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And this can really cause issues for people who are insured because if an insurance company decides not to cover something (very very common, even in-network) t

And this can really cause issues for people who are insured because 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. That is until you call the hospital and find out there's all sorts of "sliding" prices etc... I had a procedure billed for one of these drastically larger "insured" codes which got denied based on the nature of the procedure from the insurance company (apparently too new of a procedure at the time, however common now). It all got worked out in the end but what I realized was that hospitals are largely subsidizing the cost of the uninsured by over-billing the insured folk's insurance companies. We've set the American healthcare system up to be a cat and mouse game where those in need are represented the least. Best insurance here is "don't get sick"

throwaway0a5e 5y ago
<deleted>
- folkhack 5y ago
  There's police around hospitals constantly and if they get a whiff that you have a fake ID they're going to be talking to law enforcement sooner or later. Also this isn't going down to your corner liquor store and flashing your drivers license... that thing is going to get scanned etc. --- Actual protip: If you're uninsured and need care they legally can't turn you away at an ER. They have to provide the healthcare to get you stabilized regardless if they're going to be able to bill for it or not... which ironically this is a big part of why the insured end up subsidizing the uninsured at the hospital. Also, if this ends up being you - don't sign anything until you're in the right mind to sign something. They're going to try to pin you to bill your ass off one way or another and if you're half way through a heart attack or something do not sign anything until you can 100% understand what you're legally agreeing to.
  - deleted 5y ago
    [deleted]
  - throwaway23438 5y ago
    I've often wondered what would happen if you went to the ER, carried no identifying documents, and just refused to identify yourself. Just hope nobody recognizes you there. Giving a fake name is fraud, and people have been arrested for doing that at the ER. (Fuck America.) But I don't know that there's any legal obligation to give any name at all. If you don't give them a name, you're not lying to them, and oops, looks like they don't have a way to bill you. As you note, hospitals are legally required to provide emergency stabilization without regard to ability to pay. I suppose the hospital could try to call the police, but AFAIK the police cannot compel you to identify yourself without reasonable suspicion that you have committed a crime.
    - texasbigdata 5y ago
      I believe legally they have a duty to provide care.
      - throwaway23438 5y ago
        Yes, that's my understanding. So wouldn't refusing to identify yourself be an effective way to avoid a bill, without the criminal exposure of giving a fake name or ID?
    - kube-system 5y ago
      People show up at hospitals physically unable to identify theirselves all of the time. https://www.npr.org/sections/health-shots/2019/05/07/720702299/how-hospital-er-sleuths-race-to-identify-an-unconscious-or-dazed-jane-or-john-do https://www.npr.org/sections/health-shots/2019/05/07/7207022... Hospitals that accept medicare do have a legal obligation to stabilize patients. But we're talking 'stabilize' as in 'you're not dying'. If you're alert and capable enough to be arguing with people and you're not a psych danger, you're likely stable enough to legally be thrown out on the street.
      - throwaway23438 5y ago
        I'm aware of that. That's different from refusing to identify yourself to avoid paying money to the healthcare racket. The discussion here is whether there is a legal obligation to identify yourself. If there is such a requirement, it would apply to someone who is fully capacitated but refusing to identify themselves. It would not apply to someone who is unable to identify themselves due to incapacity, because such a person obviously lacks any criminal intent.
mabub24 5y ago
> Best insurance here is "don't get sick" Recent New Yorker article looking at the "Costa Rica model"[0] raised this point as well. America, by contrast to Costa Rica, has a very weak public health sector and infrastructure, and this leads to a real weakness when focusing on preventable illnesses and issues. [0]: https://www.newyorker.com/magazine/2021/08/30/costa-ricans-live-longer-than-we-do-whats-the-secret https://www.newyorker.com/magazine/2021/08/30/costa-ricans-l...
- folkhack 5y ago
  Yeah I read that too - just cherry picking here: > All adults have tests and follow-up visits to prevent and treat everything from iron deficiency to H.I.V. It’s all free. If people don’t show up for their appointments, she makes sure their team finds out why and figures out what can be done. It's common sense why they have better results and outcomes than we do here... Our system is optimized for capitalistic profit. I've got insanely good insurance and I still have no idea how screwed I am if I go to the doctor or especially a hospital. Although I've only had one major billing snafu years back I have real anxiety about going to the doctor here. And hell, even if I go my PCP is going to be stuck in an "all or nothing" mentality where it's either OTC or getting in their own conflict with my insurer... ie: "If I can't justify this test with your insurer..." --- Costa Rica's model is better than America's. The reason for this is because it's not optimized for profit, it's designed from the ground up to optimize for patient outcome.
  - fidesomnes 5y ago
    > Our system is optimized for capitalistic profit. We got a real astute analyst here. I am curious what your first hint of such a fact was?
  - Thlom 5y ago
    In a well functioning health care system screenings like that is actually of debatable value as it generates a lot of false positives and un-necessary procedures.
EvanAnderson 5y ago
> 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...
mywittyname 5y ago
> if an insurance company decides not to cover something (very very common, even in-network) Which is why hospitals charge higher prices to insurance companies. Insurance companies often blanket deny every single claim made against them. This forces the hospital revenue cycle department to have an appeals nurse review just about every procedure done in the hospital, and justify its use. This almost always results in a "discount" for something by virtue of a care provider not justifying every action they take. Revenue cycle management departments used to be small, about 1 per 1000 hospital employees. Today, they are so big - and make so much money* - that hospital systems are spinning off their revenue cycle management companies for billions of dollars. Private equity firms have been acquiring in this space like mad since about 2016. * Really, they are actually getting the money that is already owed.
jrochkind1 5y ago
>> They have a column called "Uninsured cash price." These prices are <25% of the insurance "discount" prices > And this can really cause issues for people who are insured because 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. That doesn't sound like an "inflated" price? 25% of what insurance companies are billed for? I'm confused. I'm not sure y'all are talking about the same things?
- wswope 5y ago
  He’s saying if you go in as an insured patient and get denied for a procedure by the insurance company after it’s been performed, you’ll get a bill from the hospital for the insurance-negotiated rate, not the uninsured cash pay rate. You can generally talk the billing department down to the cash pay rate, but that requires having a lot of meta-knowledge of how American healthcare works.
  - jrochkind1 5y ago
    omg, I see what you mean. Confusing as heck.
luxuryballs 5y ago
That last sentence would be a great opener to the explanation of what insurance is, it’s not healthcare, insurance is something you don’t want to have to use. Healthcare is just healthcare, you can buy it from all sorts of places in various forms without billing to insurance. Just like how car insurance is not a mechanic.
hellbannedguy 5y ago
"I realized was that hospitals are largely subsidizing the cost of the uninsured by over-billing the insured folk's insurance companies." 1. You have to back up claims like this. 2. I imagine for-profit Insurance companies would love to blame their prices on the uninsured. 3. Many poor people actually have insurance in the USA. Even if they don't apply for it, insurance can be applied for after the fact. 4. The wealthy, and the poor are usually covered by insurance. It's the middle class that needs attention. They have insurance, but it's not great. I still don't belive our healthcare costs are due to the uninsured. Oh yea, every hospital has a fierce Billing and Collections department. They are allowed to go after your assets if you can't pay your bill, and they do. Obamacare gave patients some rights, but hospitals blatantly abuse the regulations. The right to collect in municipal court was never taken away from hospitals. In my local newspaper, it's not uncommon for a hospital to sue a patient over a bill, and put a Judgment lien on the patients assets. They claim they only do this as a last resort, but bankruptcy due to medical bills are still the number 1 reason people end up in federal court (Bankruptcy). Your protections under a bankruptcy are not great either. There are many hospitals that forced a former patient to sell their home (homestead exemption needs to be higher. In TX, they can't touch your primary residence.). under a bankruptcy. In CA, for example, the primary home gets a $250,000 protection. (Look up that last figure. I know it's very low in CA, and needs to be raised to at least a million. You have a $600,000 home. You are only protected by $250,000 of it's worth. So in America, if you do get sick, and can't pay all your medical bills, you have no protections. These for-profit medical companies will come after you with more zest than an unpaid credit card. I think CC companies are less aggressive.
- folkhack 5y ago
  1. All you have to do is look at the chargemaster flat files that have been coming out. There are literally two different columns for insured and non-insured procedure cost and for every hospital I've obtained a chargemaster flatfile for this is the case. Other comments in this thread have backed this up, and have even claimed their hospital's chargemaster had the non-insured pricing column hidden potentially in bad faith. 2. I mean, I have no idea but for-profit insurance companies aren't out there really blaming anyone as they're just a faceless corporate entity. I've only heard hospital staff and normal people blame the uninsured. 3/4... no - poor people don't have insurance. I've grown up around people who were not economically privileged/who were struggling and this is just 100% untrue that poor people can get insurance as you posit. I've had private insurance and it's just not something someone can afford if poor. And, if you're referring to things like "Christian Healthcare Ministries" they're straight-up scams. Outside of that, there is no way American restaurant owners, retail franchises, etc will cover an unskilled laborer's health insurance - that just does not happen here. --- > I still don't *believe our healthcare costs are due to the uninsured. When it comes to hospital billing - yeah. It is a huge thing that's baked into their SOP. See item #1 above.
deleted 5y ago
[deleted]
maxerickson 5y ago
Underpayment is a few percent of hospital revenues. It's a component of costs for sure, but only a small one. https://www.aha.org/factsheet/2019-01-02-uncompensated-hospital-care-cost-fact-sheet-january-2019 https://www.aha.org/factsheet/2019-01-02-uncompensated-hospi... My understanding is that you would usually pay the price set by the agreement your insurance has, even if they deny coverage of it.

throwaway0a5e 5y ago

folkhack 5y ago
There's police around hospitals constantly and if they get a whiff that you have a fake ID they're going to be talking to law enforcement sooner or later. Also this isn't going down to your corner liquor store and flashing your drivers license... that thing is going to get scanned etc. --- Actual protip: If you're uninsured and need care they legally can't turn you away at an ER. They have to provide the healthcare to get you stabilized regardless if they're going to be able to bill for it or not... which ironically this is a big part of why the insured end up subsidizing the uninsured at the hospital. Also, if this ends up being you - don't sign anything until you're in the right mind to sign something. They're going to try to pin you to bill your ass off one way or another and if you're half way through a heart attack or something do not sign anything until you can 100% understand what you're legally agreeing to.
- deleted 5y ago
  [deleted]
- throwaway23438 5y ago
  I've often wondered what would happen if you went to the ER, carried no identifying documents, and just refused to identify yourself. Just hope nobody recognizes you there. Giving a fake name is fraud, and people have been arrested for doing that at the ER. (Fuck America.) But I don't know that there's any legal obligation to give any name at all. If you don't give them a name, you're not lying to them, and oops, looks like they don't have a way to bill you. As you note, hospitals are legally required to provide emergency stabilization without regard to ability to pay. I suppose the hospital could try to call the police, but AFAIK the police cannot compel you to identify yourself without reasonable suspicion that you have committed a crime.
  - texasbigdata 5y ago
    I believe legally they have a duty to provide care.
    - throwaway23438 5y ago
      Yes, that's my understanding. So wouldn't refusing to identify yourself be an effective way to avoid a bill, without the criminal exposure of giving a fake name or ID?
  - kube-system 5y ago
    People show up at hospitals physically unable to identify theirselves all of the time. https://www.npr.org/sections/health-shots/2019/05/07/720702299/how-hospital-er-sleuths-race-to-identify-an-unconscious-or-dazed-jane-or-john-do https://www.npr.org/sections/health-shots/2019/05/07/7207022... Hospitals that accept medicare do have a legal obligation to stabilize patients. But we're talking 'stabilize' as in 'you're not dying'. If you're alert and capable enough to be arguing with people and you're not a psych danger, you're likely stable enough to legally be thrown out on the street.
    - throwaway23438 5y ago
      I'm aware of that. That's different from refusing to identify yourself to avoid paying money to the healthcare racket. The discussion here is whether there is a legal obligation to identify yourself. If there is such a requirement, it would apply to someone who is fully capacitated but refusing to identify themselves. It would not apply to someone who is unable to identify themselves due to incapacity, because such a person obviously lacks any criminal intent.

mabub24 5y ago

> Best insurance here is "don't get sick" Recent New Yorker article looking at the "Costa Rica model"[0] raised this point as well. America, by contrast to Costa Rica, has a very weak public health sector and infrastructure, and this leads to a real weakness when focusing on preventable illnesses and issues. [0]: https://www.newyorker.com/magazine/2021/08/30/costa-ricans-live-longer-than-we-do-whats-the-secret https://www.newyorker.com/magazine/2021/08/30/costa-ricans-l...

folkhack 5y ago
Yeah I read that too - just cherry picking here: > All adults have tests and follow-up visits to prevent and treat everything from iron deficiency to H.I.V. It’s all free. If people don’t show up for their appointments, she makes sure their team finds out why and figures out what can be done. It's common sense why they have better results and outcomes than we do here... Our system is optimized for capitalistic profit. I've got insanely good insurance and I still have no idea how screwed I am if I go to the doctor or especially a hospital. Although I've only had one major billing snafu years back I have real anxiety about going to the doctor here. And hell, even if I go my PCP is going to be stuck in an "all or nothing" mentality where it's either OTC or getting in their own conflict with my insurer... ie: "If I can't justify this test with your insurer..." --- Costa Rica's model is better than America's. The reason for this is because it's not optimized for profit, it's designed from the ground up to optimize for patient outcome.
- fidesomnes 5y ago
  > Our system is optimized for capitalistic profit. We got a real astute analyst here. I am curious what your first hint of such a fact was?
- Thlom 5y ago
  In a well functioning health care system screenings like that is actually of debatable value as it generates a lot of false positives and un-necessary procedures.

EvanAnderson 5y ago

> 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...

mywittyname 5y ago

> if an insurance company decides not to cover something (very very common, even in-network) Which is why hospitals charge higher prices to insurance companies. Insurance companies often blanket deny every single claim made against them. This forces the hospital revenue cycle department to have an appeals nurse review just about every procedure done in the hospital, and justify its use. This almost always results in a "discount" for something by virtue of a care provider not justifying every action they take. Revenue cycle management departments used to be small, about 1 per 1000 hospital employees. Today, they are so big - and make so much money* - that hospital systems are spinning off their revenue cycle management companies for billions of dollars. Private equity firms have been acquiring in this space like mad since about 2016. * Really, they are actually getting the money that is already owed.

jrochkind1 5y ago

>> They have a column called "Uninsured cash price." These prices are <25% of the insurance "discount" prices > And this can really cause issues for people who are insured because 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. That doesn't sound like an "inflated" price? 25% of what insurance companies are billed for? I'm confused. I'm not sure y'all are talking about the same things?

wswope 5y ago
He’s saying if you go in as an insured patient and get denied for a procedure by the insurance company after it’s been performed, you’ll get a bill from the hospital for the insurance-negotiated rate, not the uninsured cash pay rate. You can generally talk the billing department down to the cash pay rate, but that requires having a lot of meta-knowledge of how American healthcare works.
- jrochkind1 5y ago
  omg, I see what you mean. Confusing as heck.

luxuryballs 5y ago

That last sentence would be a great opener to the explanation of what insurance is, it’s not healthcare, insurance is something you don’t want to have to use. Healthcare is just healthcare, you can buy it from all sorts of places in various forms without billing to insurance. Just like how car insurance is not a mechanic.

hellbannedguy 5y ago

"I realized was that hospitals are largely subsidizing the cost of the uninsured by over-billing the insured folk's insurance companies." 1. You have to back up claims like this. 2. I imagine for-profit Insurance companies would love to blame their prices on the uninsured. 3. Many poor people actually have insurance in the USA. Even if they don't apply for it, insurance can be applied for after the fact. 4. The wealthy, and the poor are usually covered by insurance. It's the middle class that needs attention. They have insurance, but it's not great. I still don't belive our healthcare costs are due to the uninsured. Oh yea, every hospital has a fierce Billing and Collections department. They are allowed to go after your assets if you can't pay your bill, and they do. Obamacare gave patients some rights, but hospitals blatantly abuse the regulations. The right to collect in municipal court was never taken away from hospitals. In my local newspaper, it's not uncommon for a hospital to sue a patient over a bill, and put a Judgment lien on the patients assets. They claim they only do this as a last resort, but bankruptcy due to medical bills are still the number 1 reason people end up in federal court (Bankruptcy). Your protections under a bankruptcy are not great either. There are many hospitals that forced a former patient to sell their home (homestead exemption needs to be higher. In TX, they can't touch your primary residence.). under a bankruptcy. In CA, for example, the primary home gets a $250,000 protection. (Look up that last figure. I know it's very low in CA, and needs to be raised to at least a million. You have a $600,000 home. You are only protected by $250,000 of it's worth. So in America, if you do get sick, and can't pay all your medical bills, you have no protections. These for-profit medical companies will come after you with more zest than an unpaid credit card. I think CC companies are less aggressive.

folkhack 5y ago
1. All you have to do is look at the chargemaster flat files that have been coming out. There are literally two different columns for insured and non-insured procedure cost and for every hospital I've obtained a chargemaster flatfile for this is the case. Other comments in this thread have backed this up, and have even claimed their hospital's chargemaster had the non-insured pricing column hidden potentially in bad faith. 2. I mean, I have no idea but for-profit insurance companies aren't out there really blaming anyone as they're just a faceless corporate entity. I've only heard hospital staff and normal people blame the uninsured. 3/4... no - poor people don't have insurance. I've grown up around people who were not economically privileged/who were struggling and this is just 100% untrue that poor people can get insurance as you posit. I've had private insurance and it's just not something someone can afford if poor. And, if you're referring to things like "Christian Healthcare Ministries" they're straight-up scams. Outside of that, there is no way American restaurant owners, retail franchises, etc will cover an unskilled laborer's health insurance - that just does not happen here. --- > I still don't *believe our healthcare costs are due to the uninsured. When it comes to hospital billing - yeah. It is a huge thing that's baked into their SOP. See item #1 above.

deleted 5y ago

[deleted]

maxerickson 5y ago

Underpayment is a few percent of hospital revenues. It's a component of costs for sure, but only a small one. https://www.aha.org/factsheet/2019-01-02-uncompensated-hospital-care-cost-fact-sheet-january-2019 https://www.aha.org/factsheet/2019-01-02-uncompensated-hospi... My understanding is that you would usually pay the price set by the agreement your insurance has, even if they deny coverage of it.