5 ms·

This is some of the best hacking I've seen on Hacker News in a long time! My son broke his arm skiing a few months ago and we went to the clinic that is at the

by krupan 3y ago

This is some of the best hacking I've seen on Hacker News in a long time! My son broke his arm skiing a few months ago and we went to the clinic that is at the ski resort. They x-rayed him, set the bone a little (thankfully it didn't need much), put on a splint, and put his arm in a sling. Straightforward simple stuff. The clinic is not on our insurance so we filed a claim with them after the fact ourselves using the detailed receipt the clinic provided. It was out of network so they didn't pay for most of it (for some reason they did pay the $12 or whatever for the sling), but they applied the cost to our out-of-network deductible. Except not the cost the clinic charged, the cost they thought the clinic should have charged, which was of course about $150 less. What?? I'd love more insight into how all that makes sense in someone's mind.

toomuchtodo 3y ago
Your health insurance doesn't want to pay for it because they deem what the clinic charged as "too expensive" or another reason there isn't a pre negotiated contract in place between provider and insurer. The clinic can extract what it can from your because your insurance didn't cover it, sending you to collections if you don't pay [1] [2]. Many folks harp about how government insurance doesn't pay enough, and there is some validity to that argument, but without cost controls or other guardrails, the patient is always caught between the payer (private insurance) and the provider. Both are attempting to maximize their profits, the former through "cost plus" accounting, the latter at point of sale/purchase/care. This might or not be helpful, depending on circumstances: https://www.cms.gov/nosurprises/consumers/new-protections-for-you https://www.cms.gov/nosurprises/consumers/new-protections-fo... Tangentially, this is why global/nomad/world traveller health insurance typically excludes the US specifically from coverage and visitors to the US in many cases will fly home for urgent medical emergencies vs receiving care in country; the economics are simply unpalatable. [1] https://www.quora.com/Why-would-a-doctor-go-out-of-network-pertaining-to-insurance?share=1 https://www.quora.com/Why-would-a-doctor-go-out-of-network-p... [2] https://www.consumerfinance.gov/rules-policy/medical-debt/ https://www.consumerfinance.gov/rules-policy/medical-debt/ (intimately familiar with the inside mechanics of private insurance from patient advocacy work)
- ecommerceguy 3y ago
  >>Your health insurance doesn't want to pay for it because they deem what the clinic charged as "too expensive" Out of network is the reason. Simple as that. >>we went to the clinic that is at the ski resort The ski resort's clinic likely doesn't participate in any network similar to a cruise ship. edit: facts get downvoted again. sigh.
  - toomuchtodo 3y ago
    These are simple explanations to a complex topic. I shared the nuance as to why you can be held hostage in a medical emergency in the United States. Please disregard my comment if you're not getting value from it.
    - ecommerceguy 3y ago
      No you are claiming the carrier "doesn't want to pay for it because they deem what the clinic charged as "too expensive"". That is not nuance, that is an knee jerk unsubstantiated misleading claim. You have 0 details into what chassis the plan is carried on, what the plan design is, who the carrier is etc. >>"this is why global/nomad/world traveller health insurance typically excludes the US specifically from coverage and visitors to the US in many cases will fly home for urgent medical emergencies vs receiving care in country; the economics are simply unpalatable." Again misleading, there are expatriate plans specifically for visitors to the USA, and frankly, it's great coverage. https://www.imglobal.com/ https://www.imglobal.com/
      - multjoy 3y ago
        The point is that you have to specifically opt for US coverage, rather than the default global coverage, because of the eyewatering expense of medical care in the US.
        ecommerceguy 3y ago
        What is default global coverage?
orbz 3y ago
You can try an appeal that the network did not have adequate coverage in the area in which your son was injured in which case they would treat it as were in network, or see if it might have been covered under their emergency room benefit instead of as out of network.
aquaphile 3y ago
Emergencies are always considered In-Network by law *. For example, if you are traveling Out of Area (OOA) and skiing in Colorado, and you have a medical emergency, emergency room care is considered In-Network. Any financial responsibility you have under your health plan (coinsurance, copay) should be calculated as part of In-Network. * If you have an HMO or EPO plan, it is black and white language. If you have a PPO plan, legally it is a bit squishy because of the already provided for out of network (OON) access. BUT - generally - any emergency is considered in network no matter what product you have and where you are. Source: I work in health insurance at Evry Health (https://evryhealth.com https://evryhealth.com)
- ecommerceguy 3y ago
  He went to a clinic, while you, me and he may all agree it fits the definition of an emergency, he didn't go to the ER. Getting emergency care: In an emergency, you should get care from the closest hospital that can help you. That hospital will treat you regardless of whether you have insurance. Your insurance company can't charge you more for getting emergency room services at an out-of-network hospital. https://www.healthcare.gov/using-marketplace-coverage/getting-emergency-care/ https://www.healthcare.gov/using-marketplace-coverage/gettin...
  - _delirium 3y ago
    For something fairly simple like a cast, that can still end up more expensive than the clinic option though, depending on your insurance. ER co-pays and co-insurance can be pretty high. For example, a typical ACA/Obamacare "Silver" level plan in my area has 20-40% co-insurance on an ER visit (until the $5k-10k annual out-of-pocket max), which can easily be more than whatever you'd end up paying for the non-ER option to set a broken arm.
- deleted 3y ago
  [deleted]
- chimeracoder 3y ago
  > Emergencies are always considered In-Network by law * Not quite. Balance billing for care received in the emergency department is illegal if the ER accepts Medicare payments. In other words - care received outside the emergency department (once admitted as a patient) can be balance billed - care received in an urgent care clinic can be balance billed - standalone ERs (which are increasingly common, as they're more profitable for the owners) can balance bill patients
bhupy 3y ago
I work in this industry and can provide some insight. Every payer has the concept of "UCR Rates" or "Usual, Customary, and Reasonable Rates" for every procedure code, for every ZIP code. For example, the median cost of an X-ray should be a certain dollar amount in Topeka, Kansas and a different (higher) dollar amount in Manhattan, NY. When a provider is out-of-network, they'll bill as much as they possibly can to see what the insurance company will pay — the insurance company will only pay up to the "UCR Rate" for the treatments (or in your case, apply that to the deductible before the payments start to kick in). Whatever the difference is between the UCR rate and the requested amount is almost always ignored, since the doctors' motivation for the high requested rate was to try and maximize payment from the insurance company. In your case, since you paid out of pocket, you're unfortunately on the hook for that difference. In other situations the provider might also invoice the patient for that difference, but it's relatively rare. In contrast, when a provider is in-network, they have contracted rates for all of the procedures (also typically varies by ZIP code). These are called the "fee schedule" rates, and every payer (including Medicare/Medicaid) has their fee schedule rates defined and agreed upon with the physicians/providers.
- frumper 3y ago
  It sounds like pure fantasy to come up with a number they should charge and it is the same for every provider in a zip code. Different hospitals, clinics and offices would pay different rents, staffing expenses, supplies, marketing, utilities, and the list goes on. Not even McDonalds charges the same price for the same meal in every location in a zip code. Malls, airports, entertainment venues are easy examples of divergent pricing.
  - bhupy 3y ago
    Right, the UCR is usually pegged at the 75th percentile price for that ZIP code — though that can vary from payer to payer, some can even go up to 90th percentile — it's usually determined by actuaries. It's basically a guidance that conveys "we've never met you before, but you're asking us to reimburse for a treatment, and we as an insurance company think this is the highest reasonable amount to charge for that treatment". It's also important to note that payers don't advertise whether they're doing 75th percentile or 90th percentile or 50th percentile or whatever, because then it just becomes an incentive for providers to anchor at that amount, even if it may be higher than they would otherwise bill for that treatment — they'd just submit a claim for that amount and say "cool, thanks, pay me". In single-payer countries in which the state is a monopsony buyer, there is only 1 rate (sometimes a narrow range), often per location. In either case, the goal is to try to keep prices down, and in many cases to prevent so called "upcoding" by providers. You'd be surprised how prevalent upcoding is among providers. I've been on the phone with a provider that included in a claim an $80 line item for "oral hygiene instructions", which is a fancy way of saying "instructing the patient to floss more". I've seen another claim that asked for $300 for sign language because the patient was deaf. I've seen yet another claim that asked for $200 for a swaddle for an infant patient. In all 3 of those cases, I personally informed the clinical administrator on the other end "this is not covered", and their response was something to the tune of "oh yeah that's okay, we just put that on there to see who covers it, you can go ahead and ignore that line item". All of this is characteristic of the fee-for-service model, which is increasingly being seen as quite flawed, regardless of whether it's done by the public sector or the private sector.
paulddraper 3y ago
> What?? According to your insurance company, that clinic charged you an excessive amount for its services. For coverage (whether reimbursement, or deductible reduction), the insurance company will only count the "reasonable" amount. This isn't an issue for in-network, since in-network providers are required by their contract to write-off anything exceeding the contracted rate. You can try to get the clinic to write off the remainder; they may be willing to if they think it will hard to collect it from you. P.S. DME (durable medical equipment, e.g. a sling) is often covered+adjudicated separately from provider services.

by krupan 3y ago

toomuchtodo 3y ago

Your health insurance doesn't want to pay for it because they deem what the clinic charged as "too expensive" or another reason there isn't a pre negotiated contract in place between provider and insurer. The clinic can extract what it can from your because your insurance didn't cover it, sending you to collections if you don't pay [1] [2]. Many folks harp about how government insurance doesn't pay enough, and there is some validity to that argument, but without cost controls or other guardrails, the patient is always caught between the payer (private insurance) and the provider. Both are attempting to maximize their profits, the former through "cost plus" accounting, the latter at point of sale/purchase/care. This might or not be helpful, depending on circumstances: https://www.cms.gov/nosurprises/consumers/new-protections-for-you https://www.cms.gov/nosurprises/consumers/new-protections-fo... Tangentially, this is why global/nomad/world traveller health insurance typically excludes the US specifically from coverage and visitors to the US in many cases will fly home for urgent medical emergencies vs receiving care in country; the economics are simply unpalatable. [1] https://www.quora.com/Why-would-a-doctor-go-out-of-network-pertaining-to-insurance?share=1 https://www.quora.com/Why-would-a-doctor-go-out-of-network-p... [2] https://www.consumerfinance.gov/rules-policy/medical-debt/ https://www.consumerfinance.gov/rules-policy/medical-debt/ (intimately familiar with the inside mechanics of private insurance from patient advocacy work)

ecommerceguy 3y ago
>>Your health insurance doesn't want to pay for it because they deem what the clinic charged as "too expensive" Out of network is the reason. Simple as that. >>we went to the clinic that is at the ski resort The ski resort's clinic likely doesn't participate in any network similar to a cruise ship. edit: facts get downvoted again. sigh.
- toomuchtodo 3y ago
  These are simple explanations to a complex topic. I shared the nuance as to why you can be held hostage in a medical emergency in the United States. Please disregard my comment if you're not getting value from it.
  - ecommerceguy 3y ago
    No you are claiming the carrier "doesn't want to pay for it because they deem what the clinic charged as "too expensive"". That is not nuance, that is an knee jerk unsubstantiated misleading claim. You have 0 details into what chassis the plan is carried on, what the plan design is, who the carrier is etc. >>"this is why global/nomad/world traveller health insurance typically excludes the US specifically from coverage and visitors to the US in many cases will fly home for urgent medical emergencies vs receiving care in country; the economics are simply unpalatable." Again misleading, there are expatriate plans specifically for visitors to the USA, and frankly, it's great coverage. https://www.imglobal.com/ https://www.imglobal.com/
    - multjoy 3y ago
      The point is that you have to specifically opt for US coverage, rather than the default global coverage, because of the eyewatering expense of medical care in the US.
      - ecommerceguy 3y ago
        What is default global coverage?

orbz 3y ago

You can try an appeal that the network did not have adequate coverage in the area in which your son was injured in which case they would treat it as were in network, or see if it might have been covered under their emergency room benefit instead of as out of network.

aquaphile 3y ago

Emergencies are always considered In-Network by law *. For example, if you are traveling Out of Area (OOA) and skiing in Colorado, and you have a medical emergency, emergency room care is considered In-Network. Any financial responsibility you have under your health plan (coinsurance, copay) should be calculated as part of In-Network. * If you have an HMO or EPO plan, it is black and white language. If you have a PPO plan, legally it is a bit squishy because of the already provided for out of network (OON) access. BUT - generally - any emergency is considered in network no matter what product you have and where you are. Source: I work in health insurance at Evry Health (https://evryhealth.com https://evryhealth.com)

ecommerceguy 3y ago
He went to a clinic, while you, me and he may all agree it fits the definition of an emergency, he didn't go to the ER. Getting emergency care: In an emergency, you should get care from the closest hospital that can help you. That hospital will treat you regardless of whether you have insurance. Your insurance company can't charge you more for getting emergency room services at an out-of-network hospital. https://www.healthcare.gov/using-marketplace-coverage/getting-emergency-care/ https://www.healthcare.gov/using-marketplace-coverage/gettin...
- _delirium 3y ago
  For something fairly simple like a cast, that can still end up more expensive than the clinic option though, depending on your insurance. ER co-pays and co-insurance can be pretty high. For example, a typical ACA/Obamacare "Silver" level plan in my area has 20-40% co-insurance on an ER visit (until the $5k-10k annual out-of-pocket max), which can easily be more than whatever you'd end up paying for the non-ER option to set a broken arm.
deleted 3y ago
[deleted]
chimeracoder 3y ago
> Emergencies are always considered In-Network by law * Not quite. Balance billing for care received in the emergency department is illegal if the ER accepts Medicare payments. In other words - care received outside the emergency department (once admitted as a patient) can be balance billed - care received in an urgent care clinic can be balance billed - standalone ERs (which are increasingly common, as they're more profitable for the owners) can balance bill patients

bhupy 3y ago

I work in this industry and can provide some insight. Every payer has the concept of "UCR Rates" or "Usual, Customary, and Reasonable Rates" for every procedure code, for every ZIP code. For example, the median cost of an X-ray should be a certain dollar amount in Topeka, Kansas and a different (higher) dollar amount in Manhattan, NY. When a provider is out-of-network, they'll bill as much as they possibly can to see what the insurance company will pay — the insurance company will only pay up to the "UCR Rate" for the treatments (or in your case, apply that to the deductible before the payments start to kick in). Whatever the difference is between the UCR rate and the requested amount is almost always ignored, since the doctors' motivation for the high requested rate was to try and maximize payment from the insurance company. In your case, since you paid out of pocket, you're unfortunately on the hook for that difference. In other situations the provider might also invoice the patient for that difference, but it's relatively rare. In contrast, when a provider is in-network, they have contracted rates for all of the procedures (also typically varies by ZIP code). These are called the "fee schedule" rates, and every payer (including Medicare/Medicaid) has their fee schedule rates defined and agreed upon with the physicians/providers.

frumper 3y ago
It sounds like pure fantasy to come up with a number they should charge and it is the same for every provider in a zip code. Different hospitals, clinics and offices would pay different rents, staffing expenses, supplies, marketing, utilities, and the list goes on. Not even McDonalds charges the same price for the same meal in every location in a zip code. Malls, airports, entertainment venues are easy examples of divergent pricing.
- bhupy 3y ago
  Right, the UCR is usually pegged at the 75th percentile price for that ZIP code — though that can vary from payer to payer, some can even go up to 90th percentile — it's usually determined by actuaries. It's basically a guidance that conveys "we've never met you before, but you're asking us to reimburse for a treatment, and we as an insurance company think this is the highest reasonable amount to charge for that treatment". It's also important to note that payers don't advertise whether they're doing 75th percentile or 90th percentile or 50th percentile or whatever, because then it just becomes an incentive for providers to anchor at that amount, even if it may be higher than they would otherwise bill for that treatment — they'd just submit a claim for that amount and say "cool, thanks, pay me". In single-payer countries in which the state is a monopsony buyer, there is only 1 rate (sometimes a narrow range), often per location. In either case, the goal is to try to keep prices down, and in many cases to prevent so called "upcoding" by providers. You'd be surprised how prevalent upcoding is among providers. I've been on the phone with a provider that included in a claim an $80 line item for "oral hygiene instructions", which is a fancy way of saying "instructing the patient to floss more". I've seen another claim that asked for $300 for sign language because the patient was deaf. I've seen yet another claim that asked for $200 for a swaddle for an infant patient. In all 3 of those cases, I personally informed the clinical administrator on the other end "this is not covered", and their response was something to the tune of "oh yeah that's okay, we just put that on there to see who covers it, you can go ahead and ignore that line item". All of this is characteristic of the fee-for-service model, which is increasingly being seen as quite flawed, regardless of whether it's done by the public sector or the private sector.

paulddraper 3y ago

> What?? According to your insurance company, that clinic charged you an excessive amount for its services. For coverage (whether reimbursement, or deductible reduction), the insurance company will only count the "reasonable" amount. This isn't an issue for in-network, since in-network providers are required by their contract to write-off anything exceeding the contracted rate. You can try to get the clinic to write off the remainder; they may be willing to if they think it will hard to collect it from you. P.S. DME (durable medical equipment, e.g. a sling) is often covered+adjudicated separately from provider services.