Another pitting of the US health ”care” system

The BBQ Pit
421

Reviving this because I just have to complain about health care billing again.

The medical billing is so screwed up that according to my insurance I have about $700 in outstanding medical expenses, but I haven’t been billed for it yet. I can’t get reimbursed from my FSA for the expenses if I don’t pay them, but instead of sending me bills, I just keep getting refunds on my credit card from the hospital.

I have no idea what is being refunded.

The online portal has a statements section, but my last one is from April. It also shows the last time I paid them was in 2022. No outstanding balance on a treatment that insurance shows a $350 copay.

In summary, if I don’t get billed for my outstanding expenses I could lose the ability to get reimbursed for them. At the same time I’m randomly getting sent money. I don’t want to call and ask what is going on, because then they might stop sending me money.

422

That’s exactly right. Your employer pays them. You cost them money every time you’re inconsiderate enough to get sick. You can hardly blame them for trying to keep down their expenses by denying claims and not even wanting to talk to you. The great capitalist profit motive + medical care working together is a wonderful thing to behold!

The entire American health care system is a seriously appalling example of why free enterprise motivations and human health care needs are directly at odds and should never come within a hundred miles of each other.

423

Just as a background, doctors in the US get paid depending on the complexity of the visit. There are crazy complex rules for each level designating the history, physical and complexity of decisions needed to meet each level. If a claim is denied or downgraded it is up to the doctor to appeal and prove that all of the required elements are documented in the note. This often requires staff to spend hours on the phone.

Well in its infinite wisdom, Cigna has decided that starting next month every claim will automatically be downgraded one level. They know that it will be impossible to appeal every claim. You may say just to upcode each claim by one which many doctors already do but that is fraud. For example, if Medicare finds upcoming the fine is triple damages and $10,000 per episode and they are allowed to extrapolate so if for example they look at 10 claims and find one episode of incorrect coding they can assume that 10% of all of your Medicare claims were up coded and can fine you accordingly.

This whole system is just a mess. I wanted to order some labs for a patient without insurance. The lab charges $1100 for this set of labs. The negotiated insurance price is $57. So if you have insurance your insurance company pays $57. If you don’t have insurance you have to pay $1100.

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Does this actually happen in practice? Because from what I can see, upcoding is rampant. Maybe they are smart enough not to do it for Medicare patients.

A friend of ours left the group practice she was in and went solo a few years ago. The group practice had been acquired by the same company that acquired my doctor’s practice. She is a pediatrician.

But she now has employed a “Billing Specialist” just to deal with insurance claims. This person is paid more than a junior doctor or even early career specialist in the UK.

She says she should have opened a med spa instead. Employ a bunch of nurse aestheticians and technicians, take no insurance, mint money.

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A friend is a dermatologist, and about a year ago she decided to stop taking anyone who actually has a medical issue, and only do cosmetic dermatology. I’m sure it has helped her mental health.

426

This is appallingly common in US medical care. When it’s a party you deal with directly (a doctor or hospital) an uninsured patient can sometimes negotiate a “discount” down to something resembling the insurance cost (if they even know to try) but when it’s a third party like a lab, you’re just screwed.

427

Given that my labs that have a list price of $700-ish and a negotiated price of $120, are usually in my EHR before I get into my car in the parking garage, I’m guessing that the $700 is wildly overpriced compared with what any transparent pricing scheme would support in anything resembling a free market.

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One bit of good news, which is ridiculous that it should have even been in question, is the issue of “free” wellness mammograms under the Affordable Care Act. Women over a certain age are supposed to get free mammograms under the ACA. However, 52% of women have dense enough breast tissue that a simple mammogram may not detect tumors. They require an extra ultrasound and more advanced mammography. Which the patient has to pay for, as it supposedly falls under “diagnostic” (the insurance companies get to define it). So how is it a free mammogram for all women if over half of women can’t get by with it? When I had my first and as-yet only mammogram in 2022, I was outraged, and wrote letters to my state insurance commissioner and anyone else I could find. All responded, “Yeah, we know, but it is what it is. We don’t make the rules, we just make sure the insurance companies follow the rules they made up.” It’s similar to how colonoscopies are only covered as free wellness visits if no polyps are removed during it - then it’s “diagnostic” and you have to pay.

Well that massive mammography loophole has finally been closed. As of 2026, additional diagnostic imaging will be covered! That is, until the powers-that-be realize that somebody’s getting the healthcare they were promised by law.

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We The Economy Ep.22: THIS WON"T HURT A BIT. Why healthcare is so expensive. (7 minutes)

430

I got my fill of health insurance companies when my son needed to diagnosed with autism (we knew he was autistic.) So.

If your kid needs speech, OT or PT, they are limited to only a specific number of sessions per year.

If your kid is autistic, you can have unlimited sessions.

This is because early intervention is critical for autism-related delays (and I suppose autism Moms lobbied hard.)

But the insurance company will only agree you have an autistic child if they are evaluated at one of a small insurance-selected handful of Autism Evaluation Centers, where wait lists run from 1-3 years.

So if you have an autistic kid who urgently needs speech therapy or OT or ABA, you’re shit out of luck for 1-3 years.

Here’s where it gets fucking weird. The insurance company also has something called “bridge authorization” which it doesn’t ever tell anyone about, that enables you to get your kid evaluated early for conditional approval, if you have access to their super secret list of places that perform these evaluations, which for some reason are managed by a third party. I don’t know how my husband knew about bridge authorization, but he did. He’s dealing with insurance companies all the time at his job so he was undaunted.

We estimate that my husband spent approximately ten hours a week for several months arguing with the insurance company about bridge authorization. You see, employees at the insurance company had never heard of it, so my husband often had to read insurance staff their own policy and explain what it meant.

Eventually we got bridge authorization, which means my son could start ABA and continue other therapies, and of course when we took him to the Autism Evaluation Center at long last, they looked at the previous diagnosis and report and said, “So, uh, I take it you’re here for insurance purposes?”

And they did the same tests and gave him the exact same diagnosis.

What a fucking colossal waste of time and resources!

And of course, just because you have a diagnosis doesn’t mean you get access to services right away. There’s also a wait list for ABA and they have to do their own evaluation. We got very, very lucky in that we got into a wonderful place with almost no wait time, but that’s not typical.

Also, in case you’re wondering, full-time ABA costs $40,000 per month. The insurance company is willing to pay 80%. My son did 24 hours a week and we’ve hit our out of pocket max in the Spring of every year.

The thing that makes me so mad about shit like this is that we pay a ridiculous amount of money in insurance premiums. It’s like $1200/month. And this is what it buys.

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What is ABA?

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Applied Behavior Analysis, the research-based gold standard therapy for autism. It generally involves teaching kids behavioral and social skills using playtime and rewards. It deals with issues as wide ranging as potty training, taking turns and replacing dangerous/harmful stims with benign ones.

The quality of it in practice varies dramatically. We got very, very lucky. My son is done with ABA but he’s still at that location doing social skills group 2x per week. I don’t know what we would do without them. And he absolutely loves it. I think he’s taking it pretty hard that he’s not there as often as he used to be.

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Just to add something to my post from up above. It IS possible to negotiate with the labs on prices if you have no insurance. We also refer uninsured patients to a local lab that charges much less than the big two (LabCorp and Quest).

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I’m so sorry - that is truly appalling.

I’m in the UK.
I was diagnosed with Asperger’s Syndrome by my doctor.and we spent time discussing possible treatments to help me.
One problem I had was that I didn’t look people in the face when talking to them. So I got a 6 week course to help me with that … it worked really well.

The cost of the diagnosis, discussion of treatment and the 6 week course?
Nothing - we have the NHS.
(I’ve happily paid my share of taxes to find this wonderful organization.)

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But do your health “care” system and insurance company executives have yachts? Huh? Huh?

436

This is one reason why, when Douglas Carswell tells us that ‘even people in Mississippi are richer than you are, losers’ we’d rather have the NHS.

437

If the US government increased my taxes by 30% for universal health care I’d still probably be better off financially.

Also: Health insurance premiums are about to go wayyyy up. People are gonna be pissed.

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I’ve said this before: when my wife and I relocated from the US to Europe, both of our salaries, on paper, seemed to show a pretty hefty pay cut — a bit more than the 30% you suggest. We tightened our belts and agreed we’d figure it out. But after a year, as we were running the numbers, we discovered our actual real-world income, the amount of money we had available to spend, reflected less than a 10% reduction. The difference, we found, was that we weren’t getting soaked for the extra 20+% with constant nickel and dime bullshit. It’s health care mostly, but there are lots of other little things that add up (e.g. our kids’ teachers get a real budget to stock their classrooms; no parental contributions required). And the quality of life overall is just incomparable.

So despite the superficial appearance of lower salaries, we will be comfortably retired before the age of 60.

Americans know they’re getting screwed, but they honestly have no idea how badly.

439

Holy shit.