4 ms·

That's all true, but from a practical standpoint providers really have no way to accurately estimate a patient's out-of-pocket financial responsibility in advan

by nradov 2mo ago

That's all true, but from a practical standpoint providers really have no way to accurately estimate a patient's out-of-pocket financial responsibility in advance. The current HIPAA adopted standard transactions don't allow for sending a prospective claim. So all they can realistically do is perform the procedure, submit a claim to the patient's health plan, wait for it to (maybe) be paid, and then send a bill to the patient for the balance. https://www.cms.gov/priorities/key-initiatives/burden-reduction/administrative-simplification/hipaa/adopted-standards-operating-rules https://www.cms.gov/priorities/key-initiatives/burden-reduct... The good news is that CMS is working on an update to those standards which will at least make prospective claims technically possible. Although it may take years until that functionality is widely implemented.

mindslight 2mo ago
One can always craft some excuse, which is how the terrible system continues to perpetuate itself. Doctors cannot even tell you how much they themselves will charge for anything. The problem I'm describing originates completely with them - no escaping blame here. (And "might take years" lol. How about eliminate whatever flagrant regulatory capture is allowing providers to create and enforce post-facto and downright fraudulent bills in the first place, and watch the system reform itself overnight)
- nradov 2mo ago
  Feel free to blame doctors if that makes you feel better but the reality is that in most cases they literally have no way to accurately calculate a patient's out-of-pocket cost in advance. Like there's just no technical way to do it. If you have specific suggestions for fixing the regulatory capture problem then you can submit a petition for rule making under the Administrative Procedures Act. https://www.govinfo.gov/content/pkg/USCODE-2011-title5/html/USCODE-2011-title5-partI-chap5-subchapII.htm https://www.govinfo.gov/content/pkg/USCODE-2011-title5/html/...
  - mindslight 2mo ago
    You keep misinterpreting "how much [a doctor] themselves will charge for something" as "patient's out-of-pocket cost". I'm certainly not asking for the doctor to get involved between the patient and their health plan [0], but rather what the doctor charges, regardless of who might pay. In other words, the straightforwardly-legible prices that exist in every other market - even markets where insurance companies often pay (eg auto repair). I don't know the specific legal details that allow doctors to make up these post-facto bills (often fraudulent) and send them to patients, but I feel it's probably at the state level rather than federal. Also the big problem with regulatory capture is that businesses paying off politicians makes that kind of citizen feedback meaningless. [0] in fact I think another good angle of reform would be "if a patient has a health plan, providers are prohibited from billing the patient directly". Any copays, outstanding balances, etc should flow through the health plan.
    - nradov 2mo ago
      Are you perhaps unfamiliar with existing price transparency rules? Patients paying cash already have the right to demand a Good Faith Estimate in advance. Those using a commercial health plan can see the negotiated rates for every participating provider. https://www.cms.gov/medical-bill-rights/help/guides/good-faith-estimate https://www.cms.gov/medical-bill-rights/help/guides/good-fai... https://www.cms.gov/priorities/healthplan-price-transparency/overview/consumers https://www.cms.gov/priorities/healthplan-price-transparency...
      - mindslight 2mo ago
        I'm aware of them, but I'm not familiar with them as they seem like band-aids that add even more patient self-administrative bloat, rather than fixing the core dynamic - making healthcare pricing work like every other industry. The word "demand" is a tell, showing that this is not the normal course of the relationship. Another tell is that it's two prongs - why can't everyone receive a "good faith estimate" from a provider? Note I'm still not asking the provider to grok the patient's health plan - rather to be upfront about the prices they themselves are choosing to charge. Also the ambiguous place between the two cases - "you have a health plan but we didn't do the work to actually bill it" - is a common source of the fraudulent shakedown bills, and this does nothing to constrain those types of fraudulent bills! In general, I don't need to request a "Good Faith Estimate" from a grocery store about my upcoming food purchase for when I go later in the week, nor for an oil change down at the mechanic. If I go to the mechanic with "something is making a noise", then they are upfront about any fixed diagnosis fee, and then give estimates routinely in terms of a shop rate and book hours. If there are still unknowns about what might need to be fixed/replaced, they are up front about that and readily communicate with the customer. All of this is straight up missing in the medical industry, even when you try to engage. Rather they shove "consent" forms at you that say nonsensical anti-contractual things like "we can bill you whatever we want and you're responsible" and when you start pushing back on them they look at you like you have three heads. (and just to head off the inevitable drive by comments like "It's not practical to shop around while you're in an ambulance" - the vast majority of medical care is scheduled ahead of time rather than on an urgent basis)
_heimdall 2mo ago
Nothing stops a doctor or an office from saying "treatment X costs $Y." Doctors can't say how much an insurance provider will cover or what a patient's out of pocket will therefore be, but that is a separate issue further downstream of clear pricing for treatment.
- nradov 2mo ago
  Right, and as I already pointed out below, cash pay patients have the right to demand a Good Faith Estimate (GFE) from providers under federal price transparency rules.
  - _heimdall 2mo ago
    That shouldn't be limited to cash payers though. Insurance companies should not be part of the process of care providers pricing their service, nor should they be able to deny a charge after the fact. Today's model is great for the insurance company, it should be great for the patient. If one wants to offer an insurance product they should be considering average cost of care based on whatever factors their actuaries come up withz they shouldn't be demanding say into pricing so they can protect their bottom line.

by nradov 2mo ago

mindslight 2mo ago

One can always craft some excuse, which is how the terrible system continues to perpetuate itself. Doctors cannot even tell you how much they themselves will charge for anything. The problem I'm describing originates completely with them - no escaping blame here. (And "might take years" lol. How about eliminate whatever flagrant regulatory capture is allowing providers to create and enforce post-facto and downright fraudulent bills in the first place, and watch the system reform itself overnight)

nradov 2mo ago
Feel free to blame doctors if that makes you feel better but the reality is that in most cases they literally have no way to accurately calculate a patient's out-of-pocket cost in advance. Like there's just no technical way to do it. If you have specific suggestions for fixing the regulatory capture problem then you can submit a petition for rule making under the Administrative Procedures Act. https://www.govinfo.gov/content/pkg/USCODE-2011-title5/html/USCODE-2011-title5-partI-chap5-subchapII.htm https://www.govinfo.gov/content/pkg/USCODE-2011-title5/html/...
- mindslight 2mo ago
  You keep misinterpreting "how much [a doctor] themselves will charge for something" as "patient's out-of-pocket cost". I'm certainly not asking for the doctor to get involved between the patient and their health plan [0], but rather what the doctor charges, regardless of who might pay. In other words, the straightforwardly-legible prices that exist in every other market - even markets where insurance companies often pay (eg auto repair). I don't know the specific legal details that allow doctors to make up these post-facto bills (often fraudulent) and send them to patients, but I feel it's probably at the state level rather than federal. Also the big problem with regulatory capture is that businesses paying off politicians makes that kind of citizen feedback meaningless. [0] in fact I think another good angle of reform would be "if a patient has a health plan, providers are prohibited from billing the patient directly". Any copays, outstanding balances, etc should flow through the health plan.
  - nradov 2mo ago
    Are you perhaps unfamiliar with existing price transparency rules? Patients paying cash already have the right to demand a Good Faith Estimate in advance. Those using a commercial health plan can see the negotiated rates for every participating provider. https://www.cms.gov/medical-bill-rights/help/guides/good-faith-estimate https://www.cms.gov/medical-bill-rights/help/guides/good-fai... https://www.cms.gov/priorities/healthplan-price-transparency/overview/consumers https://www.cms.gov/priorities/healthplan-price-transparency...
    - mindslight 2mo ago
      I'm aware of them, but I'm not familiar with them as they seem like band-aids that add even more patient self-administrative bloat, rather than fixing the core dynamic - making healthcare pricing work like every other industry. The word "demand" is a tell, showing that this is not the normal course of the relationship. Another tell is that it's two prongs - why can't everyone receive a "good faith estimate" from a provider? Note I'm still not asking the provider to grok the patient's health plan - rather to be upfront about the prices they themselves are choosing to charge. Also the ambiguous place between the two cases - "you have a health plan but we didn't do the work to actually bill it" - is a common source of the fraudulent shakedown bills, and this does nothing to constrain those types of fraudulent bills! In general, I don't need to request a "Good Faith Estimate" from a grocery store about my upcoming food purchase for when I go later in the week, nor for an oil change down at the mechanic. If I go to the mechanic with "something is making a noise", then they are upfront about any fixed diagnosis fee, and then give estimates routinely in terms of a shop rate and book hours. If there are still unknowns about what might need to be fixed/replaced, they are up front about that and readily communicate with the customer. All of this is straight up missing in the medical industry, even when you try to engage. Rather they shove "consent" forms at you that say nonsensical anti-contractual things like "we can bill you whatever we want and you're responsible" and when you start pushing back on them they look at you like you have three heads. (and just to head off the inevitable drive by comments like "It's not practical to shop around while you're in an ambulance" - the vast majority of medical care is scheduled ahead of time rather than on an urgent basis)

_heimdall 2mo ago

Nothing stops a doctor or an office from saying "treatment X costs $Y." Doctors can't say how much an insurance provider will cover or what a patient's out of pocket will therefore be, but that is a separate issue further downstream of clear pricing for treatment.

nradov 2mo ago
Right, and as I already pointed out below, cash pay patients have the right to demand a Good Faith Estimate (GFE) from providers under federal price transparency rules.
- _heimdall 2mo ago
  That shouldn't be limited to cash payers though. Insurance companies should not be part of the process of care providers pricing their service, nor should they be able to deny a charge after the fact. Today's model is great for the insurance company, it should be great for the patient. If one wants to offer an insurance product they should be considering average cost of care based on whatever factors their actuaries come up withz they shouldn't be demanding say into pricing so they can protect their bottom line.