San Francisco) and have to make do with that money. Patient gets between 0% and 30% copay depending on whether they are trying to abuse the system or came with a legit reason. This is the same as Kaiser today, but on a National scale.

akvadrako 7y ago
The problem with emergency care being free and non-emergency being paid is that people will try to make things into emergencies and it discourages preventative care. But we do need upfront pricing. It should be mandatory in non-emergency situations.

jonplackett 7y ago

It’s weird how the argument in America is always socialised healthcare VS private healthcare. Rather than people just demanding non-insane private healthcare. I have private healthcare here in the UK through work and it costs £150 a month to add my wife too, for one of the best plans around.

tux1968 7y ago
Could it be because it has to compete with the public option, or at least stand up to comparison with it?
- jonplackett 7y ago
  Exactly! Competition is what makes capitalism work, otherwise you just have a monopoly and then everything turns to crap real quick. We have a similar problem in a way with our trains. They’ve all been ‘privatised’ but if only one train company runs your route there can’t be any competition, so our trains suck big time and are really expensive.
  - lordnacho 7y ago
    Not only that, there's also only one Network Rail doing the maintenance. So the local monopoly on passengers relies on another monopoly. End result is it costs upwards of £4k for an annual pass for a half hour train journey. Add to that the fact that nobody would ever allow the trains to cease operating, and you have a really big question mark over what the point of privatizing was?
    - hogFeast 7y ago
      Do you understand what they were like when they were public? Costs have fallen dramatically, prices are actually way down, the govt subsidy is down (although will rise again with HS2), and service quality/output is up. We know this doesn't work because we tried it and it didn't work.

TYPE_FASTER 7y ago

I’ve been wondering why coverage costs to employers have been increasing, this could be an example of a cause if it happens frequently.

vladletter 7y ago

Ha. America.

deleted 7y ago

vladletter 7y ago

Ha. American Health Care. :(

annoyingnoob 7y ago

And rates are going up for everyone.

pbreit 7y ago

It's not always clear to be in these types of stories if the money actually changed hands. Just because it was invoiced, doesn't mean that's actually what was transacted.

nickik 7y ago

The US healthcare system is just fundamentally broken. Its not even about private or public. Even if they made it public, it would probably still be far and a away the most expensive system in the world. People who believe that making it public will massively lower the cost because other socialized systems are cheaper are up for a rude awakening. No matter in what direction the US system evolved those problems need some amount of addressing and those questions are more practically important then the question about public or not.

OnlineCourage 7y ago
That's a hypothesis and you have presented zero evidence to back up your very abstract claim.

avocado4 7y ago

Remember folks, physicians are the root of the problem. Don't let anybody fool you into thinking otherwise. It's easier politically to blame corporations and whatnot. And it's true - there's plenty of leeching downstream by pharmas, PBMs, hospital admins, device makers, insurance companies, vendors, labs, and many others. But at the base of the supply funnel sit the doctors (and numerous associations like AMA, ACR, ABP, AHA, AAMC, etc) who control the entire supply through licensing and state-level regulations, and are entirely responsible for all of the atrocities. It's effectively a cartel. There's a reason why any time there's a talk about pro-consumer regulation on the Hill like anti-surprise billing, pro-price transparency, and Medicare for All, each of these association is blasting their members with calls to contact their representatives and resist at all cost. Their argument is easy to understand emotionally - doctors will protect you from the harm, and hence there should be more licensing and supply restrictions. But this is the root of all problems in US healthcare.

avocado4 7y ago
Here's a couple sources https://www.usnews.com/news/health-news/articles/2019-07-03/california-doctors-oppose-expanding-nurse-practitioner-authorities https://www.usnews.com/news/health-news/articles/2019-07-03/... Amid Provider Shortage, California Doctors Oppose Expanding Nurse Practitioner Abilities https://thedo.osteopathic.org/2018/10/dos-help-defeat-bills-that-seek-to-cut-doctors-out-of-health-care/ https://thedo.osteopathic.org/2018/10/dos-help-defeat-bills-... As APRNs and nurse-midwives ramp up their efforts to practice independently, DOs are fighting back. https://www.kcur.org/post/nurse-practitioners-try-shake-free-doctors-kansas-physicians-resist#stream/0 https://www.kcur.org/post/nurse-practitioners-try-shake-free... As Nurse Practitioners Try To Shake Free Of Doctors, Kansas Physicians Resist https://www.wabe.org/bid-to-loosen-rules-on-mid-level-providers-draws-legislative-debate/ https://www.wabe.org/bid-to-loosen-rules-on-mid-level-provid... But the vote for recommending the imaging change was 3-2 in favor, with two physicians on the panel, Sens. Ben Watson (R-Savannah) and Kay Kirkpatrick (R-Marietta), voting against. https://www.aei.org/carpe-diem/whod-a-thunk-it-a-medical-cartel-doesnt-like-competition/ https://www.aei.org/carpe-diem/whod-a-thunk-it-a-medical-car... the American Academy of Pediatrics declared that retail health clinics are “an inappropriate source of primary care for pediatric patients, as they fragment medical care and are detrimental to the medical home concept of longitudinal and coordinated care.” https://www.politico.com/agenda/story/2017/10/25/doctors-salaries-pay-disparities-000557 https://www.politico.com/agenda/story/2017/10/25/doctors-sal... https://fee.org/articles/the-medical-cartel-is-keeping-health-care-costs-high/ https://fee.org/articles/the-medical-cartel-is-keeping-healt... https://www.modernhealthcare.com/patients/surprise-medical-bills-becoming-more-frequent-and-costly https://www.modernhealthcare.com/patients/surprise-medical-b... Stanford University researchers found that from 2010 through 2016, 39% of 13.6 million trips to the ED at an in-network hospital by privately insured patients resulted in an out-of-network bill. That figure increased during the study period from about a third of ED visits nationwide in 2010 to 42.8% in 2016. https://www.npr.org/sections/health-shots/2019/12/23/787403509/for-her-head-cold-insurer-coughed-up-25-865 https://www.npr.org/sections/health-shots/2019/12/23/7874035... https://www.medscape.com/viewarticle/922816 https://www.medscape.com/viewarticle/922816 More Than Half of Doctors Get Industry Payments/Meals: Poll https://revcycleintelligence.com/news/aha-others-to-sue-hhs-over-new-hospital-price-transparency-rule https://revcycleintelligence.com/news/aha-others-to-sue-hhs-... AHA, Others to Sue HHS Over New Hospital Price Transparency Rule

Gatsky 7y ago

By way of comparison, that exact same throat swab test - which some professor was trying to say was excessive - is available at no charge to the patient in Australia, and there are no 'out of network' labs. I don't know how this nonsense isn't the number one election issue in the USA. Instead everyone just puts up with it.

wyldfire 7y ago
It's a good point but the amount and payer for coverage is independent of the fraud that happened here.
AdrianB1 7y ago
The comparison is meaningless: the patient did not pay anything in this case, but the cost is astronomical, the problem is with the cost not with who is paying. By the way of comparison, I just paid approximately $25 for a bit simple test (bacteria, not virii, but it included sensibility to antibiotics) in Europe last week. Out of the pocket, waiting weeks for the free public system was too much to be effective.
- Gatsky 7y ago
  The article tries to make the sub-point that the swab was somehow an excessive test - I was trying to highlight that this is not the case, which makes the overcharging even more egregious. Also to clarify, in Australia there is no cost to anyone with permanent residency status, whether they are insured or not.
  - AdrianB1 7y ago
    I now understand what was your point. Also to clarify, there is no cost for anyone (EU residents) here too if you use the public health system, but if you cannot wait till you're dead then you can use the (optional) private system and pay for that.
- xenospn 7y ago
  Last time I went to Slovenia I got strep throat. I went to the public doctor, on a Sunday, waited about 25 minutes and got a throat swab and a prescription for $14. And I was a tourist!

imgabe 7y ago

> The third reason for the high bill may be the connection between the lab and Kasdan's doctor. Kasdan's bill shows that the lab service was provided by Manhattan Gastroenterology, which has the same phone number and locations as her doctor's office. They really buried the lede there. This sounds like fraud. She went to her doctor, who, I'm guessing, is in-network since the article says he was her primary care physician. The doctor operates a lab that is not in same network he operates his practice in? Is that some kind of coincidence? Is there any other reason for that except to bilk money out of the insurance company?

avocado4 7y ago

https://www.manhattanspecialtycare.com/doctors/internist/ https://www.manhattanspecialtycare.com/doctors/internist/ Roya Fathollahi, MD Report her to the NY Medical Board and Department of Financial Services https://www.health.ny.gov/professionals/doctors/conduct/file_a_complaint.htm https://www.health.ny.gov/professionals/doctors/conduct/file... https://www.dfs.ny.gov/consumers/health_insurance/surprise_medical_bills https://www.dfs.ny.gov/consumers/health_insurance/surprise_m...

Meekro 7y ago

Writing good rules to prevent this stuff is hard. Insurers have to create networks so they can negotiate fair rates with doctors and hospitals. These rates often end up being more than medicare would have paid, but not wildly more. Sounds pretty fair. But what to do if the patient goes to an out-of-network doctor? Insurance might say "we won't pay unless it was an emergency," but then the patient gets stuck with a $30k bill. He'll get angry, tell the media, write his Congressman, etc. Somehow the blame will always fall on the insurer (who had no way to prevent this from happening) and not the doctor (who was engaged in price gouging.) Or maybe the insurer can say "we'll only pay the same rate we would have paid an in-network provider." No problem, says the doctor-- we have the patient's signature on this huge contract that says we can bill them for the remainder. Now the patient gets a $29.5k bill instead of a $30k bill. Still no good. I'd love to say "just socialize medicine and be done with it", but this worries me too. The US already runs two 100% socialized healthcare systems: the VA for veterans, and IHS for Native Americans. Both are absolute nightmares where people sometimes wait years to see a barely-competent doctor. Many IHS doctors only work there because no private hospital would hire them[1]. I'm not sure what a good solution looks like. [1] https://www.pbs.org/wgbh/frontline/article/u-s-indian-health-service-gave-troubled-doctors-second-chance-patients-paid-price/ https://www.pbs.org/wgbh/frontline/article/u-s-indian-health...

imgabe 7y ago
Is it hard? Just eliminate insurance networks. Healthcare providers can set whatever prices they want for procedures. But, they must offer the same price to all customers. Insurance, medicare, cash, whatever. They must also publish the prices publicly. That would put a swift end to this nonsense.

wyldfire 7y ago

NPR has to be responsible journalists but we can call a spade a spade: this is insurance fraud, plain and simple. All of the noise in this thread about healthcare system in the US is a good discussion but arguably unrelated to the bill in question. Single payer government run plans can be defrauded too.

jmpman 7y ago

Why isn’t the doctor disbarred for this? It’s an ethics violation, and likely not the first.

hc91 7y ago

US people, you might already be fully aware of this but your medical system is completely totally utterly fucked if shit like this is even possible. Sort your shit out and come back amongst the civilised countries [from the healthcare services point of view]!

dang 7y ago
Could you please stop posting unsubstantive comments to Hacker News? You've been doing it repeatedly, and we ban such accounts. The site guidelines explain the intended use of the site: https://news.ycombinator.com/newsguidelines.html https://news.ycombinator.com/newsguidelines.html.