[mywittyname]

Health insurance companies have taken to denying almost every claim that hospitals file. This overtaxes the hospitals claims denial departments and costs hospitals millions in lost revenue because they don't have the staff to properly review and resubmit every claim (which has to be done by a clinical specialist).

It's like taking your car to a mechanic, and once it's fixed, refusing to pay, claiming car didn't need THAT repair in the first place. Then getting away with it because you have an arbitration agreement in place with the shop. So the shop needs to employ an entire separate department of ASE certified mechanics that are dedicated to documenting that the repairs performed on customer cars were necessary. But the kicker is, YOU GET TO DECIDE IF YOU'RE CONVINCED THE REPAIR WAS NECESSARY.

Hospitals used to have small (1 person per 10k beds) claims denial departments and use outsourcing firms if case loads increased. Now they are acquiring all the outsourcing firms and increasing their staff to like 100 people per 10k beds. It's insane.

I like to retell a particularly awful denial my partner had to deal with, which was a patient had their open heart surgery claim denied by the insurance company because they determined that the patient's condition only warranted observational care (that's right, the insurance company determines what care you need/get). The hospital eventually won that claim, but they routinely lose $100k+ claims and have to eat the cost.

[garmaine]

On the other hand, when I bring my car to an auto shop they give an estimate of cost before actually doing any work.

[mywittyname]

True story: my partner's department can't just sort denies by highest cost because they literally do not know how much the procedure actually costs and nobody in billing/finance can tell them either.

She came home one day feeling pretty good about overturning a $180k denial. She checked back a few weeks later, and found the paid in full amount to be in the neighborhood of $10k after "negotiated discounts."

The system is fucked. Had the denial gone through, that person would have been on the hook for the full 180k. (Or, to be more accurate, the hospital would have negotiated for $10k from the patient and written the remaining 170k off of their taxes)

[influx]

Not only that but car insurance is for catastrophic events, not for tune ups, and oil changes.

[majormajor]

The people I've known who needed expensive care (high-5-figures or 6-figures) were made well aware of the costs in advance, because at that point the facility wants to make sure your insurance will cover it beforehand. But it doesn't do that much for the patients - comparison shopping doctors and facilities is extremely stressful stuff and a lot of people would rather not think about it, even when some outcome info is available. And the exact details are never known up front, so then you're dealing with "it'll probably cost X more to do it at Y but there's probably a Z percent higher chance of a good outcome..." no-right-answer type serious business decisions.

Emergency care is a different matter, I imagine, insurance-coverage-wise, but pre-approval seems to be fairly widespread for planned stuff these days.

[garmaine]

Except that medical providers don't honor the estimate in the same way an autoshop typically does and is required to do in many jurisdictions. They treat it as just that -- an estimate. You still get charged for whatever procedures are performed, which can change from the estimate when situations change or they deem something to be medically necessary in the moment.

[vkou]

Your car is unlikely to experience life-threatening complications with a nearly unbounded upper cost while it's being fixed.

Your body is. A routine surgery can absolutely turn into a hundred-thousand-dollar nightmare.

Never mind that a mechanic has a much better understanding of a car, then a doctor does of a human body.

[u801e]

> Your car is unlikely to experience life-threatening complications with a nearly unbounded upper cost while it's being fixed.

If you bring your car in for repair and tell them that you need to have the car's brake rotors and pads replaced, the shop can tell you that the parts will cost X and the labor will be Y hours at Z cost per hour and give you a relatively accurate estimate. They may later tell you that there were some bolts that had to be drilled out before they could remove some parts and that may increase the labor cost somewhat.

Why can't that be the same case if I go to get a chest X-ray with posterior-antierior and lateral views? If you have the CPT code(s) and the insurance information, it should not be difficult or time consuming to get the cost estimate.

[dragonwriter]

> Why can't that be the same case if I go to get a chest X-ray with posterior-antierior and lateral views? If you have the CPT code(s) and the insurance information, it should not be difficult or time consuming to get the cost estimate.

It is both difficult and time consuming [0], and, moreover, often distant from the provider, because medical billing is quite often outsourced.

[0] Perhaps not in the median case, but there are plenty of complex cases, which is one of the reasons this is outsourced.

[prklmn]

But is the high cost of those surgeries a product of the broken system? I say yes.

[vkou]

In Canada, developing an accidental MRSA infection after a routine surgery will trivially turn a $5000 procedure into a $25,000 package of life-saving treatment and associated hospital stay.

When things go bad in medicine, your bill grows really, really, really fast.

Also, unlike a mechanic with a car, your doctor can't stop working on you after they blow through their quoted budget and ask if you still want to pay for treating the complications. I mean, they can, but unless you've got a death wish, you're not going to say 'no.'

[logfromblammo]

I certainly don't get more money if I accidentally introduce critical crash-to-desktop bugs, and then spend more time fixing them. I get paid to do the job to a minimum standard of quality. The customer is paying for the outcome they want, not for the amount of work it takes to get there. The Labor Theory of Value rears its ugly, no-good keister again.

If an actuary can quote me the price of a life insurance premium 40 years before a person is expected to die, such that the company doesn't lose money, a hospital can figure out how to price its services such that it doesn't go bankrupt. Those wailing about too many uncontrolled variables are just trying to suck the last available penny out of the patients. How can they possibly nickel-and-dime people to death on their itemized bills if they don't know exactly how many cm of plastic tubing will be needed for the surgery?! How can they charge $25 per 500mg analgesic pill if that is already included in the published price of the procedure?! It's really only a problem if your mission is to suck out all the consumer benefit of trade via price discrimination.

If my auto mechanic blows past their original quote, they don't stop work and ask for more money. They fix the danged problem, charge what they said they would, and try to estimate better on the next job. And they certainly don't plow ahead, replace the engine and transmission and exhaust system, laser-scour the rusted body panels, put on new tires, repaint the exterior, reupholster the interior, clean all the crap out of the trunk, fill up the gas tank, and then try to charge me $120k to get my 2001 Civic back. The doctor can't stop working, but they can stop charging extra for it. If I knew ahead of time that it would have cost that much, I probably would not have consented to the procedure in the first place.

[hibikir]

Ah, but your chances of an MRSA infection aren't the same everywhere. Some hospitals are far better than others at preventing infection, while others are far worse. In a bill per procedure world, like in US medical billing, while I'd not expect anyone to do it badly on purpose, lax procedures that lead to more care are paid by the patient's insurance. In a government owned hospital, or if billing is done up front, it's the hospital's problem. American billing leads to no incentive to saving money, so guess what? US hospitals charge a lot more per procedure and perform somewhat more procedures than everyone else, so ultimately the price is higher.

Even if nobody had insurance and shopped around, the US style of billing would lead to very little downward pressure on prices, as it's impossible to have a clue of what you are going to pay.

Many businesses, including freelance developers, will not charge per hour, but by job. You jack up the price to end up ahead in the case of typical complications, but there are cases where you lose money, and that's on you being bad at estimates and billing. Billing by procedure in the medical system is just setting the wrong incentives, and a recipe for maximum waste, if not downright fraud.

[prklmn]

I couldn't agree more. I've heard talks that the US is heading toward a capitation style payment system.

https://en.wikipedia.org/wiki/Capitation_(healthcare)

[fencepost]

And in the USA, it'll probably turn a 10-15k procedure into a 125+k scenario.

[garmaine]

The rare events could be priced into the routine cases.