9 ms·

> if an insurance company decides not to cover something (very very common, even in-network) then the inflated price is what you end up getting billed for... I

> if an insurance company decides not to cover something (very very common, even in-network) then the inflated price is what you end up getting billed for... Is there any reason why this kind of windfall shouldn't be illegal? I realize it isn't, but is sure seems like it should be. I was stuck with a charge from a doctor for 7x the price my insurance would have paid. My pre-ACA insurance refused to cover the procedure and I ended up on the hook for the inflated price. The doctor wouldn't negotiate and demanded the full fee. Neither the doctor, nor I, knew this would happen until the procedure was already done. It feels like an agreement, to me, when the practice takes on a patient knowing who their insurer is. I feel like the reimbursement rate that insurer has negotiated, regardless of whether the insurer ultimately covers any procedures, should act as a cap for the fees charged to the patient. It feels a lot like negotiating a contract, except that one party gets to unilaterally change the amount of consideration. How does that fly?

weaksauce 5y ago
> Is there any reason why this kind of windfall shouldn't be illegal? I realize it isn't, but is sure seems like it should be. because our senators and congress critters are all on the buy for really cheap... it's not even hidden. something like medicare for all is the thing that makes sense but has a hard time finding traction because the people that it will negatively impact have the means to buy those politicians out.
elliekelly 5y ago
> It feels like an agreement, to me, when the practice takes on a patient knowing who their insurer is. I feel like the reimbursement rate that insurer has negotiated, regardless of whether the insurer ultimately covers any procedures, should act as a cap for the fees charged to the patient. It feels a lot like negotiating a contract, except that one party gets to unilaterally change the amount of consideration. How does that fly? You aren't exactly talking about "balance billing"[1] but you'll be pleased to know the No Surprises Act[2] tries to address this situation with required cost (estimate) disclosures in advance of a procedure and capping the out-of-network amount that can be charged in the event of an emergency where there can't advanced disclosure. The HHS recently promulgated regulations[3] under the Act but the compliance date is January 2022. For some reason I think there is at least one (maybe two?) other proposed rules in the works but I can't recall what they address and I can't seem to find them. Edit: The other proposed rule is relating to air ambulance services[4] [1]https://en.wikipedia.org/wiki/Balance_billing https://en.wikipedia.org/wiki/Balance_billing [2]https://www.congress.gov/bill/116th-congress/house-bill/3630/ https://www.congress.gov/bill/116th-congress/house-bill/3630... [3]https://www.hhs.gov/about/news/2021/07/01/hhs-announces-rule-to-protect-consumers-from-surprise-medical-bills.html https://www.hhs.gov/about/news/2021/07/01/hhs-announces-rule... [4]https://www.healthaffairs.org/do/10.1377/hblog20210913.576338/full/ https://www.healthaffairs.org/do/10.1377/hblog20210913.57633...
jjoonathan 5y ago
Insurance has the worst moral hazard: the winning strategy is to sell a product that pretends to cover your customers but actually doesn't. Your customers give you money for nothing and they will only realize it once in a blue moon. You can probably buy off the few who are capable of causing actual blowback, and if that doesn't work just rebrand. Until everyone becomes a contract lawyer capable of devoting weeks to insurance shopping every 6 months, the only good insurance market is a heavily regulated one, even though heavy regulation comes with its own gigantic bag of worms.
- ipaddr 5y ago
  Aren't insurance rates regulated meaning if they payout a smaller amount than expected the rates will go down next year?
  - saalweachter 5y ago
    Now; I think the "medical loss ratio" requirements were one of the most important features of the ACA. One of the worst offenders from the before-times was an insurance plan targeted at college students that had a 10% MLR.
    - kristjansson 5y ago
      To save those looking it up: medical loss ratio is the fraction of premiums an insurer spends on actual healthcare expenses. 10% means 90 cents of every dollar paid in premium goes to admin/profit/etc.
    - munk-a 5y ago
      I wonder how MLRs interact with subsidies, backroom deals and manufacturer rebates - if an payer can inflate their MLR by double paying for a medication - but then they get a rebate back for half the cost they paid will MLR tracking catch that? Payers often get incentivized to promote certain drugs via manufacturer kickbacks and I wonder if this system is also used to run around MLR requirements.
  - deleted 5y ago
haliskerbas 5y ago
Reminds me when my dentist charged me $50 for a cup of fluoride (nothing too special about this fluoride). I asked why they said it would be covered. They said when they checked with insurance it says it’s covered, but for my age or whatever it’s not actually covered. So then I said why is it my fault that you gave me something you said was free but actually wasn’t because your check wasn’t thorough enough? They said they already spent it so someone has to pay… In the end I didn’t pay for the fluoride after hours of argument. Next year at a different dentist, same situation. I learned my lesson and just paid for the damn fluoride. Land of the free, home of the brave!
- lotsofpulp 5y ago
  The dentists peddle that nonsense because it is almost all profit for them. Insurance will not cover it because there is no strong evidence that it helps, assuming you are brushing your teeth regularly, have access to fluoridated drinking water, and otherwise have healthy eating habits.
- hamburglar 5y ago
  Yes, our medical/dental insurance industry has encouraged the attitude of “cost doesn’t matter, because it’s free to you (oh and besides, you can’t put a price on your health, can you, you cheapskate?)” which just serves to constantly let prices grow out of control. This is an instrumental part of how our healthcare costs got so high. It also is why it’s laughable to think of medical care as a free market: you can’t even find out what things cost before you buy most of the time. Not to mention that when you are in need of care, you often don’t have the luxury of shopping around. What we really need is for people to stop thinking of insurance as a big blanket you buy that reduces the price of things to zero. That’s not what insurance is for. Insurance is supposed to be a system where you still pay for the cost of the good, but that buffers it for you so when you get an outlier cost, it doesn’t break you. It doesn’t make the costs of things go away. On average, you should end up paying a little more than the cost of your healthcare by purchasing it through an insurance plan. A high deductible plan does this: you actually pay the cost of all your healthcare up until a certain point out of pocket, and if you reach a certain amount (which is pretty high, but significantly less than the premiums on a low-deductible plan), the insurance takes over. This makes you actually aware of the prices of things and is healthy. Not to mention the insurance is a hell of a lot cheaper.
brandall10 5y ago
There are services you can use which will negotiate the rate back down to the neighborhood of what the insurer pays. They won't negotiate with you specifically, you have to retain one of these services to negotiate on your behalf. They have direct access to usual and customary charges insurers pay per region. Was in a similar situation as you were, but unfortunately, what I'd have had to pay was still too much as it was clearly fraud on the part of an outpatient clinic - one side, the clinic, was approved by my insurer, the other side, the surgery center, was not, and they willfully lied about this distinction. I threatened a law suit and they demurred.
KingMachiavelli 5y ago
I've had this thought as well. If insurance is negotiating with the provider then that should be the final say. What's the point in negotiating if the patient gets charged the difference? I believe this is called 'balanced billing'. Some states prohibit it under certain conditions but it seems either the government or insurance should be prohibiting this practice.
spaztastical 5y ago
I think it ought to fall afoul of "informed consent." Did someone actually consent to paying without being informed of the price, or is it non-consent by virtue of being coerced by lack of information?

weaksauce 5y ago

> Is there any reason why this kind of windfall shouldn't be illegal? I realize it isn't, but is sure seems like it should be. because our senators and congress critters are all on the buy for really cheap... it's not even hidden. something like medicare for all is the thing that makes sense but has a hard time finding traction because the people that it will negatively impact have the means to buy those politicians out.

elliekelly 5y ago

> It feels like an agreement, to me, when the practice takes on a patient knowing who their insurer is. I feel like the reimbursement rate that insurer has negotiated, regardless of whether the insurer ultimately covers any procedures, should act as a cap for the fees charged to the patient. It feels a lot like negotiating a contract, except that one party gets to unilaterally change the amount of consideration. How does that fly? You aren't exactly talking about "balance billing"[1] but you'll be pleased to know the No Surprises Act[2] tries to address this situation with required cost (estimate) disclosures in advance of a procedure and capping the out-of-network amount that can be charged in the event of an emergency where there can't advanced disclosure. The HHS recently promulgated regulations[3] under the Act but the compliance date is January 2022. For some reason I think there is at least one (maybe two?) other proposed rules in the works but I can't recall what they address and I can't seem to find them. Edit: The other proposed rule is relating to air ambulance services[4] [1]https://en.wikipedia.org/wiki/Balance_billing https://en.wikipedia.org/wiki/Balance_billing [2]https://www.congress.gov/bill/116th-congress/house-bill/3630/ https://www.congress.gov/bill/116th-congress/house-bill/3630... [3]https://www.hhs.gov/about/news/2021/07/01/hhs-announces-rule-to-protect-consumers-from-surprise-medical-bills.html https://www.hhs.gov/about/news/2021/07/01/hhs-announces-rule... [4]https://www.healthaffairs.org/do/10.1377/hblog20210913.576338/full/ https://www.healthaffairs.org/do/10.1377/hblog20210913.57633...

jjoonathan 5y ago

Insurance has the worst moral hazard: the winning strategy is to sell a product that pretends to cover your customers but actually doesn't. Your customers give you money for nothing and they will only realize it once in a blue moon. You can probably buy off the few who are capable of causing actual blowback, and if that doesn't work just rebrand. Until everyone becomes a contract lawyer capable of devoting weeks to insurance shopping every 6 months, the only good insurance market is a heavily regulated one, even though heavy regulation comes with its own gigantic bag of worms.

ipaddr 5y ago
Aren't insurance rates regulated meaning if they payout a smaller amount than expected the rates will go down next year?
- saalweachter 5y ago
  Now; I think the "medical loss ratio" requirements were one of the most important features of the ACA. One of the worst offenders from the before-times was an insurance plan targeted at college students that had a 10% MLR.
  - kristjansson 5y ago
    To save those looking it up: medical loss ratio is the fraction of premiums an insurer spends on actual healthcare expenses. 10% means 90 cents of every dollar paid in premium goes to admin/profit/etc.
  - munk-a 5y ago
    I wonder how MLRs interact with subsidies, backroom deals and manufacturer rebates - if an payer can inflate their MLR by double paying for a medication - but then they get a rebate back for half the cost they paid will MLR tracking catch that? Payers often get incentivized to promote certain drugs via manufacturer kickbacks and I wonder if this system is also used to run around MLR requirements.
- deleted 5y ago

haliskerbas 5y ago

Reminds me when my dentist charged me $50 for a cup of fluoride (nothing too special about this fluoride). I asked why they said it would be covered. They said when they checked with insurance it says it’s covered, but for my age or whatever it’s not actually covered. So then I said why is it my fault that you gave me something you said was free but actually wasn’t because your check wasn’t thorough enough? They said they already spent it so someone has to pay… In the end I didn’t pay for the fluoride after hours of argument. Next year at a different dentist, same situation. I learned my lesson and just paid for the damn fluoride. Land of the free, home of the brave!

lotsofpulp 5y ago
The dentists peddle that nonsense because it is almost all profit for them. Insurance will not cover it because there is no strong evidence that it helps, assuming you are brushing your teeth regularly, have access to fluoridated drinking water, and otherwise have healthy eating habits.
hamburglar 5y ago
Yes, our medical/dental insurance industry has encouraged the attitude of “cost doesn’t matter, because it’s free to you (oh and besides, you can’t put a price on your health, can you, you cheapskate?)” which just serves to constantly let prices grow out of control. This is an instrumental part of how our healthcare costs got so high. It also is why it’s laughable to think of medical care as a free market: you can’t even find out what things cost before you buy most of the time. Not to mention that when you are in need of care, you often don’t have the luxury of shopping around. What we really need is for people to stop thinking of insurance as a big blanket you buy that reduces the price of things to zero. That’s not what insurance is for. Insurance is supposed to be a system where you still pay for the cost of the good, but that buffers it for you so when you get an outlier cost, it doesn’t break you. It doesn’t make the costs of things go away. On average, you should end up paying a little more than the cost of your healthcare by purchasing it through an insurance plan. A high deductible plan does this: you actually pay the cost of all your healthcare up until a certain point out of pocket, and if you reach a certain amount (which is pretty high, but significantly less than the premiums on a low-deductible plan), the insurance takes over. This makes you actually aware of the prices of things and is healthy. Not to mention the insurance is a hell of a lot cheaper.

brandall10 5y ago

There are services you can use which will negotiate the rate back down to the neighborhood of what the insurer pays. They won't negotiate with you specifically, you have to retain one of these services to negotiate on your behalf. They have direct access to usual and customary charges insurers pay per region. Was in a similar situation as you were, but unfortunately, what I'd have had to pay was still too much as it was clearly fraud on the part of an outpatient clinic - one side, the clinic, was approved by my insurer, the other side, the surgery center, was not, and they willfully lied about this distinction. I threatened a law suit and they demurred.

KingMachiavelli 5y ago

I've had this thought as well. If insurance is negotiating with the provider then that should be the final say. What's the point in negotiating if the patient gets charged the difference? I believe this is called 'balanced billing'. Some states prohibit it under certain conditions but it seems either the government or insurance should be prohibiting this practice.

spaztastical 5y ago

I think it ought to fall afoul of "informed consent." Did someone actually consent to paying without being informed of the price, or is it non-consent by virtue of being coerced by lack of information?