ChatGPT literally guided me through the whole external appeal process, who to contact outside of normal channels to ask for help / apply pressure, researched questions I had, helped with wording on the appeals, and yes, helped keep me pushing forward at some of the darkest moments when I was grasping for anything, however small, to help keep the pressure up on the insurance company.
I didn't follow everything it suggested blindly. Definitely decided a few times to make decisions that differed from its advice partially or completely, and I sometimes ran suggested next steps by several close friends/family to make sure I wasn't missing something obvious. But the ideas/path ChatGPT suggested, the chasing down different scenarios to rule in/out them, and coaching me through this is what ultimately got movement on our case.
10 days post denial, I was able to get the procedure approved from these efforts.
21 days post denial and 7 days after the decision was reversed, we lucked into a surgery slot that opened up and my child got their life saving surgery. They have recovered and is in the best health of the past 18 months.
This maybe isn't leveling the playing field, at least not entirely. But it gave us a fighting chance on a short timeline and know where to best use our pressure. The hopeful part of me is that many others can use similar techniques to win.
I've found that people often forget to call their state senator or assemblyperson. It has consistently amazed me how quickly a large company that's sitting on their butts about a topic will move lickety-split once their Government Affairs and/or PR teams are on the thread...
Another tip from having worked at a regulated entity: a physical letter to the CEO mailed to HQ creates a mandatory-response paper trail that will produce a very, very different (better) outcome than e.g. asking to talk to a supervisor while on a call that's not going well.
That's awful but I'm glad you were able to figure this out. I've had my own problems with insurance companies, but nothing to this level. I can't imagine the frustration, especially with YOUR CHILD'S HEALTH on the line.
Five years back I ended up getting surgery for a herniated disc. I was in immense and crippling pain. Before having the surgery, we decided to go through a round epidural shots. I had done that 20 years previously and it resolved the problem, so why wouldn't I?
Turns out my insurance company (who I will name: BCBSIL) delegated the approval for the epidurals through some kind of extra bureaucratic process with a 3rd party. It took days and additional effort on our end to get approved.
I remind you, I was in crippling pain at the time.
The delays getting this approved lead to me taking more Ibuprofen than I would otherwise have taken, which in turn lead to signs of internal bleeding. I had to ease off the Ibuprofen and significantly increase the amount of codeine (a drug which does not sit well with me) just to get by. Now not only did I have to wait for the approval, but I then had to wait for the signs of internal bleeding to go away before the doctor would give me the shot (which was the right call, even though it sucked).
Delays, compounding delays, compounding delays, all while I was absolutely miserable.
Anyway, I finally got approved and got the shot and it kinda helped, but didn't fix the issue. I had a second shot, got worse, and then decided we had no choice but to schedule the surgery.
The most frustrating thing (but something I am glad for) is that the surgery was approved immediately.
It's so maddening how inconsistent the whole thing is.
Calling 100's of people Ofc the find one poor guy never heard of such a sum denies this kind of line of questioning. Then the insurance company uses this to deny all claims made by the pharmacy for ALL their patients for that given drug/medication.
The pharmacist told me the mountain of documentary evidence they have to collect to rebut these denials is very large. Once a customer at their pharmacy said he did not want to sign off on a paper that he got a medication, the pharmacist got the customer's ok though to video record his consent, just so he does not have to deal with this mess.
He also mentioned to me that a pharmacist should NEVER pay any kind of reimbursement to an insurance company on a claim that was denied cause that somehow legally can let the insurance company deny future claims. Not entirely sure what exact legal procedure allows them to do that.
Baby got regular inspections of the heart, lungs and eyes (too much oxygen in the blood can lead to problems with the cornea or something), including after checkout.
They got billed exactly zero.
Both parents even got full pay during the hospital stay, so didn't have to worry about the economy.
Ok, so I pay a fair bit of taxes here in Norway, and some of it is used on stupid stuff. But overall I like knowing my life won't be ruined because of some random event forced me into insolvency.
Without getting into details, the moment I realized that he was being intentionally obtuse I started looking into options.
First contacted an attorney who essentially said, “Yes, I can do it but I’m going to cost a lot and the insurance company won’t reimburse you for my time.”
Kept looking and discovered public adjusters were a thing. Did some research, found one who was reputable and he took me on for free. Pretty sure we used net, about 2-4 hours of his time.
He told me exactly what was going to happen, how the insurance company was going to react and it played out exactly as he said.
1. He requested a process to take the valuation of everything damaged in the fire to a 3rd party arbiter.
2. Insurance company will send you a letter saying it’s not time for that yet. We will proceed anyway. And we did.
3. He will nominate 3 arbiters and the insurance company will nominate 3 arbiters. Neither will select either of the others nominees and an independent 3rd party will select one instead.
4. The moment the insurance company realizes the valuation of your things will be outside of their control, they will become extremely agreeable. And they did.
And honestly the only thing I really wanted was another week in a hotel for my family because the company cleaning my house of smoke was short staffed over the holidays. Would have cost them likely $1,000 but instead he escalated the situation dramatically.
No, that's the goal. Denying coverage is how insurance companies make money. The less money they give, the more money they keep.
> The hopeful part of me is that many others can use similar techniques to win.
And the realistic part in me says that these tools will be used to deny appeals without a human ever looking into them and making sure you will never get to talk to a human or get approval for anything ever again.
Is this incorrect?
Insurance companies, or the companies they pay to launder their involvement, would pay a lot more for that than the public would be able to.
The US healthcare system sounds horrific
The lack of data standardization in health insurance is atrocious. (In the US, CMS/Congress pushing what it can, but at a glacial pace)
The strongest argument for single payer is that a diverse marketplace has demonstrated a fundamental inability to interoperate.
Eventually, we'll just have a free (or at least much cheaper) psychiatrist in our pocket.
Sure, AI advice is workse than the advice of a competent professional, but it's very often better no advice, and that's what you get if you can't afford the professional.
This month, the practice was called out (https://www.help.senate.gov/rep/newsroom/press/chair-cassidy...) so the Overton window may be opening.
The AMA (a nonprofit!) clears ~$300M/year revenue from the codes, which is the direct cost passed through to consumers, but the indirect costs are the byzantine nightmare of OP.
Does not stop people threatening you though.
This is my opinion only, not legal advice, and does not relate to my employment.
It can't pay out profits to shareholders, but it can hire its owners as employees and pay them any number of millions.
I would expect that if (when) the AMA folds on the matter, concerns around the codes will be somehow forgotten
So you think the same Senate that is planning on gutting healthcare for millions of Americans is going to go after the AMA billing codes? Is this real life? They MIGHT demand some donations to the ballroom, but I doubt they care enough to even do that.
Ahh, here's the correct link and as I suspected, this has absolutely nothing to do with reducing healthcare costs for the average american. It is a direct attack on the AMA for advocating for supportive care for transgender citizens.
https://www.help.senate.gov/rep/newsroom/press/chair-cassidy...
With opinions like this, you can rest assured Cassidy is concerned with healthcare costs for the average citizen:
>This comes after Cassidy denounced the AMA for defying President Trump’s Executive Order by promoting gender mutilation and castration of children.
The white coats are far from blameless here.
I seem to remember this test is why the Mozilla Foundation and the Mozilla Corporation exist, but I could be mistaken.
Edit: Seems that the AMA is a 501c6, which is a different kind of non profit.
The license is meaningless if training AI is considered fair use, and if you never agreed to the license.
They might be able to lean heavily on medical researchers and the like (who probably need a license for other uses), but when push comes to shove I suspect Google and OpenAI would win.
It would also be permissible to search existing records and prices (if an actor has them) to cross check average prices for some procedure.
I'd be interested to hear from a charge coding expert about Claude's analysis here and if it was accurate or not. There's also some free mixing of "medicare" v.s. "insurance" which often have very different billing rates. The author says they don't want to pay more than insurance would pay - but insurance pays a lot more than medicare in most cases.
It's pretty clear that even access to a potentially buggy and unreliable expert is very helpful. Whatever else AI does I hope it chips away at how institutions use lengthy standards and expertise barriers to make it difficult for people to contest unfair charges.
The discounts he negotiated left me with tons of cash & were in excess of the fee he charged me.
If the OPs brother-in-law had had insurance, the hospital would have billed the insurance company the same $195k (albeit with CPT codes in the first place).
The insurance company would have come back and said, "Ok, great, thanks for the bill. We've analyzed it, and you're authorized to received $37k (or whatever the number was) based off our contract/rules."
That number would typically be a bit higher for private insurance (Blue Cross, Blue Shield, United Healthcare, etc), a little lower for Medicare, and even lower for than that for Medicaid.
Then the insurance would have made their calculations relative to the brother-in-law's deductible/coinsurance/etc., made an electronic payment to the hospital, and said, "Ok, you can collect the $X,XXX balance from the patient." ($37k - the Insurers responsability = Patient Responsibility)
Likely by this point in a chronic and fatal disease, the patient would have hit their out-of-pocket maximum previously, so the $37k would have been covered at 100% by the insurance provider.
That's basically the way all medical billing to private and government insurance providers in this country works.
"Put in everything we did and see what we can get paid for by insurance" isn't criminal behavior, it's the way essentially every pay-for-service healthcare organization in the country bills for its services.
I don't say that to either defend the system, or to defend the actions of the hospital in this instance. It certainly feels criminal for the hospital to send an individual an inflated bill they would never expect to pay.
Tons of institutions that specialize in screwing people are built this way because it's pretty hard to "overtly" build an institution to screw people.
Im increasingly of the opinion that AI gives people more confidence than insight. The author probably could have just thought of the same or similar things to assert to the hospital and gotten the same result. However, he wouldn't have necessarily though his assertions would be convincing, since he has no idea whats going on. AI doesn't either, but it seems like it does.
This will always happen, especially if you don't have health insurance. I had to have surgery without insurance in the early 2000s, and I was able to knock off a large percentage of the bill (don't remember how much, it's been decades) by literally just writing back to the hospital and asking them to double check and verify the line items I was being charged.
(edit: more stories along similar lines in this thread: https://news.ycombinator.com/item?id=45735136)
But you better believe that hospitals all over the place are also using AI to find ways around Medicare/Insurance rules to maximize their profit too.
The rules are probably going to get WAY more complex because they will rely less on a few humans, and more on very powerful AIs.
I just did this with a pet insurance bill, and ChatGPT was very helpful. They denied based on the pre-existing condition exclusion even where it was obviously not valid (my dog chipped her tooth severely enough to need a root canal, and they denied because years before when she wasn't covered under the policy, she had chipped the same tooth in a minor, completely cosmetic way).
I was sure they were in the wrong and would've written a demand letter even in the pre-AI days, but ChatGPT helped me articulate it in a way that made me sound vastly more competent than the average consumer threatening a lawsuit. It helped make my language as legally formal as possible, and it gave me specific statutes around what comprises a pre-existing condition in CA as well as case law that placed very high standards on insurers seeking to decline coverage by invoking an exclusion (yes I checked, and they were real cases that said what it thought they said).
Gave them fourteen days to reverse the denial before I filed in small claims court, and on day fourteen got a letter informing me that the claim would be paid in full. It's of basically no cost to them to deny even remotely borderline cases, so you have to make them believe that you will use the court system or whatever other escalation paths there are to impose costs, and LLMs are great for that.
What exactly do you think negotiating is? Real negotiation in business transactions is more often based on agreements around certain facts than emotional manipulation.
Yes, because, there is an entire department _dedicated_ to this function. You just call them and say "I can't pay this" and you'll get the same result.
I'm a cofounder of Turquoise Health and this is all we do, all day. Our purpose is to make it really easy to know the entire, all-in, upfront cost of a complex healthcare encounter under any insurance plan. You can see upfront bills for many procedures paid by various healthcare plans on our website.
The information posted in the thread is generally correct. Hospitals have fictional list prices and they on average only expect to collect ~30% of that list price from commercial insurance plans. For Medicare patients, they collect around 15%. The amount the user finally settled for was ~15% of the billed amount, so it all checks out.
The reason for fictional list prices (like everything in US healthcare) is historical, but that doesn't make it any more logical. Many hospital insurance contracts are written as "insurer will pay X% of hospital's billed charges for Y treatment" where X% is a number like 30. No one is 'supposed' to pay anywhere near the list price. Yes, this is a terrible way to do things. Yes, there are shenanigans with logging expected price reductions are 'charity' for tax purposes. But there isn't a single bad guy here. The whole system that is a mess on all sides.
Part of the problem is that the US healthcare billing system is incredibly complex. Billing is as granular as possible. It's like paying for a burger at a restaurant by paying for separate line items like the sesame seeds on the bun, the flour in the bun, the employee time to set the bun on the burger, the level of experience of the bun-setter (was it a Dr. Bun Setter or an RN bun setter?), etc. But like the user said, some of these granular charges get rolled up into a fixed rate for the main service.
However, the roll-up rules are different for every insurance contract. So saying the hospital 'billed them twice' is only maybe true. The answer would be different based on the patient's specific insurance plan and how that insurance company negotiated it. Hospitals often have little idea how much they will get paid to do X service before it happens. They just bill the insurance company and see what comes back. When a patient comes in without insurance, they don't know how to estimate the bill since there is no insurance agreement to follow. So they start from the imaginary list prices and send the patient an astronomically high bill, expecting it to be negotiated down. In some areas, there are now laws like 'you can't charge an uninsured patient more than your highest negotiated insurance rate' but these are not universal.
If you find yourself in this situation, there are good charities like 'Dollar For' that can help patients negotiate this bill down for you. We are trying to address this complexity with software and have made a lot of progress, but there is much more to do. The government has legislation (the No Surprises Act) that requires hospitals to provide upfront estimates and enter mediation if the bill varies more than $400 from that amount. But some parts of the law don't have an enforcement date set yet, which we hope changes soon.
Which is a great description of the American health care industry, even before its involvement with AI in any capacity.
But the raw numbers like $200k for this poor gentleman’s heart attack or $500k aren’t the most alarming. It’s the Terry-Gilliam-level of absurdity of the billing process. Absolutely no one will tell you how much things are, and when you ask, they sass you that it is a ridiculous question. Even though one of my providers just recently started offering estimates, those are off by 100-200% , and completely missing for about half of what has been ordered.
We are both very strong accountants, and despite trying to do audits of these services, it’s impossible. There are 3-4 levels of referred services, bundled codes, nested codes, complication / technical / professional codes , exceptional status codes . Providers overbill, double bill. On accident and on purpose. When we call to get it corrected there is no way to make corrections.
You’ll be asked to take a diagnostic not knowing whether it will cost $10 or $15000 . Even if you try to be responsible and call the provider (who isn’t your doctor, clinic, or hospital ) – they won’t be able to tell you.
The point I’m trying to make isn’t to make you sympathetic. It’s to reinforce in all of the great technical minds here that healthcare billing is the most complicated spaghetti code cluster flock of a system that you’ve ever imagined. It’s far worse than any piece of software you’ve ever seen. And we all just accept the bills and pay them.
Supply and demand and finding a better vendor doesn’t work. There are some rare exceptions like elective MRIs – but those aren’t the norm. Nearly every service is something time sensitive or your disease will get significantly worse. Moreover, signing up a new provider has $1000+ in billing and a few hours in paperwork to make the transfer. is it worth saving $500 for one MRI when $250k worth of services are unaccountable?
The only thing I’m sure of is that there has to be tremendous amounts of incidental and deliberate corruption . Auditing a single patient’s billing is impossible – so a population’s worth is a goldmine .
I went through this with my ex after a surgery. It was totally insane to figure out where the numbers are coming from and basically a full time job.
Even if we don't want to go to single player or similar, I don't understand why it's not at least possible to mandate clear and binding estimates and billing a normal person can understand. And let the market work its magic through competition.
America has doubled down on middlemen controlling the prices of medical care and making sure that there is no set price for anything. With the ACA effectively falling apart in the new budget, we do have a chance to move to a different reality, one where medicare prices are the set prices for everything, but that is nearly a political impossibility given the amount that these middlemen spend in keeping politicians who support that from winning primaries. Instead, we are stuck in a situation where companies get to dictate prices and access to care while we get diminishing returns in health quality and longevity.
His mom died poor.
Crazy country.
> You’ll be asked to take a diagnostic not knowing whether it will cost $10 or $15000
I feel this in my bones and it makes me irrationally (or maybe it's rational actually) angry. Find me any other industry where you can get away with not telling how much something will cost (or even a realistic range) before services are rendered.
I had a medical procedure a year or so ago and when I asked how much it would cost I got an eye roll, a lengthy and exasperated lecture, and in the end the number they quoted was wildly different. I knew I was going to hit my out-of-pocket maximum so I gave up after a while and moved on but it makes me so mad. I _wish_ I could "vote with my wallet" but good luck doing that unless you have unlimited time and energy. By the time I finally got to asking about the price I had been through multiple appointments that took forever to schedule, were weeks or months in the future, all while I needed relief. After being strung along for 6 months I gave up and rolled the dice even though I disliked how they treated me when I asked for the price.
People talk about how you need to be an informed customer but I have to assume those people are lying snakes, have never used the system, or just too stupid to understand that it's impossible.
"I don't know" should _not_ be a valid answer when asking how much something costs, it's ridiculous.
Here in India when my dad underwent bypass surgery, I checked the bills the breakdown is insane. This how a charge goes, Nurse comes to see you, so she wears a pair of gloves, that gloves is billed. And often something like 10x the price those are available in the regular pharmacy. Each and everything is billed, and you would be surprised just how many things like these can be be billed.
>>You’ll be asked to take a diagnostic not knowing whether it will cost $10 or $15000 . Even if you try to be responsible and call the provider (who isn’t your doctor, clinic, or hospital ) – they won’t be able to tell you.
Often some 'visiting doctor' comes to see you. Like in the case of my dad we were billed for a diabetic consultation, despite clearly telling them he wasn't diabetic, even more so, the same doctor came in the day before and had to told the same. We didn't need it. But you will see they bill you like 2000 rupees just for the person to enter the room say 'Hi' and exit.
>>The only thing I’m sure of is that there has to be tremendous amounts of incidental and deliberate corruption . Auditing a single patient’s billing is impossible – so a population’s worth is a goldmine .
In these situations most people are so stressed and anxious often people just have no mental bandwidth to fight side battles.
Its really a corrupt system to the core, and I don't see hospitals and doctors giving all this up anytime soon. Or even ever.
It took me a week and hours of phone calls to figure out what would be covered, and how much the non-covered tests would cost. The doctor pointed at the lab, the lab pointed at insurance, insurance pointed at the doctor.
Finally it was the lab that was able to produce numbers.
And when I was finally billed those numbers were still incorrect! (and thankfully cheaper)
I got a bill for $250,000. Uninsured at the time. I have refused to pay it (due to inability), consequences to my credit be darned.
Of course that would only work if you can take the time off from work, have the same treatment available elsewhere, and being able to actually travel with whatever illness you have.
> The point I’m trying to make isn’t to make you sympathetic. It’s to reinforce in all of the great technical minds here that healthcare billing is the most complicated spaghetti code cluster flock of a system that you’ve ever imagined. It’s far worse than any piece of software you’ve ever seen. And we all just accept the bills and pay them.
The world does not move in a positive direction at the direction and discretion of “great technical minds”. They are too busy being narrowly technically brilliant that they fail to see what a sufficiently generalist and curious 15-year-old could figure out what is the root cause. Which this post demonstrates.
I can see them being out of network this year, but can't you change insurance in the following year to one where it will be in network?
We contacted the service and provided our info (the context of the situation, the billing information, the actions we'd taken so far, etc) and a couple weeks later, the service reported that they had converted the ambulance ride from an uncovered insurance to covered by insurance (since the transport was between a covered urgent care to a covered EHR) and had our insurance cover the majority- we ended up paying $500 to the ambulance company.
While I am not surprised that such a service exists, what did surprise me is that it's just a division of my insurance company: they literally have a division that negotiates with another part of the insurance cmpany to get better coverage for patients. I was pretty lucky to notice the mail about this- there's nothing on my employer's site saying we have this coverage(!) and the vast majority of people in the US likely don't have this service.
If there is anything that will bankrupt the US, it's excessive medical charges and a lack of knowledge of how to address them. Maybe AI will help, but I really doubt it long term.
> we ended up paying $500 to the ambulance company
I get where you’re coming from but that’s still a loss to me from the perspective of the broken system.
I'm sure people from first world countries would be stunned by this number. And that makes it even sadder.
> Maybe AI will help, but I really doubt it long term.
I'm guessing it will help up until the point where hospitals start using AI for this process.
100 years ago I used to work for the fruit company in phone support.
My KPI's were 100% customer satisfaction. However, I needed to get approval from another team to advance any kind of free/gratis repairs replacements or gifts.
That team's KPIs were opaque to me, but my understanding is that they were find as long as they offered some resistance.
Between those two pillars we got a lot of good done for customers. I dont think theres anything necessarily wrong with having internal friction like that if its designed correctly. Its probably better than having both responsibilities in a single person.
In terms of health insurance however it seems ghoulish.
This is the core truth that all of healthcare in the US spins out from. A few personal experiences which back this up:
1. I received a $1500 bill because an ambulance that was sent when I called 911 was an "out of network ambulance". I looked it up: One small ambulance company in SF is in-network with that insurer. The SFFD runs the vast majority of ambulances and is "out of network." Insurance companies of course are not allowed to penalize you for accepting the first ambulance that arrives in an emergency. I filed a formal complaint with the California regulator that regulates that insurer and within 2 weeks the bill had been properly taken care of.
2. Our family has met its family Out of Pocket Maximum this year. Twice in the past month I've had doctor's offices lie to me and say that we still have to pay a copay. The last one claimed "well, you still have to meet your individual one though." Lie. That's literally the opposite of the way it works. We've paid copays to these people accidentally in previous years and they would never give the money back, they just keep it and also double dip since insurance pays them anyway.
In all cases, both hospitals and insurance companies simply ask for the maximum possible thing they can ask for, knowing that a frightening majority of people are afraid of them, and will pay whatever they're told. In OP's case, an unsophisticated payer would have gotten a $195k bill, been sent to collections, the hospital would have sold the bad debt, and then the person would have maybe "gotten a good deal" by getting it cut down to $50k over many years of high-interest payments and having ruined credit.
Insurance and hospitals are both filthy, money-grubbing machines. To paraphrase a famous cartoon character, their business is bad and they should feel bad.
I think a public option is the only feasible path forward.
Not once have I had a sleepless night since been diagnosed over a decade ago about insurance, co-pay or how to afford my drugs/medical treatment.
I’m on two prescriptions per month, total cost to me is £114 a year (about 150 bucks).
Folks over in the US are getting hosed, twice the per capita with a worse outcome and it costs you a fortune on top personally.
That healthcare is tied to employment is just the insane cherry on top (I’m aware of the historical reasons why that happened but should have been fixed not long after).
I notice regular doctors and dentists do this too. They’ll bill my insurance for extras in case they’ll pay and when insurance says no, the doctor doesn’t bill me either.
Everyone is just trying to suck the most money out of everyone else. It sucks if you’re self-pay because you don’t have the weight of a whole company to do that due diligence for you.
OP agrees: "Ultimately, my big takeaway is that individuals on self-pay shouldn’t pay any more than an insurance company would pay—and which a hospital would accept as profitable business—than the largest medical payer in the country. I had access to tools that helped me land on that number, but the moral issue is clear. Nobody should pay more out of pocket than Medicare would pay. No one. ... Hospitals know they are the criminals they are and if you properly call them on it they will back down."
> I've heard a ton of cases where folks basically "pay what they can" for the bill and that's good enough for both parties. I doubt the reasoning Claude provided was ultimately what got the hospital to knock the bill down, probably more around the legal action and PR threats. Ironically, the hospital will probably count this as charity even though OP didn't want to be considered charity, as they had to write off part of the bill.
I read that OP refused to sign something that fraudulently said the full price was $195k but rather insisted on signing on a bill that said the full price was $33k or $37k or something. (Maybe $4k was called charity.) They might have presented a completely different bill to the IRS to justify tax-exempt status, but that illegal action would be totally on them; OP is not participating in their tax fraud. I applaud OP for that and hope this becomes the norm.
They can't really claim their records are any kind of proof if apparently they now agree that 82% of it was wrong?
I'm sure they also have a long arsenal of various legal tricks they bundle into offerings like they did in the linked thread with respect to attempting to relabel it a charitable donation, etc.
The past few years, I've been receiving some very expensive treatments for my eyes... given the job market, I've been without and switched jobs a couple times... been caught with a few unexpected bills for around $15k... it just sucks. I'm currently making about 2/3 of what I was a couple years ago, with no better job prospects, the insurance I have is "emergency" based and doesn't cover my regular doctor bills... I'm at my max at this point, thinking about bankruptcy for a while now.
The system sucks... the billing system(s) suck and the fact that it's as messed up as it is, is so much worse. From monopoly positions, to messed up billing, to everything else... I don't even know. Even on a six figure salary, I cannot afford private insurance and the multiple $300-400 doctor and pharmacy bills each month are seriously destroying me.
I think the correct solution is stronger laws for price disclosure, strong penalties for the kinds of abuses mentioned in this thread, and incentives for patients to question every charge.
I don't know a single Canadian who would swap their system for the USA's. Theirs might not be perfect, but nobody argues that it isn't at least better than the literal worst system the world has ever come up with.
I'm sorry but I don't understand this discourse. While we have gripes with the state of some hospitals that fall short of first world standards (e.g. Gatineau Hospital) and wait times for specialists for non-urgent care (it can take 2-3 months to see a dermatologist after referral for non-cancerous skin conditions in Manitoba for example), I really can't think of more than 3 Canadian residents having ever said in my lifetime that they prefer the US system (and for all of them, their objection had to do with the fact that the government funds treatments they don't like for gender dysphoria and abortions, not that they felt the US system was an effective economy of scale).
On top of that, there is a myth perpetuated in the US that we are constantly at the brink of a healthcare system collapse. We are certainly not - there is room for improvement and health inequalities that we must address, but to say that we're all an ER wait away from dying is simply untrue. [1]
I have been on the receiving end of health care inequalities here in Canada (in Manitoba and Quebec), but I don't go as far as to write off the achievement of having set up an effective single payer health system in a federal state.
The alleged shooter was clearly referencing this book which talks about it: https://en.wikipedia.org/wiki/Delay,_Deny,_Defend
I haven't read the book, I'm just recalling what I've read about it.
we have a capitalist bastard child of for-profit "insurance" companies who are heavily subsidized (yet are still allowed to profit massively and turn profits over to shareholders) and in cahoots with hospitals who often employ more "billing specialists" and lawyers than they do actual doctors and nurses.
the whole thing is a racket.
using AI to deny claims to maximize profit seems bad enough to me. More Luigi please.
By the way, Private is cheaper when you are younger, gets more expensive when you are older. So if you choose private, under very phew circumstances you can switch to Public.
In the other side, you have the US health care which is probably one of the worst in the world. Crazy.
Not really. If you have money, the US system is one of the best. It just really, really sucks if you don't have money.
Typically hospitals are overwhelmed by the sheer amount of patients. Waiting times for procedures are incredibly long.
Where the system kind of shines is emergency care and long term illnesses, you go in and they save your life for free.
For any other kind of treatment you are generally better off turning to the private sector in Europe. You are going to have to pay depending on the country the cost might be outrageous but typically you will get access to procedures in days vs months.
Stop lying. It's trivial in Europe to end up without any health insurance even as a citizen, e.g. in Poland without employment and without unemployed status (the offices make it very difficult to register and keep the unemployed status).
And when the bills started coming in, it helped there too. Hard to say if we actually saved anything — but it certainly didn’t hurt.
LLMs are a good way to double check if the service you're getting is about right or steer them onto the right hypothesis when they have some confirmation bias. This assumes that you know how to prompt it with plenty of information and open questions that don't contain leading presuppositions.
An LLM read my wife's blood lab results and found something the doctor was ignoring.
Not saying the doctors did anything wrong but… oof
I'm Argentinian and while we might be a country lagging behind in so many things these kind of ripoffs do not happen.
How come the US government allows this? From other stories sometimes posted, the US seems to be one of the worst countries in the world to either die or get sick.
Allows? The government works for the wealthy and powerful. That includes the masses, who (if they organize) have their own power, but it also includes every other powerful group or individual.
Why would the government want to stop this? It's the average person who would want to disallow this, and they'd have to pressure the government enough that the pain of popular opposition outweighs the brazillions of dollars they're making.
Using the latest in technology to move an a bill from existential to merely crippling
All said and done, you end up with a very small sliver of people who are legitimately uninsured, which means the problem mostly exists as scary stories rather than people actually experiencing it.
But not hard to imagine United Health "investing" in OpenAI and Anthropic to "curate" the information they generate.
This suggests an 'AI can't see gorillas' problem here in that, during an AI-human interaction, identification of relevant big-picture context that a human advisor could have helped with is also missed.
As OP says: "I had access to tools that helped me land on that number, but the moral issue is clear"
https://fighthealthinsurance.com/ was previously posted about a year ago, but I see no traction. There is no moat, just build and distribute, right?
Show HN: Make your health insurance company cry too Fight Health Insurance - https://news.ycombinator.com/item?id=41356832 - August 2024
(broadly speaking, my thesis is generative AI can be weaponized to break down bureaucracy designed to extract from the human, from cost efficiency and power asymmetry perspectives)
Not mentioned, and I'm interested, is how accurate Claude's reading of the various medicare rules are. I presume these letters went to someone who had only slightly more knowledge of medicare billing rules than the author -- hospitals are arcane and cryptic places, most especially the billing departments.
The good news is this should be easy to reproduce to see how it does - just google around for an example medical bill with billing codes and feed it to Claude.
I think given this story they totally messed up.
After having this same thing happen a few times I now ask at the beginning of the appointment to confirm that it's a wellness visit. Then I ask the provider to tell me if I inadvertently ask a question that will turn it into not a wellness visit. Then I ask at the end to confirm it will be billed with the wellness visit billing code.
The usual benchmark is the "usual and customary" charges for a procedure. You can look it up for a procedure for your area. You then go to the hospital and point out these charges. My guess is they're much more likely to agree with this than the Medicare rates.
It's also the rate your insurance will use if you go out of network. So if your insurance pays 40% out of network, and you get billed $1000 for a $100 procedure, your insurance will pay only $40 (4%).
(Although by all means, you can start your negotiation with whatever is lower).
Yes - Medicare is typically lower than private insurance plans, but if you can't deliver care for the reimbursement that Medicare offers as a health system/plan/office/provider, you're probably overcharging.
More than that, Medicare is the de facto starting place for most reimbursement negotiations between providers and payers. One of its benefits is that it's transparent and readily available. Blue Cross isn't gonna tell you what it's contracted to pay an individual provider (and that individual provider often won't know what they'll be reimbursed untill after they submit a bill) - but with Medicare the data's out there.
I know a good number of private clinics that'll offer cash pay discounts that effectively mirror Medicare or even slightly below Medicare, since you're saving them the trouble and expense of going through the medical billing process.
The Stanford visit was predated by a two night stay at Eastern Plumas Hospital (rural, interesting experience). EPH wanted as much for two days and Stanford charged for three. Seeing the billed amount and what insurance agreed to in each case was enlightening -- basically 1/3-1/2.
I would not want to deal with fighting this if I was chronically ill.
I got ChatGPT to come up with some plausible interpretations of the electrical code that allowed the install to continue, including citations. I don't know how accurate it all was, but I sent the argument off to the installer, and he came back and did the work the next day. Even if it gets audited, the chances of the auditor picking apart the arguments are probably slim to none. He has plausible deniability.
This is also why schools and colleges are struggling. No one expected superficially "high quality" work from average and poor students, and now that they have to carefully evaluate everyone's work, they've been caught with their pants down.
Someday superficial AIs will talk to other superficial AIs and they'll deadlock, requiring humans back into the mix. Until then, it's a useful way to do bureaucratic judo.
Their contracts with insurers says they can't bill the insurer more than what's on the standard price list, but the insurer won't pay more than the contracted amount for each billing code. As a result, the standard way to make a price list is to periodically review what insurance has paid on all the billing codes you've used lately, and if there's any billing code for which insurance has fully paid, increase the price.
This is exacerbated by the fact that a single encounter might be encoded into multiple billing codes. One billing code for an aspirin, one for the nursing time to administer it, for example. Suppose insurance A pays reasonably for the nursing time but in exchange pays a pittance for the aspirin, but insurance B pays enough for the aspirin to cover the nursing time to administer it, but doesn't pay the nursing time billing code, but insurance C pays for an omnibus code for "spent a couple hours in the ER", but doesn't pay for nursing time or aspirin separately at all. A provider can agree to all three contracts, because they each give them enough money to profitably provide the service, but that requires that their price list has a high price for the aspirin, an high price for the nursing time, and a high price for the omnibus billing code.
A cash payer gets the same bill an insurance company would - high prices on all three items. But insurance companies never pay that. In the old days, you would just have a totally separate cash pay price list, but medicare rules don't allow that anymore, and limit the magnitude of cash discounts.
Fix the insurance system, and the bogus hospital bills that the hospital doesn't actually expect people to pay go away.
I've had $10k+ bills brought down to $200. $2k+ tests re-coded and fully covered, etc.
There is definitely a business in a LLM-powered medical billing agent that could handle this end to end (esp, contacting hospitals/insurance, waiting on hold, etc).
Every EOB I receive shows medical charges many multiples of what insurance actually pays (and the provider actually accepts). IMO that is not only prima facie evidence of fraud, but - since every provider does the same thing - of collusion on fees amongst and within the medical industry - worthy of anti-trust investigations (I have no anti-trust experience).
Provider wants to do procedure. You need it right away, or the procedure allows pre approval with the assumption insurance won’t haggle or deny payment
insurance company denies payment
provider bills you
what i learned is, often, the provider will eventually be paid. do they tell you? not usually. oh woops. I haven’t very successfully fought these other than just hours of phone calls with both companies chasing down what actually got paid and when, and they on purpose make it difficult. If you find yourself in this situation do NOT pay the hospital until the last possible moment it will go to collections. often, you’ll find it mysteriously disappears. it also doesnt hurt your credit very much anyway if it does.
There’s no real defense of these practices or of the industry in general as it exists in the USA.
anything <$500 now by CA law cant show up on credit report so I basically stopped paying those. unethical? sure. will it affect the quality of my care? probably. sometimes though being a deliberate pain in the ass feels better than letting the system fuck you over and over.
Here in Australia, our 2nd biggest private hospital owner has just gone broke.
At a fire sale, there was so little interest in buying the hospitals that many will be shut down.
The rest of the unsalable hospitals will be shoved into a stripped down charitable tax exempt trust so that the creditors ( banks and pension funds ) can recoup a small amount of the money they lent the hospitals.
My SO had to take a medevac helicopter once: we got a $65k bill just for the 20-minute helicopter ride which suddenly became under $4k with insurance. The discount made me feel like I was getting a deal, so I gladly paid.
You could probably tell them to eat dirt,the receiver of services can't be collected against as he's no longer physically here.
Getting the money from his estate would probably take years, if possible at all. I am not a lawyer, so I might be completely wrong, but suing a widow for 200k would be a nightmare for any hospital.
Anyway, maybe one day we'll join the civilized world and not bankrupt families for the crime of being suck.
Hospitals will pull all sorts of shady stuff to strongly imply that you should pay for a family members medical bill, however. From very strongly hinting that you're obligated to, through to impugning honor, "It would be doing the right thing by your dad", etc.
CMS maintains a service and set of tools to help prevent payers from getting hit with this called the National Correct Coding Initiative (NCCI) [1]. NCCI only applies to provider services and outpatient billing codes, but is still applicable for emergency room services.
There are a bunch of technical details for implementing the edits in the NCCI, but I think it's worth taking a moment to reflect on this.
It's pretty popular to point to the insurance company as the "bad guy" in healthcare, but this is the sort of stuff they deal with thousands of times per day.
As frustrating and horrible as this story is, it's not unique to an uninsured individual. A big problem in US healthcare is provider overbilling.
One of the most tragic jobs I held in healthcare tech was developing software for billing negotiation between providers and insurance companies. It was pretty eye-opening how terribly everyone behaves, and I learned to have a lot more sympathy for what insurance companies/government payers have to deal with.
As a patient trying to have necessary treatment paid for, it's incredibly frustrating to have a claim denied, and these are what we see in the news and experience personally.
As an insurance company, building robust systems that authorize necessary care while catching overbilling, overutilization and outright fraud is unfathomably complex and error prone.
This one of the reasons I've become a fan of DPC (direct primary care) models [2] with HSAs and supplement high-deductible catastrophic insurance to protect against hospital stays. It puts primary care back into a direct relationship with the patient, and lets insurance companies do what they are good at: pricing risk.
Some of the unintended consequences of how insurance companies are currently regulated is that in some states it can be difficult or impossible for an insurance company to provide a low cost, high deductible plan. They are forced to cover things that drive the costs up, so it's hard to do a DPC + catastrophic insurance option.
[1] https://www.cms.gov/national-correct-coding-initiative-ncci
[2] https://www.aafp.org/family-physician/practice-and-career/de...
As a result, the nominal general charge to the uninsured public is generally inflated, but also tend to be very easy to negotiate down.
The problem is that America's healthcare system is ridiculously broken. The symptom of that problem is that prices are astronomically high.
I am happy AI is useful for things like this, but I want to focus on CURING the problem and not just making the symptoms more tolerable.
A meager amount of AI will insulate you from a lifetime of woe, exactly as it was designed to.
NPR Investigation: Many U.S. hospitals sue patients for debts or threaten their credit - https://www.npr.org/sections/health-shots/2022/12/21/1144491... - December 21st, 2022
Some Hospitals Kept Suing Patients Over Medical Debt Through the Pandemic - https://www.propublica.org/article/some-hospitals-kept-suing... - June 14th, 2021
Of course, I hadn't actually lived there since I was a teenager over a decade ago, and I'm sure they knew that, but the harassment tactic worked and I just paid it.
As a not-American, I wonder what are the rules of this "game". Can anyone in the US just ignore their bills and debt and it's all ignored anyway?
Because in most European countries, debt is a very serious thing. Even small debt like an unpaid 50 Euro bill can be sold to debt collectors who can seize your property or garnish your wage, pension or bank accounts to pay your debt plus the collection fee, so people here are incredibly weary of unpaid bills or taking debt for unnecessary things other than houses or cars.
https://www.nytimes.com/2025/07/17/business/medical-debt-cre...
What state is this? At least in Minnesota my understanding is I'm not on the hook for my wife's medical bills if she were to pass.
America in a nutshell.
To be fair, I'm taking this whole twitter thread at face value.
The bigger concern, IMO, is insurance is tied to employment. The time you get your massive bill is when you get very sick after being fired/laid off and your COBRA is up.
The next biggest concern is the ACA which is the greatest scam ever pulled on Americans. It started out as, what would've been, universal healthcare. Instead, it simply played into the insurance company profit centers by forcing people (now by law) to hold some kind of insurance or pay a large tax fine. So you're stuck paying $1,500 for sub-par care on a bronze plan with a massive deductible and no limit. So much for "increasing the competitiveness of the market".
Healthcare spends more money on lobbying than any other sector in America. The solution isn't to start breaking it down with crap like the ACA. That will get gutted by the bought and paid for politicians (which it did). What we need to do is begin by repealing citizen's united, limiting campaign contributions to 0 from industry professionals (in both their professional and personal capacity), and fire the congressmen taking the most money from them.
They don't have hearts. They have large wallets. Hit them where it hurts.
If you are not going to do universal healthcare at least do outcome based charging.
I appreciate the author’s disclaimers about that and especially about double checking AI output.
Also...having heard a talk given by the hospital administrator's association lobby...you can kinda get a sense where this funny math comes from....
what would the outcome of the charity option have been? they did not change any practice here, the hospital almost got caught, once, for one bed that was occupied for 4 hours in a single day
This sums up my experience with US Healthcare. They bill expecting you to autopay, and either have no incentive to bill correctly or they outright are trying to scam but the result is that every hospital bill is sus.
This also makes insurance a lot less inherently valuable: you are paying for someone to do this untangling shitshow on top of the actual insurance. As if the hospitals just put the billing burden on the client.
There has to be a penalty for sending wrong bills, or they should pay me for my time wasted.
Finally, the prices are so inflated that often the price without insurance in Europe is the same as the copay/coinsurance in the US.
Its a fucking catastrophe.
I don’t think the ai is being particularly smart in my case, and its occasionally flat wrong.
What it does give me is persistence and motivation. I have a nice workflow cobbled together that lets me dump OCRd scans and digital comms into “workspaces” organized by topic. With that workflow, I can basically dump a letter in, say “wtf is it now?”, and have the llm spit out a response. I do basic due diligence and send. Done. They don’t have to be that accurate, and neither do I.
I feel like I have a new superpower now: outlasting it, whatever it is this time.
Or, more likely, they’ll just sell enterprise products to wealthy hospitals and look the other way.
Uh. Call me naïve, but how is this not fraud?
Negotiating with a hospital caught double and triple billing and somehow being happy with a bill for four hours down to just $33k? This should have ended in litigation.
Elsewhere I see people facing $4k Ambulance rides jubilant at only paying $500. People laughing that they've already paid so many tens of thousands out of pocket that year so can't be gouged any further. And so many others just saying "Oh that's how hospital billing works" as if you've just explained how central locking works.
Guys, this isn't civilised. It's exploitative and in many cases just outright fraud. Why can't you fix it?
So close, yet so, so far! If a corporation commits fraud against you, and you literally ask if the corporation has committed fraud against you, and you proceed to voluntarily send that corporation THIRTY-THREE THOUSAND DOLLARS anyway, are you not a willing co-conspirator in the fraud?
Why are we accepting this?
The system is totally absurd.
I work in healthcare RCM. I have no trouble believing the staff here that nothing in their system works.
