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I do medical billing for a major hospital and I believe for-profit health care is evil. AMAA

Title says it all. I work for a major medical facility in the midwest. I'll be fairly limited on specific information (obviously) but ask away.

My work ID (with some edits to keep me out of law suits) as proof:

November 26th 2019
interview date

I recently had bloodwork done to determine if I had signs of potential cancer, after a 25cm ovarian cyst was discovered. I received a letter from my insurance stating that the claim for coverage of those tests was denied, as they considered it "unnecessary for treatment/investigational". I'm pretty sure it's necessary to know if I potentially have cancer, but I digress.

I am in my mid 20s and have never had anything medically wrong with me. No stitches, no broken bones, no hospital visits. I have used insurance purely for routine yearly checks, dentists visits, and eye exams. Therefore, I have no idea what to do about making insurance cover this, as I can't afford the $600 after paying $2,000 for the surgery to remove this cyst. Any advice on appealing the decision and how that process even works?


You might be able to get the clinic that performed the procedure to notify the insurance of medical necessity and provide medical records, but if that already been done you might be out of luck. As far as the appeals process goes, your best option is always to talk regularly with the clinic and keep them informed that you're appealing, trying to stay on top of it, etc.


Block out the bar code btw.

What type of nonsense codes should we be looking for in our billing statements that hospitals have added to line their pockets that don't relate to actual care?

How can we counter bills from doctors who "consult" on a case but never actually see the patient but expect a huge fee (many times not covered by insurance)?

If you receive a bill from a doctor for a bullshit exam how can you fight the bill? (Real world example: My sister went into the doctors for a checkup because she has some on going health issues. The doctor walked in and asked her if she'd had a period recently. She said yes, 2 weeks ago. Doctor walked out and sent her a bill for $600 with no explanation and no help with her medical issues.)


The thing about codes is that they're all essential in one way or another. The shittiest ones are those for Medicare and Tricare because their rules change so often and they're both very picky. My employer does facility based billing as opposed to provider based because we're non profit, so all our codes will say 'hospital' or 'outpatient'. The problem there is that some insurances wont pay certain procedures if they're outpatient.

As far as consulting physicians, you can try requesting the ranking physician because that's typically who consults, but it's unlikely you'll get your pick. The best choice there is to avoid large facilities. More docs = more residents = more consults.

On the bullshit charges... exasperated sigh

Doctors have no idea how billing works. They don't know that every single thing they enter becomes a charge, and if a patient has existing conditions, they will almost certainly charge for 'maintenance' of that condition. If you're following up on that specific issue, only schedule a consultation for that, and do NOT let the doctor change the subject. Anything else? Say no. They're required to write down anything discussed, and as a result, coders are required to turn every word in to coding.

Pro tip; talk to your insurance about what's covered and NEVER the doctor. They have no clue, and will 100% tell you its covered to get you to come in.


I am NOT saying you shouldn't discuss issues with your doctor. You absolutely should. What I'm trying (and failing) to say here is that your appointment's status is not set in stone until its entered in coding. If you go for a wellness exam but discuss your diabetes/former cancer diagnosis/menstrual cycle, the visit will no longer be considered annual wellness. If you discuss an issue other than the original reason for scheduling, the coding can/will change. Absolutely discuss medical issues with your doctor.


How long after a visit can I be billed? I got one from over a year ago. Can I contest it?


Your insurance legally has up to 2 years to reprocess your claims before issuing final billing


Thanks for doing this!!! I have a question, because I'm in a bit of a pickle myself. I had a standard surgery go wrong, and now I owe the hospital a whole fuckton. But they did this to there any point in arguing with them? My insurance company already shelled out 5 figures at what point do they cover it because they fucked up?


Malpractice suits and quality of care issues are really the only ways to get it back to them. They'll do everything they can to fight it though. Truly, best of luck.


I work with someone who never pays her medical bills and hasn’t for years. She claims she has a credit score in the high 700’s and that none of her medical collections show up on her credit reports. Is that possible?


I've never heard of it. I know ours show up in a couple days


My Medicine cost $147k a year, so Im pretty much fucked no matter what right?


Jesus. I mean, I dont want to say yes to that, but like




It depends on the facility. In mine, we're "non-profit" (as if) so we have various discounts and financial assistance. I know of one other facility in my state that actually offers "pay off" discounts for paying in full. Some, the prices are set and that's too bad if you dont like it.


It sounds like you work at a not for profit and still encounter a bunch of issues. Why do you think for profit is the issue as opposed to the design of the system itself?


The system itself is for profit, which is why it still presents us with so many issues. Getting private insurers to pay is more difficult a lot of times because they come up with fun new ways to deny every time. Medicare's biggest problem, honestly, is how impossible it is to keep costs standardized when the market fluctuates like crazy. They change constantly because they have to keep up with the market.


What does the last a stand for in AMAA?


Anything. But the second one stands for Almost.


As someone working for a non-profit healthcare provider, what makes it substantially better than a for profit healthcare provider in your opinion?


Nothing. Because the industry is still for profit, and my organization still cares mostly for the bottom line.


Wait, you're telling me the corporations profiting from sick and diseased people is not a good thing? Well that sounds too close to socialist propaganda for me to listen to. I'm going to lock myself in a closet and blast Tucker Carlson until I forget about this post.


What other response could I expect from NotTedCruz?


How much do you make and should I get a degree in medical coding?


I make $16.50/hour, personally, but our department has two operating systems to keep track of, a shitload of incoming calls, and we're the gobetween for a lot of other departments.

My MIL has a coding degree, and i know a few of the coders at my facility. I can say that they all seem to have a pretty 'medium' opinion of their jobs. The pay is decent, the hours are decent, and they're some of the only people able to work from home, but their work is VERY closely analyzed and nit-picked, so if you're not in to criticism or review, maybe not.


Thank you for doing this AMA. I know several insurance salesmen and most of them are very nice, caring people, making a living like everyone else. What do you think drives the constant cost increases in medical care? I recently had a surgery that "costs" $40,000 and I think it would be considered minor surgery.

Also, even though I met my deductible, my private insurance provider bill shows almost every charge to be over the allowable amount. This basically makes it look as if the hospital is overcharging, even after the insurance company boasts 'discounts' for having their policy. Just who is getting rich here?


If I had to make a guess, the rising costs are a combination of insurance companies getting to say they 'saved' their customers so much money every year and hospitals getting to say they 'wrote off' so much in medical expenses.

Insurance companies will try anything to avoid paying for something. When it comes to deductibles, there are some procedures that let them make you pay the whole charge in stead of just the amount left to meet your deductible. Their contractual adjustments are the real key on the charges though. If a facility is contracted with an insurance, their forced discounts are typically the biggest paid amount, and usually a good reflection of the actual value of a procedure. The US loves their 100% markups, so if a procedure 'costs' 40k, the hospital writes off 22k, the insurance pays 18k, the procedure probably cost under 9k, but everyone gets a shit load of tax credits, except for the patients


I took my daughter to the ER recently at Dr's orders for a breathing treatment for Croup. I was in the waiting area for about 5 hours, and when given a room waited another hour+ until a Dr arrived, who quickly dismissed her saying she didn't need the treatment. I haven't been billed yet, but I see non-coveree claims in my insurance EOBs for upwards of 1400 bucks. For waiting around all day for a treatment the original Dr and multiple nurses at the hospital said she definitely needed, and then being basically denied. Is there anything you can recommend I can do to fight or reduce these insane charges once they hit me?


You're not going to like my answer, but the most you'll probably be able to do is dispute the charges and request a review for quality of care with the hospital itself. I'll set your expectations though; it's not likely you'll get a good result. The line they'll tow is 'you were still given a service that has to be paid for'.

I sincerely hope it works out for you though.


I’m not sure if you’re still answering, but I recently had a consult to have my wisdom teeth removed. My dental covers wisdom teeth removal 100%, so I was sure I was covered.

However no one told me that my wisdom teeth removal (including the consult) would only be covered by dental if my wisdom teeth had erupted. But my teeth are literally growing in sideways so they will never erupt; they’ll just keep pushing into my molars causing ridiculous pain.

So after my consult, in which the doctor literally talked to me for 15 minutes telling me what to expect during the surgery (didn’t even look at my teeth because my X-rays were up on the screen already), I went to check out and got slapped with a $200 bill for a fucking consult... I was so pissed that they would charge my medical instead of my dental for this just because my teeth will physically not erupt thru the gumline.

Is it common in the health insurance world to have policies like this? It just seems so predatory to have policies that are based exactly on the details of a medical situation, and honestly completely diabolical.


Very. Example: most insurance will deny charges for anesthesia for a colonoscopy of it's not coded just right.


does considering R&D justify the high prices, or is that just an excuse?


Honestly both. R&D is expensive, sure, but if a facility has enough money to do insane bonuses for CFOs? Highly suspect.


If a (large) medical bill was first denied as being medically unnecessary (it was for lifesaving measures and aftercare ) but the insurance company told me when I called that it was actually denied because they don’t have coordination of benefits info (no other insurance and no info requested by the company), what are the chances they’re just hoping to get out of paying?

Asking for a friend.


It wouldn't surprise me if that was just something that slipped through the cracks, nor would it surprise me if they were hoping you wouldn't ask questions. I'll say though that COB issues are crazy common, and especially so if someone has had no services for a long time and then suddenly has a major procedure


i am Australian

i do not have health insurance

i needed an emergency appendix removal

got taken to hospital in an ambulance and had the appendix removed by an emergency surgery

walked out of hospital and did not pay a cent and dont owe anyone a cent

how do you feel about that OP?


Envious, and not even on a personal level. I hate what this system does to people.


Ok I've reported this thread in hopes that the mods do something about the OPs proof, he's easily identifiable with what information can be seen and he'll end up losing his job.


I removed the photo


Where is the incentive to provide quality health care if it isn’t for-profit? What about the amount of jobs that would be lost under Medicare for All? What about the fact that it costs $4 trillion a year for a period of 10 years? How would the government negotiate with hospitals when the cost of services is high and they would set a limit on how high the cost of services will be? Would the dramatic reduction in price of services decrease the wages of employees? Are private institutions that offer medical services going to be forced to no longer be for-profit? How wouldn’t they go bankrupt?

If you think for-profit health care is evil, you got another thing coming - socialized medicine is evil too. It would hurt the Middle Class the most. The Upper Class will continue to make money - just not in medical insurance. $1.5 billion was spent on - why on Earth would anyone want to give the government more control? They don’t even try to negotiate.

  1. You seem to have me confused with an economist
  2. If you need an incentive to provide quality care, you have no business being a health care provider.
  3. Where are all the Canadian and Scandinavian refugees if it's so bad?
  4. American health care costs are intentionally inflated to raise money. I see it every three months at our financial meetings. Ic the profit is removed, the health care publicly funded, costs go down.
  5. Middle class individuals are the ones I walk through filing bankruptcy every day. Seems like maybe they could be doing better.

I am european so I am not into US system but I am curious.

who do you bill to? the patient or the insurance? if the hospital is no profit does it mean that his that costs are equal to income? which is the highest voice of cost? how much does a physician is paid by the hospital? thanks!


Billing goes to insurance first, then the patient, unless the patient was involved in a third party incident (worker's compensation, car wreck, etc.)

My employer is listed as non-profit, which is supposed to mean we operate with charges at a low profit level to compensate cost of operations and employee pay.

I'm not sure what you mean by voice of cost

Physicians at our facility all make at least 100k/year, and they are also given division bonuses based on their divisions cash collections every quarter.


As someone who also works for evil for-profit healthcare, what keeps you going to work everyday without losing your mind or having weekly mental breakdowns?


Needing to feed my children


How do you propose we fund healthcare without a profit incentive?


The taxes we already pay to give massive credits to private insurance companies would be a good start. Then taxing billionaires would be cool.


What are the profit margins at hospitals actually like?


Absolutely ludicrous


What is the best way then to create a system that offers quality health care to communities where it's not like the VA, in which you wait forever to be seen by a doctor? I think of Canada in which you could theoretically die waiting for a doctor?


You can do the same here, and then they'll bill your family. My suggestion is single payer with no market, but regulation through lack of profit margins. Cut the red tape. It's that barrier that makes it so most people can't get in to a doctor, and can't get one to talk to them for more than 10 minutes.


Why do you think The U.S. cannot simply adopt the healthcare system of other countries who have universal healthcare?


Because of people like Stellarspace1234. They think helping people needs to be about profits instead of just like... about helping people.


What are, if any, possible ways to fix this disgusting broken system?



But also, letting doctors do their jobs without pinching every penny and regulating the system in to single payer. That's my suggestion.


Why when I go to a hospital in network (ER or surgery) is there always a doctor who is out of network?

Is this done on purpose?


I've actually asked about this myself and gotten no answer, but I think that's because all of our docs are contacted with our facility, so that doesnt happen to us unless theres an issue with their credentials


All those expensive medicines cost max 572€ (around 630$), after that they are 2,5€ (2,75$) to refill. This is Finland, so this is what Sanders is trying to get for you guys? So my question is, how do you keep yourself sane, while seeing people being destroyed by medical bills? As nurse I can handle peoples sorrow etc, but I wouldn't be able to handle money > saving lives mentality.


I honestly dont have an answer. I hate what I do most days. I try to be there for people as much as possible, and i dont know what else to do. I'll say that i do everything i can for every one of them that i talk to, and i can only hope that counts for something


Do you think ICD coding made medical care better and less expensive? Do you think ICD standards lower the cost of healthcare?


I really couldn't say there, honestly. So little of what I see is the back end. I mostly speak with patients and insurance reps, not coders.


What do you think of newer pay for performance models? Do you use these or want to? You think there’s any downsides to it?


To which ones are you referring? I've heard of healthcare-centic ones, and I'm not in to that. Seems to me like a physician should help their patients as best they can, regardless of what's in it for them. Otherwise they're just capitalists with weird short knives.


Why do the scum of the universe control medicine?


Because we assign dollar values to everything and social value to nothing.


As I Wave to you working for a non-profit, would you work for a public for-profit organization?

Second question, what is the hardest part of your job? Be it physically, mentally, or emotionally.


Telling people they owe us money for their dead relatives.


I'm curious as to what software you using for medical billing?


IDX for back end, Powerchart front end


How would you do it differently? If you had the power to reform the system, how would you tear it down and rebuild?


Single payer, merits in the form of time off, eliminate the profits factor


Is it not evil to force doctors to work minimum wage to reduce health care costs?


I mean... nobody said they should?


If I were to lose my health insurance coverage, my lifespan will be fairly short. My conditions need management from specialists as things change every few months and I have to decide which organ to stress/damage to treat another. Meds are horrifically expensive. I have excellent insurance and prescription coverage right now, but I'm at about $80k/year for specialists and lab tests, then another ~$1k/year for prescription copayments. One medication has an organic component to it and needs to be discarded even if unused every 4 months. A 20 vial fill for that prescription is $5k at the negotiated price between insurance and the pharmacy. It's higher retail, and that's for the generic of it. A bad week will have me using 9 vials.

My question is, can some insurance companies unload expensive patients? Our premium for my wife and I is about $6k/year. I've not dealt with any denials for testing since I am sick with several physiological and psychological conditions, at least.


Officially, no. What they'll do is scare you off with ridiculous premiums. Getting insurance through work is always the better version of the deal, but it's still insane.


How do you propose paying healthcare workers and funding new research?


We already pay taxes that fund research grants, so like that


How do private insurers pay for inpatient hospitalizations if they don't use MS-DRGs (Medicare) codes?

why does Medicare pay less than Private insurance for inpatient hospitalizatoins?


It seems to be a benefit/drawback situation. Part A literally ONLY pays for inpatient, and since they're what's called a guaranteed payer and they're nation wide, they get superb rates. Part B covers most everything else, but their clinic costs usually adjust UP not down, to $103.86 if memory serves.

The supplemental do a lot of the work too, which reduces the top line on medical charges a lot. Privates like United and BCBS have higher deducties, which is how they get away from having worse rates than Medicare gets on procedures.


Do you believe you're evil, or contributing to evil?


I ask myself this all the time. I dont have a good answer for you. On the one hand, I stop doing it and pretend it's not happening, it's still happening, and I'm not doing anything to help. On the other hand, I can't change anything, and I give people a lot of bad news. I dont know what that makes me.


If saving people's life is not a good reason to deserve profit, then what is?


What a gross question. If you're a doctor, just fucking do the job. Why did you become a doctor if not to help people. Gross.


It's all over the news that people go to the hospital who have insurance and, while the hospital takes their insurance, some specialists who doesn't can work on you and you're responsible for the entire bill.

If I'm knocked unconscious, what 100% full proof thing can I do NOW to prevent this from happening? And yes, I'd rather risk death than be put in a lifetime of debt if they have to wait to find someone in-network.

If there isn't any and it happens to me, what is the best way to hide my emergency savings from the hospital. My current plan is to transfer it all into my mother's account and hope she doesn't steal it and quit my job and work under the table (I know ways...).

  1. I love you. Don't tell u/SEXIsGoodForTheAss. We're getting married.

  2. You can get an alert bracelet that lists a preferred provider, then call the hospital you're wanting to put down as preferred and request their Tax ID. Give it to your insurance and ask them to confirm if they are in network/contract. As far as particular specialists, I haven't found a way around that one.




Money is the name of the whole game. That's all any of us are to these people. I see it at slavery wlquarterly financial meeting.


Not sure if it is too late but let me explain a situation....

I had slight chest pain from running 10 miles a day for a week,not sure if it was something bad but I figured I would check it out in immediate care. I go to immediate care and the doctor concludes it is probably soreness which I concluded to since the pain came up when I did certain movements. They did take an xray and then let me go back to work. I get off work a couple hours later and start biking home. I get a phone call that I have a "hole" in my lung and that I need to go to the ER ASAP. I felt fine but I never go to the ER and rarely go to the doctor but the doctor was freaking out so I bike really fast to the ER.

I see the front desk person slightly worried. I sit down and notice people around me are dying and suffering while I am just chilling. After 40 minutes the ER doctor sees me(2 nurses saw me to check heart beat and ekg which took 2-5 minutes while in the waiting room). The ER doctor puts a gel on me and after 5 minutes tells me I am fine and no emergency exists. I get an invoice of 600 dollars after.

What I think is wrong is that an emergency was called for but no emergency existed and I am being billed for that. Maybe I am ignorant but I think that is unfair. I wouldn't mind paying if I had an emergency and what is stopping them from saying an emergency exists when it doesn't. What was concluded when the ER doctor saw my xray is that I had very small amount mucus in my lung area,which makes sense since I was sick and had a cold at the time. What should I do and is it possible to contest this? I spoke to the immediate care manager and he said an emergency existed since a possibility of what they claimed could have existed and I had a triage level 3. I got that number after asking what an emergency is since according to the illinois general assembly an emergency is life threatening exists and not a possibility. I can do more in depth but this is the overview of the situation. What do you think and can anything be done?


It sounds to me like they have you over a barrel. I had a similar situation on a call a while back, and the defense used was "well you still went to the ER and received emergent care" as though that somehow makes it your fault/decision.

The only thing I can think of would be to attempt a quality of care complaint with the clinic, but I wont lie to you. I think you're gonna get stuck with it.


Where do you believe the evil in for profit care resides specifically?


Within the greed of shareholders and the people they've convinced that capitalized illness is a good thing.


Why do it if you think it's evil?


My original reasoning was that I could be a friendly voice delivering bad news, and that that was somehow enough. Now, though... I have trouble looking myself in the mirror some days, but it's not like the system will stop if I quit, and someone who doesn't care could take my spot.


Do you outsource medical billing to Asian countries?


Ours is all locally grown, organic opportunism.


How can anything change if you're only willing to be anonymous?


How does me getting myself used in to the stone age help anyone?


How much do you feel doctors should be paid?


Enough to survive, and on far fewer hours


Is easy to find a job as medical billing? How much time do you have to study for the career? How much do you have to pay?


Customer service, not coding. It's a job, not an educated position


Can a pregnant woman prepay for labor/delivery of a child for a discounted rate?


This is another one that would depend on the facility. Call the hospital you want and ask if the have a department for self pay patients who are interested in prepaying. That should get you your starting point.


How much do you think a colonoscopy and an endoscopy cost out of pocket?


They're all over the place. And the prices you see are almost never what's actually paid.


How is the charge master determined at your hospital?


Board of Trustees, if I've been told correctly

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