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An interesting story I heard on the radio: A father got a call from his daughter that she went to the emergency room, because she had a vitamin C pill stuck in

An interesting story I heard on the radio: A father got a call from his daughter that she went to the emergency room, because she had a vitamin C pill stuck in her throat and she was scared. In NY, they are required to give an estimate of costs, and estimated $1600 for the exam and the can of ginger ale they gave her to drink so she could swallow it. Fast forward a few weeks, and they got the bill. They ended up charging his insurance $2,200, and the insurance company valued the trip at $3,500 (presumably to bump up his co-pay? not sure). The radio host (a lawyer) recommended reporting both the hospital and insurance company to the state regulators who oversee hospitals and insurance companies. Obviously, this is an instance of price gouging and abuse. The question I have is, are state regulators sufficiently empowered to take action here, not only to help this family, but prevent such abuse in the future? I think the answer is likely not- part of the benefit of being so heavily regulated is they seem to get more leeway. Personally, my wife went into an ER for a migraine that had lasted 3 days. A few drugs, an hour stay in a dark room, and we were sent on our way. This was not a busy ER; I think there was maybe one other patient there the entire time we were. After whatever the insurance covered, I was expected to pay $900. One of the drugs was given intravenously so it acted faster, but... if these had been available OTC or if doctors could operate out of pharmacies and prescribe something on the spot, it would have been so, so much cheaper. The joys of regulatory capture, I guess.

bombcar 4y ago
State regulators are VERY empowered to make everyone's life a living hell. They may not be able to beat back the general case, but if you get them involved the hospital and the insurance company will almost instantly fold. And it's worth doing, because regulator offices work off of accumulated data - so the more complaints they get, the more they have to go on.
- theGnuMe 4y ago
  I had to do this once.
deleted 4y ago
[deleted]
everforward 4y ago
> if these had been available OTC or if doctors could operate out of pharmacies and prescribe something on the spot, it would have been so, so much cheaper. Just a tip for future cases, a lot of those pharmacies have small clinic in them staffed by a nurse practitioner. They can prescribe most things in most states. If it happens again, you can probably take her and her discharge paperwork and have the nurse write out prescriptions for whatever it is. Should be way cheaper unless the meds are something exotic that only a hospital pharmacy would carry. It's pretty close to having a doctor in the pharmacy for anything you'd feel okay not going to the hospital for. This is the chart of what they can prescribe per state (you'll have to look up what schedule the particular meds she needs are): https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/specialty%20group/arc/ama-chart-np-prescriptive-authority.pdf https://www.ama-assn.org/sites/ama-assn.org/files/corp/media...
- ars 4y ago
  I've refused simply treatment from a hospital that I can just do at home. They billed me for them anyway - so I refused to pay the entire bill. The refused to budge and remove the charges, so I never paid them. Nothing happened after that. I've rarely gotten an accurate medical bill (vastly inflating the time I was seen by the doctor is the most common mistake), and if it's inaccurate I just don't pay.
caycep 4y ago
slightly OT, but I'm hoping the new CGRP meds will eventually be OTC. They work well and don't have any major issues that would make sumatriptan prescription (small risk of cardiac related issues and serotonin syndrome). That being said...just came on the market so the powers that be need to "recover their investment"...
yamtaddle 4y ago
Regardless of whether they can ultimately fix the problem, bringing regulators and/or state legislators into the conversation is often enough to make providers and insurers get a lot more reasonable (I mean, the figures involved still won't actually be reasonable, but more reasonable, at least) in a hurry, because regulators and legislators are annoying enough to deal with that they'd really rather not. But all of this means you're probably gonna lose the equivalent of a work week or two of hours playing go-between with everyone involved, largely sitting on hold on hospital billing department and insurer phone lines. Record everything because they all have a habit of "losing" their own fucking records. Reference numbers aren't enough, they'll say they can't find it—record the calls (check your state laws and make sure you comply, which may require nothing in some states, or may require your notifying each person who comes on the line in others)
boplicity 4y ago
It gets even worse than that. When our first child was born, in the States, it was in a birthing center associated with the local hospital. This was in its own building, but in that building they have a room they call the "ER" -- this is where they decide whether to admit you, in terms of being ready to give birth. The entire function of that room, though, is just to charge exorbitant ER rates for admitting into the birthing center. (A 10 minute dilation exam.) This is completely fraudulent, of course, but they've been getting away with it for many, many years.
tpmoney 4y ago
>Fast forward a few weeks, and they got the bill. They ended up charging his insurance $2,200, and the insurance company valued the trip at $3,500 (presumably to bump up his co-pay? not sure). This makes no sense. Insurance companies NEVER pay more than they are asked to pay. It's half the reason why medical billing is such a royal pain. A doctor or pharmacy knows they've left money on the table if they get exactly what they ask for from the insurance company. And there's no way that increasing the coinsurance for the patient (co-pays are fixed dollar amounts so there's no "bumping it up") does anything for the insurance company. If your coinsurance is 20%, the insurance company is still paying paying 80% whether that's 80% of the $2200 or the $3500. Even if the person had an HDHP plan and was paying all of that out of pocket, all the insurance company raising the the cost from 2200 to 3500 would have done was move the patient $1300 closer to their deductible and out of pocket limits and make it more likely the insurance company is paying out more money in the future. More likely is that the ER billed $3500 and the insurance's allowed amount was $2200.
- zdragnar 4y ago
  This was a point of contention for a minute on the radio show- the host was flummoxed as well that the insurance company "valued" the trip higher than what the hospital billed for. It's possible that the (clearly upset) father on the phone had the story mixed up, but I'm not sure that NY law would allow an estimate for a medical bill to end up being billed at more than double the original estimate. Hell, in my state car repairs can't exceed 10% of the original estimate without approval from the customer. Either way it shakes out, if the story is real the state commissioners are going to have fun with it.
  - HCDevid 4y ago
    On US healthcare bills there is: Billed Amount - what the provider/health system tags as the “billed amount” Allowed Amount - what the insurer sets as the actual total $ allowed to change hands for the visit Patient Responsibility - the portion the patient is responsible for. The Billed Amount is supposed to exceed the Allowed Amount by 2.5-5x typically so that the Allowed Amount the insurer/provider has negotiated “saves” money thanks to Insurance ostensibly in how the bill is displayed. Put differently, your provider/health system is supposed to per the billing contract put in an inflated value well in excess of expected payment so your insurance company can reduce it so you can “save money” superficially on your bill. It is as smoke and mirrors as it sounds. Sounds like your provider / HS forgot healthcare billing 101 in this case. The Billed - Allowed Amount value is also usually called Contractual Adjustment

bombcar 4y ago

State regulators are VERY empowered to make everyone's life a living hell. They may not be able to beat back the general case, but if you get them involved the hospital and the insurance company will almost instantly fold. And it's worth doing, because regulator offices work off of accumulated data - so the more complaints they get, the more they have to go on.

theGnuMe 4y ago
I had to do this once.

deleted 4y ago

[deleted]

everforward 4y ago

> if these had been available OTC or if doctors could operate out of pharmacies and prescribe something on the spot, it would have been so, so much cheaper. Just a tip for future cases, a lot of those pharmacies have small clinic in them staffed by a nurse practitioner. They can prescribe most things in most states. If it happens again, you can probably take her and her discharge paperwork and have the nurse write out prescriptions for whatever it is. Should be way cheaper unless the meds are something exotic that only a hospital pharmacy would carry. It's pretty close to having a doctor in the pharmacy for anything you'd feel okay not going to the hospital for. This is the chart of what they can prescribe per state (you'll have to look up what schedule the particular meds she needs are): https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/specialty%20group/arc/ama-chart-np-prescriptive-authority.pdf https://www.ama-assn.org/sites/ama-assn.org/files/corp/media...

ars 4y ago
I've refused simply treatment from a hospital that I can just do at home. They billed me for them anyway - so I refused to pay the entire bill. The refused to budge and remove the charges, so I never paid them. Nothing happened after that. I've rarely gotten an accurate medical bill (vastly inflating the time I was seen by the doctor is the most common mistake), and if it's inaccurate I just don't pay.

caycep 4y ago

slightly OT, but I'm hoping the new CGRP meds will eventually be OTC. They work well and don't have any major issues that would make sumatriptan prescription (small risk of cardiac related issues and serotonin syndrome). That being said...just came on the market so the powers that be need to "recover their investment"...

yamtaddle 4y ago

Regardless of whether they can ultimately fix the problem, bringing regulators and/or state legislators into the conversation is often enough to make providers and insurers get a lot more reasonable (I mean, the figures involved still won't actually be reasonable, but more reasonable, at least) in a hurry, because regulators and legislators are annoying enough to deal with that they'd really rather not. But all of this means you're probably gonna lose the equivalent of a work week or two of hours playing go-between with everyone involved, largely sitting on hold on hospital billing department and insurer phone lines. Record everything because they all have a habit of "losing" their own fucking records. Reference numbers aren't enough, they'll say they can't find it—record the calls (check your state laws and make sure you comply, which may require nothing in some states, or may require your notifying each person who comes on the line in others)

boplicity 4y ago

It gets even worse than that. When our first child was born, in the States, it was in a birthing center associated with the local hospital. This was in its own building, but in that building they have a room they call the "ER" -- this is where they decide whether to admit you, in terms of being ready to give birth. The entire function of that room, though, is just to charge exorbitant ER rates for admitting into the birthing center. (A 10 minute dilation exam.) This is completely fraudulent, of course, but they've been getting away with it for many, many years.

tpmoney 4y ago

>Fast forward a few weeks, and they got the bill. They ended up charging his insurance $2,200, and the insurance company valued the trip at $3,500 (presumably to bump up his co-pay? not sure). This makes no sense. Insurance companies NEVER pay more than they are asked to pay. It's half the reason why medical billing is such a royal pain. A doctor or pharmacy knows they've left money on the table if they get exactly what they ask for from the insurance company. And there's no way that increasing the coinsurance for the patient (co-pays are fixed dollar amounts so there's no "bumping it up") does anything for the insurance company. If your coinsurance is 20%, the insurance company is still paying paying 80% whether that's 80% of the $2200 or the $3500. Even if the person had an HDHP plan and was paying all of that out of pocket, all the insurance company raising the the cost from 2200 to 3500 would have done was move the patient $1300 closer to their deductible and out of pocket limits and make it more likely the insurance company is paying out more money in the future. More likely is that the ER billed $3500 and the insurance's allowed amount was $2200.

zdragnar 4y ago
This was a point of contention for a minute on the radio show- the host was flummoxed as well that the insurance company "valued" the trip higher than what the hospital billed for. It's possible that the (clearly upset) father on the phone had the story mixed up, but I'm not sure that NY law would allow an estimate for a medical bill to end up being billed at more than double the original estimate. Hell, in my state car repairs can't exceed 10% of the original estimate without approval from the customer. Either way it shakes out, if the story is real the state commissioners are going to have fun with it.
- HCDevid 4y ago
  On US healthcare bills there is: Billed Amount - what the provider/health system tags as the “billed amount” Allowed Amount - what the insurer sets as the actual total $ allowed to change hands for the visit Patient Responsibility - the portion the patient is responsible for. The Billed Amount is supposed to exceed the Allowed Amount by 2.5-5x typically so that the Allowed Amount the insurer/provider has negotiated “saves” money thanks to Insurance ostensibly in how the bill is displayed. Put differently, your provider/health system is supposed to per the billing contract put in an inflated value well in excess of expected payment so your insurance company can reduce it so you can “save money” superficially on your bill. It is as smoke and mirrors as it sounds. Sounds like your provider / HS forgot healthcare billing 101 in this case. The Billed - Allowed Amount value is also usually called Contractual Adjustment