[colbyh]

One of my favorite things about the US insurance market is that the lack of transparency into pricing actually hurts both the insured and the institutions providing care.

Small and medium size practices have very few guarantees about how much they will get reimbursed for a procedure and the patient has no idea how much they will pay. It's truly insane.

Is anyone honestly trying to solve those problems right now?

[stanmancan]

I'm pretty sure that's either exactly what YC alum Eligible (https://eligible.com) is trying to solve, or at least part of it.

[skue]

Sure, the space is called Revenue Cycle Management.

OODA Health already has some major partnerships/investments from providers and payers. https://www.ooda-health.com/

Lumedic was acquired last year by Providence St. Joseph, a large hospital system. https://lumedic.io/

[epmaybe]

I have an idea of how to improve transparency, similar to how some insurers provide more information to patients regarding the cost of an MRI at different places in town. However, it requires healthcare consumer buy in at a larger scale, with potential privacy hurdles.

I'm not entirely sure if it would have the intended effect of reducing costs, but it would definitely add more transparency.

[whydoineedthis]

Hrmm...not sure most of what you said is true. Small and medium business may lose claims, but they know the reimbursement for each procedure and if thier claims are legit, they will get reimbursed. There's a requirement to share how much a consumer needs to pay before procedures are done also. Unless your talking about ER care specifically, that's a different beast where you are somewhat correct.

[whoisjuan]

I think he is definitely talking about ER but I’m pretty sure you don’t get the up front cost for random doctor visits or procedures. They simply collect your insurance information and then tell you that the insurance will send the final outstanding balance. This happens regardless if you have enough coverage or not.

I recently visited an Emergency Room and the whole process behind is really obscure.

Like for example, I got a bill from the health care provider for an owed amount and one letter from the insurance company saying that I owed the healthcare provider another different amount. They are not even close.

The whole experience in the ER was pretty fast and high quality but I feel they did a bunch of extra blood work and stuff just for the sake of getting more money out of the insurance and not necessarily because it was needed.

The way I see it the healthcare system in the US is just designed to squeeze as much as possible from the carriers and viceversa but without thinking too much who is the actual liable party which happens to be the sick individual.

I think this is how we ended up with a super expensive healthcare system that bankrupts people. All parties involved (insurance carriers, healthcare providers, healthcare product suppliers, pharmaceutical companies, doctors) think that the opposing party in any transaction is swimming in money so they optimize for squeezing the shit out of the other. That’s how you end up with ridiculous bill items like $1500 dollars for a simple fluids IV.

[whydoineedthis]

how are "small and medium businesses" the same as "definitely ER"? To me, those are the exact opposite things.

[whoisjuan]

There are hundreds of medium-size providers that do Urgent Care & Walk-In Clinics. So maybe my error was generalizing ER. I'm speaking about going to an urgent care clinic and then being remitted to an actual ER. Either way, I have never been charged upfront or given a cost beforehand in neither of those.

[ineedasername]

Recently had to take my son to the hospital. It started in the ER, but he was then admitted to the pediatric ward for a few days. There was nothing, not a thing, that changed in pricing disclosure for procedures and tests between the two. Neither in the ER nor the pediatric unit was any price or any money ever at all spoken about. The closest it ever came was when the admiting clerk in the ER took the insurance card. Now, a few months later, come the bills, and fighting with insurance over partial or no coverage for miscellaneous line items.

[red-indian]

"they know the reimbursement for each procedure"

This is not true.

"There's a requirement to share how much a consumer needs to pay before procedures are done"

This is not true.

[whydoineedthis]

Used to do medical billing. How is this not true? Your telling me doctors are running their businesses with just some random returns for procedures? are you out of your mind?

Also, it is true that thier is a requirement for estimates. Granted, insurance companies can turn down procedures - but like I said, if it's a competent diagnosis than it works out.

But you can just ignore all the words in my post to be dramatic, that's fine.

[buzzerbetrayed]

Sounds like it is your word against his. Do either of you have any sources?

[colbyh]

I work in the industry. Fee schedules are an upper bound, but the lower bound is very hard to get numbers on and often approaches 0.

If I go in for a procedure at a medium sized specialist clinic they are going to take the fee schedule for this CPT, discount by my 20% expected contribution (or whatever), and then hope that the insurer pays them > 50% of the remainder.

A lot of the time my insurer will, but not always. Bigger systems negotiate their own fees and many doctors at larger clinics only track RVUs for each procedure (specifically because the clinics realize that paying based on insurance payout isn't fair or scalable, in that way RVU allocations act as a pool). But overall it's not a transparent system for the majority of people working within in.