[mwerd]

I can't imagine the stress of having a loved one, especially a child, in a life threatening state. Adding byzantine medical documentation, coding, billing, and collections on top is certainly insult to injury. As a patient and consumer, we just really shouldn't have to care.

If your daughter's treatment had complications, such as a hospital acquired condition and/or sepsis during treatment, her diagnosis at discharge may change. That would change the cost. It's not disingenuous to say that you don't know what a final claim will say until all of this complexity is adjudicated. The existing billing system exists for good reasons. I am not particularly in favor of them, but there are real constraints that must be considered before we can improve. I think the burden on clinicians is unreasonably high and the regulations, driven by Medicare, are so complex that they require an army of clerical staff to navigate. That's the reality of the situation and if the cost and customer experience of healthcare matters to you, I believe you need to confront that reality instead of dismissing it.

edit: changed son to daughter, my mistake.

[nostrebored]

But this is _not the case_ in other countries. In South Africa, if you go into a private ER, there are buckets of severity and a clear price tag. If they are going to do something to you that might change the price at discharge, they will tell you. If you have a discrete problem like 'my ear hurts and I want to go to an ENT doctor' then they tell you what the price will be upfront.

It does not have to be a gigantic mess. Being back in the US, I just went to the ER and it was shocking being discharged and not being able to know what I owe.

[mwerd]

Well in the u.s. the decision about severity has to be supported by medical documentation from a licensed provider. That medical documentation has to be converted to billing codes and put on a Medicare designed claim form. Payers, primarily government institutions like Medicare and state Medicaid offices, regularly audit these claim forms by random sample. If they find errors on those forms, such as a severity code that was not supported by the documentation, they extrapolate the number of failed tests in their sample to the population of claims they paid and claw back those payments. Depending on context, they might actually impose treble penalties as well and run your name through the press as committing fraud.

Do they do something like that in South Africa? It's not exactly known for the high quality of it's institutions.

Paying for better care and experience is possible in any country. Perhaps it's relatively easy, in a high inequity country like SA, to pay for an experience you like. Labor is pretty cheap there. It's gonna cost you more in the U.S. but you can get that experience here too, if you want. Find a doctor who doesn't take insurance or maybe look at Atlas. Bring your checkbook...

[yamtaddle]

> It does not have to be a gigantic mess. Being back in the US, I just went to the ER and it was shocking being discharged and not being able to know what I owe.

One of the outright-grossest things about US ERs is they have dedicated vulture-like staff wandering around to extract billing information from the sick, injured, and distraught, but those folks can't even tell you anything about what it's going to cost (and neither can anyone else).

[DavidPeiffer]

My personal favorite is when they come around with their computer cart and have you sign on a 2x6 inch signature pad without showing you the documents. Growing up as the son of an attorney, I read documents before signing and get annoyed that this ever became the status quo.

It seems to be about 3 signatures. But if you don't insist they print the documents off and give you a copy, you could be signing away tons of rights you wish you had down the line.

--

Tangentially related to billing, the workflow to check in with one of my clinics requires me to give them permission for more aggressive collection practices than are legally required. I can revoke that permission anytime, but there's no option to turn it down while checking in. So every time I check the box, then immediately talk with the receptionist to add a flag on my account. She takes a screenshot and prints it off for me. From doing that interaction a couple times, I think I'm one of very few people who do it.

[GrinningFool]

I agree to a point. Complications come up in treatment, and of course nobody can know those ahead of time. However I called out your comment as disingenuous because it added a lot of variables to what was originally described, then more or less said "Well, of course we can't know what the cost will be ahead of time."

So let's take it as a given that because we're not prescient, it is not possible to give a 100% guaranteed-accurate price up front[1].

Even in the presence of those variables, the system should not prevent providers from saying "here's what we normally have to do in this case, and here's what those procedures should cost. Less often, we run into these other things - we'll get into them if we need to, but the cost for those can range from _ to _. Of this, your insurance plan will _usually_ cover $_ to $_."

I'm not dismissing the history behind the brokenness, but that doesn't mean it's not broken. The fact that it's broken for complicated reasons doesn't mean it can't be made significantly better.

I'd like to understand, but nobody is really explaining. "Regulations are expensive to comply with" doesn't really explain why those costs can't be predicted and incorporated into the up-front pricing. On the other hand, different prices for different payers seems like something that would add a lot of unpredictability to pricing.

[1] though this doesn't explain why prices aren't disclosed for common, fixed procedures - diagnostics, removing a mole and having it biopsied, etc.

[mwerd]

I would point to a few key reasons for the complexity.

1) Value based care - It used to be simpler with a model called fee for service. Get paid for what you provide. Insurers, Medicare in particular, aggressively drove the industry away from that because they argued it incentivized unnecessary care. The general approach now is value based care, where the insurers and providers negotiate a rate for each type of procedure or case, usually quoted as a percentage of the Medicare rate. In practice, that means that hospitals don't get paid for what they did, they get paid for the problem they solved, regardless of what it took to solve it. I'm oversimplifying, as this all depends on the setting for the care and the contract specifics, but this is certainly a major factor in how things got so complicated.

2) Supporting documentation - To combat fraud, insurers require that an appropriately licensed clinician provide medical documentation supporting the problem's conclusion. The insurers actually check for compliance, i.e. that the notes support the conclusion, in a significant number of instances. In response, the provider side of the industry has instituted expensive software (Epic, Cerner) and employs an army of clerical workers to be prepared to respond to audits from payers. These audits come in many forms, the most common is a denial where the payer essentially calls bullshit on a single claim, and the providers have to cough up detailed justification to get paid. Many providers find responding to denials so onerous that they don't even try, they just eat the loss. You can't do that in isolation though, that expected loss gets baked into the prices over time. And now you've got your most highly trained, value add people in the industry, doing data entry, by the way.

3) silos of information and decision making - The hospital cannot definitely tell you what you will pay out of pocket. They may be able to tell you the negotiated rate they have with your payer for a specific service, but they do not know if you will have met your annual deductible by the time you are billed. Your insurer has that information, not the hospital or the doctor's office. Your doctor is also not likely to know the complex billing logic, so even if they could tell you what they typically write in their notes for what they intend to do to you, you would still have a few steps before you could figure out what's likely to be billed (because it has to be converted to billing syntax). You may also know things that would affect the billing decisions that your provider doesn't know yet. If you're going to have a procedure and you've got diabetes, for example, your case might be considered complicated and command a higher rate. The list of complicating diagnoses is long. That's one reason you usually get labs done before a procedure. The provider needs to know what they're dealing with and that information can affect how much you and your insurer will ultimately pay.

Each of these factors complicate the billing logic. They all exist for good reasons. You don't want call center workers diagnosing patients and telling them how much things are going to cost. You don't want providers performing unnecessary procedures to drive up billings. Insurers have found that well intentioned providers are often sloppy with their notes or outright unethical with their billing practices. If the insurers can catch those mistakes, they can deny payment, and make more money, some of which will be used to keep premiums lower.

It all exists for a reason but put it together and you've got a damn mess and no one's happy.