[wayne_skylar]

I'm currently uninsured and trying to deal with the healthcare system in the US is so annoying it makes me want to give up and move to Canada.

I went to an urgent care center and had a doctor perform a routine examination for a sinus infection. No special tools or materials were used. Before I went in I signed a form stating that I acknowledged that I was on the hook for whatever extra it cost if the situation required it. I was thinking along the lines of bloodwork, x-rays, etc. The doctor was very helpful in avoiding unnecessary expense as well.

A month after I paid and left I got a bill in the mail stating the that doctor had performed an 'extensive examination' and that cost an extra hundred dollars. They had all the information necessary to bill me this as I left the urgent care. Yet they chose to wait and send me a bill because it's a complete fraud.

I really wish I could find out the answer to how this works, but my guess is that there is some automated process that tacks on extra billing where possible as a way of boosting income. Ordinarily it's a 'victimless' crime in that it is paid for by an insurance company.

But ultimately we're fucked in this country with regards to healthcare. It is a disaster that keeps people sick, yet we need it because it's such a large part of our economy. Little by little this sector has inserted themselves into the literal lifeblood of the nation's finance and health and is holding everyone hostage.

[cabaalis]

I've never had to do this before from a patient standpoint, but perhaps you could try to find out what codes were billed for the visit. [1] Compare this to what was actually performed. It is possible they upcoded your visit, either inadvertently or on purpose (illegally.)

Aside from that, (EDIT: More likely) it could also be that lots of billing actually takes place when a coder reviews the doctor's note of the encounter. This can be several days after the visit. This is a legitimate and very common practice. They might not have known the correct amount to charge until everything was properly coded.

[1] https://coder.aapc.com/cpt-codes-range/2869 [2] https://www.verywellhealth.com/what-is-upcoding-2615214

[Ididntdothis]

My girlfriend had a surgery two years ago and she is still getting random new bills from providers we don’t even know. Often in the range of several 10000 dollar. It’s really infuriating. She had cleared everything with the insurance but she still has to spend hours and hours trying to clear this up. In my view dealing with the mafia is more transparent and easier to understand than what hospitals do. I have never seen such a clusterfuck in any other industry.

They believe they can charge whatever they want even years after the service. You can never be sure if you are really done with them.

[refurb]

Your exam notes are sent to billing, who, using the notes tries to determine which billing codes are correct. Obviously they have every incentive to “up code” and get the most amount of money.

[sizzle]

This process needs to be more transparent upfront. The physician should know exactly what services they are referring between the course of you entering their room, a formal diagnosis and treatment plan of action being made, and you exiting the room.

Why is it okay to tack on all these mysterious services rendered after the fact that may not have actually transpired and were instead 'upcoded' as the insurance company may cover it. This creates perverse incentives and allows physicians to bill the max rate and optimize for rendering the most lucrative number of services and they can reasonably get away with.

I've seen dentists do this time and time again if you come in with PPO and put the pressure on you for extra services if you have an HMO cause they are barely getting paid, recommending laser treatment for killing bacteria and a plethora of other scare tactics to get you to pay for their fancy equipment and hygienists, etc (confirmed this with a dentist relative).

[refurb]

Agreed!

I can understand when some complicated procedures can’t be correctly estimated until after, but there is no reason why routine procedures can’t be priced out ahead of time.

When my daughter had her tongue tie fixed at a dentist, they gave us the procedure codes ahead of time and I could ask insurance exactly what it would cost. It was beautiful.

It’s such a big problem now I’m surprised a hospital doesn’t use it as a selling point “we give you a guaranteed estimate and if we’re wrong, we eat any additional cost”. I know that would weigh pretty highly when I’m selecting a hospital.

[ohazi]

You're lucky it was only $100.

Every hospital system does this, and it's a complete fucking racket.

I've gotten these "three months after you thought you were done with this shit" bills for anywhere between $300 and $1000. All were minor, single specialist visits or tests that lasted < 30 minutes.

[sizzle]

I wish I could go in with a GoPro and record every damn second so I can prove they didn't provide the maxed out 'upcoded' services they are claiming they rendered to get the most out of insurance companies.

This is literally extortion, you are on the hook when the artificially inflated bill arrives that insurance won't cover and you were duped into signing for just to be seen by a physician at their practice and your credit will take a hit when the debt collectors are hounding you for their cut if you don't pay up for these services that were upcoded after the fact.

[cosmie]

> I really wish I could find out the answer to how this works

It's billing code optimization. Doctors aren't specialists in billing/diagnosis codes, and their time is really valuable, so many of them tend to use a handful of fairly generic defaults they're most used to and then move onto the next patient. This is what you paid when you left.

There are really, really specific requirements for many billing/diagnostic codes, which will each have a fee defined against them. If a code requires a specific question to have been asked or a specific set of actions to have been performed by the doctor, if even the most minor component is missing it risks having the claim rejected[1]. Or more specifically, if it's missing _from the doctor's notes_[2], such that there's no documentation that it was done/asked, then it risks being rejected.

An asynchronous process got kicked off after your visit, where your visit details went into the queue for either a medical coder (either human or software) to review visit details, prognosis, and doctor notes. Then, based on their findings, they adjusted the code your doctor originally used (either changing it entirely, or adding supplemental codes). That's why you got an incremental bill at the end.

[1] This is in the case of insurance companies. If a medical practice wants to charge for a code, the insurance company demands the requisite documentation to justify the use of that code. I've never tried it, but you may have some success disputing the bill by _also_ requesting the specific diagnostic codes that led to the incremental bill, as well as the supporting documentation to justify the coding. Which is what an insurance company would do, too.

[2] This is one of the big benefits of an EHR to a practice. The EHR workflows can be set up to require a bunch of boilerplate information be collected and processes be followed, which generates very rich visit notes and provides a lot of opportunity (and documentation to justify) for upcoding a visit. Which usually makes administrators/practice managers happy, while mildly annoying physicians.

[sizzle]

Wouldn't a physician be incentivized to bill for the max amount of services that can reasonably be rendered per diagnosis that insurance companies will pay out for once they learn how to game this system?

[cosmie]

Yes. Which is why they pay for medical coders (or equivalent software) to optimize it for them. It's the equivalent of using an accountant for your taxes - you can certainly do your own, but your accountant likely has a far better idea of what the IRS considers "reasonable" and therefore where they can and can't get creative on your behalf.

Different insurance companies have different tolerances, requirements, and denial tendencies for specific codes. So the definition of "reasonable" is highly contextual.

At least in this instance, the surprise bill was _only_ $100 from what sounds like a fairly standard medical coding practice. He could have just as easily been surprised with a several thousand dollar ER bill[1] if he had chosen a more financially creative urgent care facility.

[1] https://www.houstonchronicle.com/business/medical/article/Co...

[gnopgnip]

Why would you move to Canada instead of purchasing insurance?