> Here's the trap: if you don't have insurance, you are not just hit with the high bill that represents what the hospital would pay an HMO, you're hit with he wildly inflated bill they send to an HMO in anticipation of being paid much less.

I spent years working in medical billing. You can negotiate these down to prices as much as 10% of the bill. Typically, you go: "I don't have insurance, but I'm willing to pay 50% now."

The vast majority of the time, they'll accept, because that's more than they expected.

DON'T give them the option to distribute the payments. Explain, you're willing to pay now at X% AND that you don't have insurance. The person on the other end is usually a human and can accept that (somewhere in the billing chain).

If they offer to distribute payments, explain financially, that may put more burden on you. If you actually can't pay or are living pay-check-to-paycheck, explain it may bankrupt you. At that point, they get nothing, so negotiations can ensue.

Another thing to do is debate billing codes, as the error rate is relatively high. For reference, even a 1% error rate means out of 10 visits you're likely to get one, because you'll have multiple billing items every visit.

This is depressing.

It's good advice but... how broken is our society that this advice is needed and we can't just force companies that are extorting people over healthcare costs to charge reasonable prices.

What about this tactic: find out what percentage they get if they sell the account to a collector. Offer a bit more than that.

Funny story, our billing service was also collections. Meaning, the doctor / hospital earned X% of what ever we got, regardless of if you were in collections or not.

So, we had no incentive to really negotiate in that regard.

Arguably a significant percentage of healthcare companies have their billing setup in such a way. Or they handle it entirely in house.

I want to know what the legal basis for collecting from an ER patient is. At the point of needing ER services, most people are not able to form a binding contract so it cannot be that.

I do agree that hospitals should be paid for the services they perform. It's just that our society's free market notion of price-agreement is predicated on voluntary contracts.

> I talked about this with some of my physician friends, and they told me this is typical. In fact, the original bill doesn't represent what they expect to be paid

For instance, if the hospital is billing under a theory of reimbursement for services provided on your behalf, lying about their costs is textbook fraud.

Or are there explicit state laws that allow hospitals to collect from ER patients without a contract in place? If so these need to be reformed to have uniform charges no matter who the payer is. Like say towing.

If not statutory then the patient could be said to have been unjustly enriched. The remedy for the ER provider is the court-imposed equitable quasi-contract. The pluses for the patient include the limitation that the amount has to be reasonable (quantum meruit damages)

The wiki page is brief but ok https://en.wikipedia.org/wiki/Quasi-contract

Copyedited...

So the real dynamic is that very few ever get to litigating the matter, because the path of least resistance is to simply speak the hospital's language and they will reduce it in-house to something more provably in-line with their expenses?

Still, it seems worthwhile to work towards penalizing hospitals for routinely going over the line, otherwise they will continue to monetize the difference between what is right and what they can get away with.

And on that front, I still have to ask how it's not straightforward fraud to lie about the expenses incurred? If we're roommates and I pick you up a gallon of milk at the store knowing you want some and will reimburse me, but I add it to our tab as $20 - am I not attempting to defraud you?

Trumped up costs do routinely happen across all sectors. It just seems on this topic that grassroots pushback is never discussed, yet could be quite appropriate. For example, a self-help form letter that demands an "out of network" hospital substantiate exactly why their expenses were double that of every other hospital.

> how it's not straightforward fraud to lie about the expenses incurred?

It is fraud. It's just not prosecuted, because it's a wealthy corporation doing it.

Are you telling me that the American healthcare works like an Arabic bazaar, where you start with a price that is 20x the real value and negotiate it down to a fraction of the initial offer?

Difference is, the buyer haggles after receiving the non-returnable service, so they cannot shop around, or use the threat of shopping around as a bargaining tactic. The buyer is entirely captive, while seller may freely decide how low to go (if at all), depending on factors opaque to the buyer.

... And frequently they won't give you a price even if you ask what it costs upfront.

Bingo

If you don't have insurance you can negotiate your bill. The problem is that people don't understand that, that Americans hate negotiating, and that negotiating the price of something after you bought it (or even after you need it) stinks.

Get this though: if you have insurance and your insurance doesn't cover something, you often can't negotiate. I had a $10,000 procedure that insurance didn't cover (i.e., I hadn't met my high deductible yet), and I had no choice but to pay the insurance's agreed-upon rate (which I feel was higher than what I should have been paying out of pocket).

So it was kind of negotiated, but through insurance and their negotiated rates not an individual's out of pocket negotiated rates.

This was also a service where I wasn't informed that a second doctor was out of network, which also screwed me me (and there's literally nothing I can do about this after the fact).

You can always negotiate and threaten to not pay. They might send you to collections or even sue you for the debt, but often they'll agree to a smaller number to avoid the hassle.

really? I've been told by different hospital billing departments that they will put me on a payment plan, but will absolutely not negotiate beyond an insurance provider's agreed upon rate.

Of course, that stance is in their best interest and not mine... so maybe I wasn't being forward enough?

This all feels quite ridiculous.

It is all ridiculous.

It honestly depends on the individual hospital. They almost always have a contract with insurance that they can't accept less, but nobody's checking and it's common for them to do so. Some hospitals are reasonable and especially if they see if you have low income/assets, will settle with you. Others don't care at all and will not accept any less and just send you to collections or sue.

Well of course the hospital billing department is going to tell you that you have to pay the entire bill. What did you expect? Ask to speak to a manager, make a specific counter offer, and threaten to pay $0 if they don't accept. It only takes a few minutes and even if they refuse you won't be any worse off than before. (I agree this is a ridiculous system.)

I've said things like "really? there's nothing you can do about the cost?" but that's a really weak push for it... I just hate kind of being a dick about it (asking for a manager and making a counteroffer makes me feel pretty shitty, but I'll give it a shot).

I would think it depends if they think you have money (or future earning capacity). If I'm the hospital, and I think you have or will have money, then why not pursue you. On the other hand, if you're poor and having nothing to pursue, then I'll settle for less.

Sure, but the people in the billing department have never met me? So unless they're doing a credit check or doctors are taking notes on suspected financial situations... I doubt they're doing this.

Employment status, Medicaid status, and zip code you live in are all pretty good proxies. Someone who doesn’t offer employer provided insurance is probably not worth pursuing unless they have some other indicator of wealth.

People also don't know how far they can negotiate. For a lot of people these numbers are close to financial ruin so it's hard to negotiate with clear head. Add to that being sick. It's a perverse, heartless system.

I mean, the closer the number is to financial ruin, don't you think it's more likely that someone will negotiate? What you're saying, essentially, is: the higher the price of something, the less likely someone will negotiate.

Clearly, that is not the case.

And in regards to your last point, what has made the system so perverse is the insurance companies in the first place. If most people were actually responsible for paying all of their healthcare costs themselves, the prices would be pretty cheap.

For example, I live in Tanzania, and I can get medication that is over $500/month without insurance in the US, or like $75 with insurance, for around $1-$2. Also, I can get a tooth pulled for under $5.

No one has health insurance here, I don't think it even exists, and therefore, hospitals are forced to charge an amount that the people can pay for. The system actually works, and if for some reason you can't pay, you can volunteer at the hospital until your bill is paid off.

Consequentially, even though there aren't laws about accepting all patients (hospitals are allowed to turn away whoever they like), they don't, because they know they will be paid at the very least in labor.

Though, honestly, at this point in the US the system is so fucked up that I'm not sure it's even possible to create a free-market system anymore. It pains me to say this (as a staunch libertarian), but I think maybe it would be better at this point for the government to just foot the bill for everyone.

“I mean, the closer the number is to financial ruin, don't you think it's more likely that someone will negotiate? What you're saying, essentially, is: the higher the price of something, the less likely someone will negotiate.”

I have been close to ruin and you can reach a point where things are so overwhelming that you basically just give up. I am sure some people are natural fighters but a lot of people aren’t. In addition when you run out of money you can’t afford lawyers and other advice which makes things even worse. It’s a really bad negative spiral.

> I mean, the closer the number is to financial ruin, don't you think it's more likely that someone will negotiate?

No. Such panic-inducing tactics are not likely to make someone a better negotiator.

Learned helplessness is a real problem.

Please don't cross into incivility, even when the topic is sensitive and you feel someone else is wrong. It just makes this place worse.

https://news.ycombinator.com/newsguidelines.html

Okay, edited, is that better? I think the incredulity of the OP was quite incivil, for what that's worth. Would be more effective to catch this stuff further up the chain.

> Clearly, that is not the case.

when it "clearly" is the case.

Yes, that's better. Thanks!

Please don't do this here.

This used to be true but is no longer so. Almost every hospital would negotiate with you if they could see that you had no money or were willing to pay a lump sum. You could end up paying 4-10x medicare rate.

However, starting about 5 years ago some hospital got the idea they could refuse to negotiate with everyone and it seems to have spread. Now there are a bunch of these unreasonable hospitals. You can open up all your finances and show that you have no money and that their bill is 100x medicare rate and they would rather get $0 and you declare bankruptcy. I guess they end up getting more revenue overall this way?

Of course they do! "Rely on the mercy of a for-profit (or faux not-for-profit) organization to whom you have already handed a blank check" is a terrible plan, nobody should be surprised that it doesn't work very well, and the people who propose it as anything other than a desperate hail-mary should be ashamed of themselves.

gowld, I'm looking at you.

That’s interesting. The friends I talked to did mention this, but it sounded more like you could knock the bill down a bit, perhaps in the 10-25% range (10% being a lot more likely). The er physician I spoke with seemed skeptical That you could negotiate it down anything like and hmo with massive negotiating power could, but that is just one conversation, and ER docs may actually not be the most knowledgeable people about this. A hospital admin or financial person would probably be a better source.

Why should the amount you need to pay for life-saving care depend on your social/intellectual wherewithal to negotiate? Is this a good outcome for society?

It shouldn't. It also shouldn't be hidden in "employer contributions" to insurance premiums. Large parts of the sector shouldn't be financed through massively inefficient wealth transfers and block grants to states.

We have too much third-party payer, especially mandated third-party payer, that distorts the face value of these services.

Sectors of health care that are largely cash-based, such as corrective eye surgery, many orthodontic treatments, most plastic surgery, are all quite cheap and have up front pricing that is easy to follow. Actual healthcare reform needs to rip out the old, broken systems and replace them with a simple plan for chronic healthcare needs, insist on transparency in pricing, and let the market take care of the rest.

Shareholder value doesn't care about society.

Except the vast majority (4,888 of 6,210) of hospitals have no shareholders because they are run as non-profits or by governments.

https://www.aha.org/statistics/fast-facts-us-hospitals

Non profit means profit for management and their friends. They aren’t do gooders.

Government isn't made up of do-gooders, either. Churches are full of hypocrites. Private companies want to make money.

We manage to solve all kinds of other problems with these same structures despite the fact that the people working in them have not achieved your level of sainthood.

I'd reckon the people downvoting you have never tried to negotiate a bill.

You wish a dissected aortic aneurysm in front of Zuckerberg General on the folks arguing for negotiation or a market-based solution. The pox aren't serious enough.

Just look at he ownership structure of a lot of non profit hospitals. It’s always the same well connected guys.

It's difficult and painful to negotiate anything better than than a payment plan if you don't have a lump sum to offer. Patients have very little leverage.

How does one actually go about negotiating the ER bill after you've received one?

Hospitals have a billing department. You go talk to them and say "I am unable to pay this amount." There is probably a number on your bill to call.

And then they look up your income on one of a dozen information gathering platforms and decide that you qualify for a 2% discount, because privacy doesn't matter and hospital price gouging isn't a problem. Enjoy!

First hit on Google for that exact question: https://www.forbes.com/sites/financialfinesse/2017/03/30/wha...

Actually it is a lot easier to negotiate the price after you’ve already gotten the service. They can’t take back the service if you don’t agree to their price.

It depends if the courts find you liable for the service regardless of having agreed upon a price beforehand or not.

With medical care, I would guess the court would side with the medical care provider, and negotiating beforehand would help you, whereas not negotiating beforehand would give a blank check to the seller (as the system is now).

Debt & collections exist.

Why aren't there services that negotiate people's medical bills, for a fee?

Because "negotiating" the blank check that you already signed does't work.

Yes, it works if they have actually stuck you with a bill that exceeds your net worth and expected income, but in that case you can't afford and/or don't need a negotiator -- you just default. It also works if you've stirred up a media frenzy, but you can't turn that into a business model for obvious reasons. The only place it does reliably work is in the imagination of those looking to downplay the severity of the current state of affairs.

They exist but many have actually gone out of business in the last few years, perhaps due to hospitals refusing negotiation. Most of mine were referrals from health insurance brokers. They're usually commission based so they only charge if you they save you money.

Like the parent comment said, there are. Insurance companies play that role. Hiring a negotiator without having to buy insurance would be valuable, though.

> As part of a powerful group, I have someone not just paying the bill but knocking it down for me. I may not like being part of a group plan, but on my own, I'm toast.

This sounds a lot like going to court with/without getting a lawyer.

that's why when the whole country is in the same union all prices go down

Yes, this is the fundamental argument in favor of a single-payer public health insurance. This is why the US spends so much more on healthcare per-capita, and as a percentage of GDP, than Canada, for example.

> In 2006, per-capita spending for health care in Canada was US$3,678; in the U.S., US$6,714. The U.S. spent 15.3% of GDP on healthcare in that year; Canada spent 10.0%.[6]

https://en.wikipedia.org/wiki/Comparison_of_the_healthcare_s...