shocking hospital fee estimate

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random_walker_77
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shocking hospital fee estimate

Post by random_walker_77 » Sat Nov 09, 2019 12:02 am

So, we're just about to have a scheduled surgery, using an in-network doctor, in-network hospital, and in-network anesthesiologists. We found out that the hospital fee for the surgery at insurance-negotiated rates is $90K. Our PPO has a 10% co-insurance, which means we'd owe $9K, except that our out of pocket max is $3K. So this will cost us $3K. This is a surprise, because we thought this would be at most $20K-$30K and probably less after insurance discounts, so our OOP would be closer to $2K.

Searching on the CPT codes 58571 and 52000, it sounds like medicare would be under $8K, so $20-30K sounds more reasonable than $90K. What, if anything, should we do? This surgeon is highly recommended and only operates at this particular in-network hospital. On one hand, this just means we'll max out our OOP, and there's no short-term impact to us whether insurance pays the rest of $20K or $90K. At the low end of $20K, our OOP share at 10% would save us maybe a thousand, but that's not that material to us. It seems difficult to "shop" this at other hospitals and hunt for another surgeon, so we're likely to just go with it.
1) Is there anything really to be done to avoid gouging?
2) Or is this just a case of how the game is played between the insurance company and the hospital? It seems so wrong, but it's unclear if we should do anything more to be a "responsible" consumer.

I've called my health insurer and asked them to investigate and determine cost estimates. They don't require a pre-auth for these particular codes and don't have cost estimates for this procedure for any nearby facilities. I'm expecting to hear from them next week, but anticipate the same numbers that the hospital has presented.

On our previous encounters w/ hospital bills, this insurance company seems to get 50-75% knocked off the bill.
3) Does this mean that the hospital was going to bill even more than $90K?
4) Or does this mean our insurance company just didn't pre-negotiate a good deal on this particular procedure in favor of deals on more common procedures, so we're looking at the regular/inflated rack rate? To some extent, I suppose I'll find out when I get the insurance EOB in a month or three.

Note that I'm just discussing the hospital fee and this is separate from the Surgeon/Nurse/Anesthesiologist's bills, which are expected to be insignificant compared to this hospital fee.

5) With such variability in medical fees between what's typical and what one might be charged (even while in-network!) does this mean that for open enrollment and HDHPs, the co-insurance percentage is almost meaningless and it's really the Out-Of-Pocket Max that matters (after taking into account premium fees)?
6) Is this kind of in-network surprise unusual?

J295
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Re: shocking hospital fee estimate

Post by J295 » Sat Nov 09, 2019 12:14 am

If I’m understanding your post, your total out-of-pocket for everything, will be $3000 maximum. You were thinking it might have been $2000 +10% of the professional bills.

You are confident with the surgeon, and presumably he/she is confident with the hospital. That is to say, you have done due diligence and are comfortable that the quality of care will be sufficient.

If it were me, I would concentrate on my health care and ignore the other matters you address.

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White Coat Investor
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Re: shocking hospital fee estimate

Post by White Coat Investor » Sat Nov 09, 2019 12:17 am

random_walker_77 wrote:
Sat Nov 09, 2019 12:02 am
So, we're just about to have a scheduled surgery, using an in-network doctor, in-network hospital, and in-network anesthesiologists. We found out that the hospital fee for the surgery at insurance-negotiated rates is $90K. Our PPO has a 10% co-insurance, which means we'd owe $9K, except that our out of pocket max is $3K. So this will cost us $3K. This is a surprise, because we thought this would be at most $20K-$30K and probably less after insurance discounts, so our OOP would be closer to $2K.

Searching on the CPT codes 58571 and 52000, it sounds like medicare would be under $8K, so $20-30K sounds more reasonable than $90K. What, if anything, should we do? This surgeon is highly recommended and only operates at this particular in-network hospital. On one hand, this just means we'll max out our OOP, and there's no short-term impact to us whether insurance pays the rest of $20K or $90K. At the low end of $20K, our OOP share at 10% would save us maybe a thousand, but that's not that material to us. It seems difficult to "shop" this at other hospitals and hunt for another surgeon, so we're likely to just go with it.
1) Is there anything really to be done to avoid gouging?
2) Or is this just a case of how the game is played between the insurance company and the hospital? It seems so wrong, but it's unclear if we should do anything more to be a "responsible" consumer.

I've called my health insurer and asked them to investigate and determine cost estimates. They don't require a pre-auth for these particular codes and don't have cost estimates for this procedure for any nearby facilities. I'm expecting to hear from them next week, but anticipate the same numbers that the hospital has presented.

On our previous encounters w/ hospital bills, this insurance company seems to get 50-75% knocked off the bill.
3) Does this mean that the hospital was going to bill even more than $90K?
4) Or does this mean our insurance company just didn't pre-negotiate a good deal on this particular procedure in favor of deals on more common procedures, so we're looking at the regular/inflated rack rate? To some extent, I suppose I'll find out when I get the insurance EOB in a month or three.

Note that I'm just discussing the hospital fee and this is separate from the Surgeon/Nurse/Anesthesiologist's bills, which are expected to be insignificant compared to this hospital fee.

5) With such variability in medical fees between what's typical and what one might be charged (even while in-network!) does this mean that for open enrollment and HDHPs, the co-insurance percentage is almost meaningless and it's really the Out-Of-Pocket Max that matters (after taking into account premium fees)?
6) Is this kind of in-network surprise unusual?
Now you know why you should buy insurance. $3K seems pretty fair to me all things considered.

1. No
2. Yup
3. Who cares what they bill? Not your problem. You bought insurance like you were supposed to.
4. Maybe. Again, not your problem.
5. Yes.
6. Not based on the number of postings about it I see here at Bogleheads.
1) Invest you must 2) Time is your friend 3) Impulse is your enemy | 4) Basic arithmetic works 5) Stick to simplicity 6) Stay the course

surfstar
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Re: shocking hospital fee estimate

Post by surfstar » Sat Nov 09, 2019 12:26 am

This is our healthcare system.

Its also why many of the well-off Bogleheads, "coincidentally" are physicians.

itaos
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Re: shocking hospital fee estimate

Post by itaos » Sat Nov 09, 2019 12:41 am

#2 is your answer. The system is imperfect and rigged, it is nice when you have insurance to CYA.

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whodidntante
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Re: shocking hospital fee estimate

Post by whodidntante » Sat Nov 09, 2019 1:33 am

surfstar wrote:
Sat Nov 09, 2019 12:26 am
This is our healthcare system.

Its also why many of the well-off Bogleheads, "coincidentally" are physicians.
I've always thought tech was a better honeypot than medicine. You can get started younger, and with less debt and less overhead. Plus no one dies or sues you. Plus the hours are better and you can dress like you just woke up and you never have to wash your hands. Although doctor pajamas are not so bad.

The site does seem surprisingly thin in rich attorneys, however.

anoop
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Re: shocking hospital fee estimate

Post by anoop » Sat Nov 09, 2019 1:38 am

J295 wrote:
Sat Nov 09, 2019 12:14 am
If I’m understanding your post, your total out-of-pocket for everything, will be $3000 maximum. You were thinking it might have been $2000 +10% of the professional bills.

You are confident with the surgeon, and presumably he/she is confident with the hospital. That is to say, you have done due diligence and are comfortable that the quality of care will be sufficient.

If it were me, I would concentrate on my health care and ignore the other matters you address.
Totally agree with this.

anoop
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Re: shocking hospital fee estimate

Post by anoop » Sat Nov 09, 2019 1:45 am

White Coat Investor wrote:
Sat Nov 09, 2019 12:17 am
3. Who cares what they bill? Not your problem. You bought insurance like you were supposed to.
Totally disagree with this.

2 issues:
- It is this very attitude why we pay so much for healthcare and there is ZERO price transparency.
- If, for any reason whatsoever, insurance doesn't pay, patient will have signed paperwork saying they are responsible for it.

I'm going through a mess now where my insurance says they paid but the provider says the 3rd party that the insurance company uses to pay them hasn't paid it. They sent me a letter saying if they are unable to resolve the issue, I will be on the hook for the amount that was billed to insurance, which incidentally, is almost 4x what insurance has negotiated. The issue is still unresolved as of now and it is for services received in January. Since I have no way to reach said 3rd party I have gotten my employer's benefits rep involved.

If I didn't understand the system or I had someone else taking care of matters because I was not in a condition to do so, guess what would happen?
Last edited by anoop on Sat Nov 09, 2019 4:28 am, edited 4 times in total.

Anonperson
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Re: shocking hospital fee estimate

Post by Anonperson » Sat Nov 09, 2019 2:14 am

surfstar wrote:
Sat Nov 09, 2019 12:26 am
This is our healthcare system.

Its also why many of the well-off Bogleheads, "coincidentally" are physicians.
How does being a physician have anything to do with the estimated $90000 cost the OP is being quoted. The surgeon is responsible for probably 1% of that.

The procedure (58571, laparoscopic hysterectomy ) reimburses around $900 to the physician for the procedure, in hospital rounding, and the 90 day global fee (that is the Medicare going rate so a PPO will be higher) . The 52000 code won't even get reimbursed because insurance companies and Medicare don't pay anything to check your work.

The bulk of the cost is due to the hospital charging for the OR, post op care, medications, equipment, and other overheard.

This is why hospital administrators are well paid.

Anonperson
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Re: shocking hospital fee estimate

Post by Anonperson » Sat Nov 09, 2019 2:24 am

random_walker_77 wrote:
Sat Nov 09, 2019 12:02 am


1) Is there anything really to be done to avoid gouging?
2) Or is this just a case of how the game is played between the insurance company and the hospital? It seems so wrong, but it's unclear if we should do anything more to be a "responsible" consumer.

I've called my health insurer and asked them to investigate and determine cost estimates. They don't require a pre-auth for these particular codes and don't have cost estimates for this procedure for any nearby facilities. I'm expecting to hear from them next week, but anticipate the same numbers that the hospital has presented.

On our previous encounters w/ hospital bills, this insurance company seems to get 50-75% knocked off the bill.
3) Does this mean that the hospital was going to bill even more than $90K?
4) Or does this mean our insurance company just didn't pre-negotiate a good deal on this particular procedure in favor of deals on more common procedures, so we're looking at the regular/inflated rack rate? To some extent, I suppose I'll find out when I get the insurance EOB in a month or three.

Note that I'm just discussing the hospital fee and this is separate from the Surgeon/Nurse/Anesthesiologist's bills, which are expected to be insignificant compared to this hospital fee.

5) With such variability in medical fees between what's typical and what one might be charged (even while in-network!) does this mean that for open enrollment and HDHPs, the co-insurance percentage is almost meaningless and it's really the Out-Of-Pocket Max that matters (after taking into account premium fees)?
6) Is this kind of in-network surprise unusual?
If you want this physician to operate and this is the hospital they have privileges and operate at, then you are stuck.

The $90k being quoted is ridiculously high for a surgery that requires under 24 hours in the hospital. Studies usually quote cost at under $50k for this type of surgery.

If this is the type of hospital with a super fancy lobby and harp players, then you know where your money is going.

bberris
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Re: shocking hospital fee estimate

Post by bberris » Sat Nov 09, 2019 7:01 am

It doesn't matter to you, but the insurance company is probably getting kickbacks from the hospital, so they may not be paying that much. They set rates that way so that the patient gets socked as much as possible.

Emg
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Re: shocking hospital fee estimate

Post by Emg » Sat Nov 09, 2019 7:32 am

[/quote]

If this is the type of hospital with a super fancy lobby and harp players, then you know where your money is going.
[/quote]

Hey my sister used to play her harp at a hospital. She did it out of kindness on a volunteer basis.

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1210sda
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Re: shocking hospital fee estimate

Post by 1210sda » Sat Nov 09, 2019 8:36 am

Very appropriate thread during the Medicare Enrollment period.

I suppose the Max OOP really is a major factor in deciding on which plan to choose. (there are other factors of course).

1210

mcraepat9
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Re: shocking hospital fee estimate

Post by mcraepat9 » Sat Nov 09, 2019 8:45 am

whodidntante wrote:
Sat Nov 09, 2019 1:33 am
The site does seem surprisingly thin in rich attorneys, however.
LOL I agree and I am one.
Amateur investors are not cool-headed logicians.

HoosierJim
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Re: shocking hospital fee estimate

Post by HoosierJim » Sat Nov 09, 2019 8:59 am

Here are some posted transparent pricing for this clinic using one of the codes you mentioned, this site was posted here a few weeks ago

Image

Gynecology Surgeries

Image

Here is a link to the pricing disclaimer

HoosierJim
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Re: shocking hospital fee estimate

Post by HoosierJim » Sat Nov 09, 2019 9:16 am

Triple check that EVERYTHING is going to be in your network.

The other risk is that your anesthesiologist calls in sick the morning of the surgery and another anesthesiologist stands in. EXCEPT this doctor is not in your network, now you get to pay the $3k that you thought would be $2k PLUS an out of network bill of $5k that the insurance company refuses to pay.
About 1 in 7 patients received a surprise bill despite obtaining care at an in-network hospital, according to new data that fuels the momentum behind potential fixes to the fragmented billing process.

The share of in-network hospital admissions with at least one out-of-network claim ranged from 1.7% in Minnesota to 26.3% in Florida, according to the Health Care Cost Institute's analysis of nearly 620,000 in-network inpatient admissions and associated claims across 37 states and the District of Columbia in 2016.

Anesthesiology accounted for the largest share of out-of-network professional claims associated with an in-network admission at 16.5%. Independent labs were the most likely to bill out of network at 22.1%.

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Watty
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Re: shocking hospital fee estimate

Post by Watty » Sat Nov 09, 2019 9:32 am

random_walker_77 wrote:
Sat Nov 09, 2019 12:02 am
1) Is there anything really to be done to avoid gouging?
You do your shopping for the best price when you(or your employer) buys the health insurance.

Even though you have tried to get quotes once all the bills are paid you will likely be amazed at how much smaller the final bill is once it is reduced to the negotiated insurance rate.

One of the big problems with the system is that it is virtually impossible to find this out in advance so that you could do some intelligent shopping for the best price. I have tried to do this several times but I basically gave up trying.

SimonJester
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Re: shocking hospital fee estimate

Post by SimonJester » Sat Nov 09, 2019 9:39 am

The game is rigged... My son just had wrist surgery, the day of the surgery the surgery center ran his insurance and provided a detail of what would be billed to my insurance, what the negotiated fee was, and what the Co insurance would be. They required payment of the co insurance that day.

Fast forward several weeks, and the EOB comes out from my insurance and they billed almost twice what they said the day of the surgery. No details in the EOB at all for the other charges, all line items are the same with just "Ambulatory Surgery" .

Im not sure if I should bother calling to try and find out why the bill was double what they originally told us or just accept this is the game we get to play. :(
"They who can give up essential liberty to obtain a little temporary safety, deserve neither liberty nor safety." - Benjamin Franklin

Longdog
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Re: shocking hospital fee estimate

Post by Longdog » Sat Nov 09, 2019 9:48 am

whodidntante wrote:
Sat Nov 09, 2019 1:33 am
surfstar wrote:
Sat Nov 09, 2019 12:26 am
This is our healthcare system.

Its also why many of the well-off Bogleheads, "coincidentally" are physicians.
I've always thought tech was a better honeypot than medicine. You can get started younger, and with less debt and less overhead. Plus no one dies or sues you. Plus the hours are better and you can dress like you just woke up and you never have to wash your hands.
Ah, to live in a world where nobody has to wash their hands. That is the dream! :)
Steve

MikeG62
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Re: shocking hospital fee estimate

Post by MikeG62 » Sat Nov 09, 2019 9:54 am

random_walker_77 wrote:
Sat Nov 09, 2019 12:02 am

...Searching on the CPT codes 58571 and 52000, it sounds like medicare would be under $8K, so $20-30K sounds more reasonable than $90K. What, if anything, should we do? This surgeon is highly recommended and only operates at this particular in-network hospital. On one hand, this just means we'll max out our OOP, and there's no short-term impact to us whether insurance pays the rest of $20K or $90K. At the low end of $20K, our OOP share at 10% would save us maybe a thousand, but that's not that material to us. It seems difficult to "shop" this at other hospitals and hunt for another surgeon, so we're likely to just go with it.
The only thing I'd add to this discussion is a question of whether it's medically fine for you to wait and have this surgery in early 2020 or not? If so, would you be better off financially if it happened in 2019 or 2020 from the standpoint of using up your OOP maximum? In other words, if you have used little of your OOP maximum in 2019, then maybe it's better for you financially to have this surgery done in early 2020, such that if you incur additional health care costs in 2020 (which would otherwise go against your co-insurance) at least those would be paid fully for by your insurance company.
Real Knowledge Comes Only From Experience

sport
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Re: shocking hospital fee estimate

Post by sport » Sat Nov 09, 2019 10:02 am

OP, the OOP maximum of $3000 is probably for the calendar year 2019. So, having the procedure this year will use up your OOP, but starting in January, you will have another $3000 OOP for treatment in 2020. If there is no medical problem in delaying the surgery until January, you will have met the OOP for the entire year. Of course, if the surgery cannot wait another 2 months, health considerations come first.

sawhorse
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Re: shocking hospital fee estimate

Post by sawhorse » Sat Nov 09, 2019 12:16 pm

HoosierJim wrote:
Sat Nov 09, 2019 9:16 am
Triple check that EVERYTHING is going to be in your network.

The other risk is that your anesthesiologist calls in sick the morning of the surgery and another anesthesiologist stands in. EXCEPT this doctor is not in your network, now you get to pay the $3k that you thought would be $2k PLUS an out of network bill of $5k that the insurance company refuses to pay.
About 1 in 7 patients received a surprise bill despite obtaining care at an in-network hospital, according to new data that fuels the momentum behind potential fixes to the fragmented billing process.

The share of in-network hospital admissions with at least one out-of-network claim ranged from 1.7% in Minnesota to 26.3% in Florida, according to the Health Care Cost Institute's analysis of nearly 620,000 in-network inpatient admissions and associated claims across 37 states and the District of Columbia in 2016.

Anesthesiology accounted for the largest share of out-of-network professional claims associated with an in-network admission at 16.5%. Independent labs were the most likely to bill out of network at 22.1%.
You might also get hit with a $117k bill for an out-of-network "assistant surgeon" you've never met and were never told about and whose presence was dubious. Or a $250k bill for two surgeons called in just to stitch up the incision. Or a $94k out-of-network bill for neuromonitoring services that insurance companies value at $816.

https://www.npr.org/sections/health-sho ... ackbreaker

https://www.nytimes.com/2014/09/21/us/d ... bills.html (requires subscription)

https://www.aol.com/article/2014/09/22/ ... /20965696/

IMO
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Re: shocking hospital fee estimate

Post by IMO » Sat Nov 09, 2019 12:37 pm

HoosierJim wrote:
Sat Nov 09, 2019 8:59 am
Here are some posted transparent pricing for this clinic using one of the codes you mentioned, this site was posted here a few weeks ago

Image

Gynecology Surgeries

Image

Here is a link to the pricing disclaimer
THIS is exactly what is needed to make health care transparent and allow natural market forces to provide competition.

Thanks for sharing/posting. You only posted the gynecological surgeries, but this center offers a number of specialists/surgeries. I'd suggest anyone look at this site because this is truly a viable means to provide transparency to a broken system.

For elective surgeries, it can be well worth it to make a trip out of state for such procedures.

If anyone else knows of other centers with transparent pricing like this, please post them.

Here's the price disclaimer:

What is included in the price?
Should you be a candidate for surgery, the facility fee, surgeon’s fee, and anesthesiologist’s fee are included in the price. (See the pricing page for specific procedures which may require additional fees such as implants for certain orthopedic procedures.)

minimalistmarc
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Re: shocking hospital fee estimate

Post by minimalistmarc » Sat Nov 09, 2019 12:39 pm

fru-gal wrote:
Sat Nov 09, 2019 12:29 pm
simplesimon wrote:
Sat Nov 09, 2019 7:11 am
minimalistmarc wrote:
Sat Nov 09, 2019 4:09 am
Shakes head at insane American healthcare system.

In the U.K., somebody who has no money would get this routine operation for free, and the total cost to the tax payer would be well under 5k.
Yes, but doesn't the U.K. ration healthcare as well?
I understand there are waiting times. That isn't rationing.

I had a broken tooth that was wrecking the inside of my mouth this year, and it took two months to get an appointment with an oral surgeon to extract it. I was paying out of my own pocket. How's that for a nice U.S. healthcare system. Heck, I'm lucky I could pay for it. I would have been out of luck if I couldn't. Would be interested to know what happens with that in the UK.
It’s free, but waiting time might be similar. Occasionally government chucks in funding if waiting lists are really bad.

My wife had a benign cyst appear on her jaw line. Was referred to max fax surgery and was offered an appointment on a Saturday 2 weeks later. Surgeon did a beautiful job. All free.

The only downside of the NHS is that the public abuse it because there is no cost to them. It’s completely free at the point of use so people frequently don’t attend for appointments/scans/procedures/operations and that means the slot is wasted.

I would like to see a financial penalty applied to the abusers but it will never happen.

In Northern Ireland the government is dysfunctional and I hear that waiting lists for routine stuff is 3 years +

Big Dog
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Re: shocking hospital fee estimate

Post by Big Dog » Sat Nov 09, 2019 12:49 pm

1) Is there anything really to be done to avoid gouging?
There is no 'gouging' since this is a contracted rate between your hospital and your insurer.

2. Yes, to be a responsible consumer, make sure you use a in-network hospital and even ask about in-network anethesiologists and radiologists. But different hospitals could have different rates, so if you want to save your insurer a few bucks you could call around to other network hospitals and ask what they would charge.

3. Generally, yes.

4. They negotiated what they negotiated. There are thousands of cpt codes and each one has a separate price. All are negotiated.

5. If you have major surgery scheduled, then yes, assume that you will hit your OOP max.

6. What surprise? What did you expect the fee to be, and why did you expect it to be that price? (hint: Medicare's "negotiated" rates have zero to do with a private insurer's negotiations in that Medicare does not negotiate, it just sets a fee that it will pay to docs and hospitals -- take it or leave it.)
I understand there are waiting times. That isn't rationing.
Yes, wait times are in fact one form or rationing.
Last edited by Big Dog on Sat Nov 09, 2019 12:52 pm, edited 2 times in total.

fru-gal
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Re: shocking hospital fee estimate

Post by fru-gal » Sat Nov 09, 2019 12:50 pm

Unwilling to clean up previous mangling of attributions:

Someone posted:
If this is the type of hospital with a super fancy lobby and harp players, then you know where your money is going.

Someone else replied:
Hey my sister used to play her harp at a hospital. She did it out of kindness on a volunteer basis.

and I add:

The piano player at my local hospital is a volunteer. Also the gift shop is run by volunteers. Not sure what else qualifies as super fancy. I assume cafes at least break even?

jacoavlu
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Re: shocking hospital fee estimate

Post by jacoavlu » Sat Nov 09, 2019 1:04 pm

https://www.mdsave.com/

if you want to pay a flat fee, you can get most anything done

Anonperson
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Re: shocking hospital fee estimate

Post by Anonperson » Sat Nov 09, 2019 1:42 pm

fru-gal wrote:
Sat Nov 09, 2019 12:50 pm
Unwilling to clean up previous mangling of attributions:

Someone posted:
If this is the type of hospital with a super fancy lobby and harp players, then you know where your money is going.

Someone else replied:
Hey my sister used to play her harp at a hospital. She did it out of kindness on a volunteer basis.

and I add:

The piano player at my local hospital is a volunteer. Also the gift shop is run by volunteers. Not sure what else qualifies as super fancy. I assume cafes at least break even?

Just because the Harp player is a volunteer doesn't negate my point. They are usually playing in a fancy large lobby with lots of wasted non revenue generating space.

Some patients want to be in a hospital like this. That is fine. But you are kidding yourself if you don't think this doesn't impact the bottom line.

The more utilitarian hospitals are not generally going to be charging twice the national average for a straightforward surgery with a 23 hour hospital stay. This is my experience having been at several hospitals across the country (county, private, not for profit, academic etc)

runner540
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Re: shocking hospital fee estimate

Post by runner540 » Sat Nov 09, 2019 2:33 pm

aida2003 wrote:
Sat Nov 09, 2019 2:15 pm
anoop wrote:
Sat Nov 09, 2019 1:45 am
White Coat Investor wrote:
Sat Nov 09, 2019 12:17 am
3. Who cares what they bill? Not your problem. You bought insurance like you were supposed to.
Totally disagree with this.

2 issues:
- It is this very attitude why we pay so much for healthcare and there is ZERO price transparency.
- If, for any reason whatsoever, insurance doesn't pay, patient will have signed paperwork saying they are responsible for it.

I'm going through a mess now where my insurance says they paid but the provider says the 3rd party that the insurance company uses to pay them hasn't paid it. They sent me a letter saying if they are unable to resolve the issue, I will be on the hook for the amount that was billed to insurance, which incidentally, is almost 4x what insurance has negotiated. The issue is still unresolved as of now and it is for services received in January. Since I have no way to reach said 3rd party I have gotten my employer's benefits rep involved.

If I didn't understand the system or I had someone else taking care of matters because I was not in a condition to do so, guess what would happen?
I totally agree with you on the both raised issues!! Your provided one of examples of a terrible healthcare system in the USA.
It's very discouraging that a healthcare professional would have such an attitude. No wonder then why other people are appalled by their salaries which I think also contributes to the cost of the healthcare in this country. In addition, it could be that he's looking through totally different money lenses than the rest of us. Once you reach a certain financial/monetary level your attitude to issues/things that general population (even on BH) is concerned with shifts.

All the clowns running the system have open cards to them and we, consumers, are just a punching bag. The sad part is that the consumer will be the loser most of the time. In your case, it sounds as if fraud is involved. If the insurance co. can prove with a transaction code and an amount, but the provider cannot find it on its end, there must be a hole somewhere.

Also, OOP max is one thing but I frequently hear/read that people incur much higher expenses beyond the OOP max. I wish I understood why that happens and what expenses are usually involved.
I'm aware of one good example. It is a colonoscopy if a person is younger than 50. A doctor might order it because of some serious concerns, but insurance can decline to cover it because of the age. In that case, you don't even get to pay the negotiated price. You have to pay the retail price ($5k+ all fees included unless lab services needed which would be a lot extra) and this amount doesn't go against your yearly deductible or OOP max.
It will be my problem: I went for a routine test related to a very common condition, and it wasn't covered AT ALL (I got the $1000 bill) - because my diagnosis code wasn't "bad enough" for the insurance company to cover the test. So I am stuck negotiating with the provider (who verified my insurance and gave me an estimate before the test) to pay and whatever I pay, doesn't even go to my OOP max.

fru-gal
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Location: New England

Re: shocking hospital fee estimate

Post by fru-gal » Sat Nov 09, 2019 2:53 pm

Anonperson wrote:
Sat Nov 09, 2019 1:42 pm
fru-gal wrote:
Sat Nov 09, 2019 12:50 pm
Unwilling to clean up previous mangling of attributions:

Someone posted:
If this is the type of hospital with a super fancy lobby and harp players, then you know where your money is going.

Someone else replied:
Hey my sister used to play her harp at a hospital. She did it out of kindness on a volunteer basis.

and I add:

The piano player at my local hospital is a volunteer. Also the gift shop is run by volunteers. Not sure what else qualifies as super fancy. I assume cafes at least break even?

Just because the Harp player is a volunteer doesn't negate my point. They are usually playing in a fancy large lobby with lots of wasted non revenue generating space.

Some patients want to be in a hospital like this. That is fine. But you are kidding yourself if you don't think this doesn't impact the bottom line.

The more utilitarian hospitals are not generally going to be charging twice the national average for a straightforward surgery with a 23 hour hospital stay. This is my experience having been at several hospitals across the country (county, private, not for profit, academic etc)
I would say that the space that contains the piano and gift shop is about 25x25 feet. I don't think that is going to trash the bottom line, and I would argue that a more pleasant environment makes patients feel better. There's a major hospital elsewhere in the state where some of the rooms look like something out of the Snake Pit. That can't be good for people. And I'm sure that hospital makes a bundle of money compared to the one near me.

Startingover2019
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Re: shocking hospital fee estimate

Post by Startingover2019 » Sat Nov 09, 2019 2:58 pm

HoosierJim wrote:
Sat Nov 09, 2019 9:16 am
Triple check that EVERYTHING is going to be in your network.

The other risk is that your anesthesiologist calls in sick the morning of the surgery and another anesthesiologist stands in. EXCEPT this doctor is not in your network, now you get to pay the $3k that you thought would be $2k PLUS an out of network bill of $5k that the insurance company refuses to pay.
About 1 in 7 patients received a surprise bill despite obtaining care at an in-network hospital, according to new data that fuels the momentum behind potential fixes to the fragmented billing process.

The share of in-network hospital admissions with at least one out-of-network claim ranged from 1.7% in Minnesota to 26.3% in Florida, according to the Health Care Cost Institute's analysis of nearly 620,000 in-network inpatient admissions and associated claims across 37 states and the District of Columbia in 2016.

Anesthesiology accounted for the largest share of out-of-network professional claims associated with an in-network admission at 16.5%. Independent labs were the most likely to bill out of network at 22.1%.
As an anesthesiologist, I don’t know what to say about this. I know a doctor in Dallas who does this full time and makes an insane amount of money. But it is coming to an end soon.

HoosierJim
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Re: shocking hospital fee estimate

Post by HoosierJim » Sat Nov 09, 2019 3:01 pm

IMO wrote:
Sat Nov 09, 2019 12:37 pm
For elective surgeries, it can be well worth it to make a trip out of state for such procedures.
One problem with going out of state is that many plans now are very narrow networks and this would be an out of network procedure. With the high deductibles in ACA plans, paying out of pocket if it's out of network could make sense. My question on this would be what happens if a complication develops at this out of state out of network facility?

wootwoot
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Re: shocking hospital fee estimate

Post by wootwoot » Sat Nov 09, 2019 3:03 pm

minimalistmarc wrote:
Sat Nov 09, 2019 4:09 am
Shakes head at insane American healthcare system.

In the U.K., somebody who has no money would get this routine operation for free, and the total cost to the tax payer would be well under 5k.
And they would likely wait for months or years to get the surgery.

OP you did the right thing, you have insurance and it's covering you as expected. The out of pocket cost sounds really reasonable too. Just beware of any out of network surgeon assistants or anesthesiologists that may be present during the operation, they could try to hit you with out of network or surprise billing.

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Re: shocking hospital fee estimate

Post by minimalistmarc » Sat Nov 09, 2019 3:37 pm

wootwoot wrote:
Sat Nov 09, 2019 3:03 pm
minimalistmarc wrote:
Sat Nov 09, 2019 4:09 am
Shakes head at insane American healthcare system.

In the U.K., somebody who has no money would get this routine operation for free, and the total cost to the tax payer would be well under 5k.
And they would likely wait for months or years to get the surgery.

Months yes, years no.

Most things can wait a few months.

Cancer surgery is prioritised

My dad had an aortic valve replacement done a month after diagnosis of aortic stenosis. Pre op tests including angiogram, Echo etc, operation, several days on ICU all free.

No medical bankruptcies in countries with kind healthcare systems

sawhorse
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Re: shocking hospital fee estimate

Post by sawhorse » Sat Nov 09, 2019 3:50 pm

Startingover2019 wrote:
Sat Nov 09, 2019 2:58 pm
HoosierJim wrote:
Sat Nov 09, 2019 9:16 am
Triple check that EVERYTHING is going to be in your network.

The other risk is that your anesthesiologist calls in sick the morning of the surgery and another anesthesiologist stands in. EXCEPT this doctor is not in your network, now you get to pay the $3k that you thought would be $2k PLUS an out of network bill of $5k that the insurance company refuses to pay.
About 1 in 7 patients received a surprise bill despite obtaining care at an in-network hospital, according to new data that fuels the momentum behind potential fixes to the fragmented billing process.

The share of in-network hospital admissions with at least one out-of-network claim ranged from 1.7% in Minnesota to 26.3% in Florida, according to the Health Care Cost Institute's analysis of nearly 620,000 in-network inpatient admissions and associated claims across 37 states and the District of Columbia in 2016.

Anesthesiology accounted for the largest share of out-of-network professional claims associated with an in-network admission at 16.5%. Independent labs were the most likely to bill out of network at 22.1%.
As an anesthesiologist, I don’t know what to say about this. I know a doctor in Dallas who does this full time and makes an insane amount of money. But it is coming to an end soon.
Is there anything patients can do?

masonstone
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Re: shocking hospital fee estimate

Post by masonstone » Sat Nov 09, 2019 3:59 pm

whodidntante wrote:
Sat Nov 09, 2019 1:33 am
surfstar wrote:
Sat Nov 09, 2019 12:26 am
This is our healthcare system.

Its also why many of the well-off Bogleheads, "coincidentally" are physicians.
I've always thought tech was a better honeypot than medicine. You can get started younger, and with less debt and less overhead. Plus no one dies or sues you. Plus the hours are better and you can dress like you just woke up and you never have to wash your hands. Although doctor pajamas are not so bad.

The site does seem surprisingly thin in rich attorneys, however.
You’re mistaken, a doctor has on average triple the salary of a tech worker and better job security (I rarely see an older tech worker who isn’t worried about being laid off). Also tech workers have to live in very high cost of living areas. But that’s why it’s also a lot harder to get an MD than a BS computer science.

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Re: shocking hospital fee estimate

Post by 1210sda » Sat Nov 09, 2019 4:07 pm

Startingover2019 wrote:
Sat Nov 09, 2019 2:58 pm
HoosierJim wrote:
Sat Nov 09, 2019 9:16 am
Triple check that EVERYTHING is going to be in your network.

The other risk is that your anesthesiologist calls in sick the morning of the surgery and another anesthesiologist stands in. EXCEPT this doctor is not in your network, now you get to pay the $3k that you thought would be $2k PLUS an out of network bill of $5k that the insurance company refuses to pay.
About 1 in 7 patients received a surprise bill despite obtaining care at an in-network hospital, according to new data that fuels the momentum behind potential fixes to the fragmented billing process.

The share of in-network hospital admissions with at least one out-of-network claim ranged from 1.7% in Minnesota to 26.3% in Florida, according to the Health Care Cost Institute's analysis of nearly 620,000 in-network inpatient admissions and associated claims across 37 states and the District of Columbia in 2016.

Anesthesiology accounted for the largest share of out-of-network professional claims associated with an in-network admission at 16.5%. Independent labs were the most likely to bill out of network at 22.1%.
As an anesthesiologist, I don’t know what to say about this. I know a doctor in Dallas who does this full time and makes an insane amount of money. But it is coming to an end soon.
[/quo
te]

Can you explain what you mean

Katietsu
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Re: shocking hospital fee estimate

Post by Katietsu » Sat Nov 09, 2019 4:13 pm

Before this thread gets shut down...
Back to the OP,
As long as it is all in network, you do have a very low OOP. So, I am not sure why you would spend your time tracking this down.

I am highly suspect about the 90k being the amount the insurance company will pay. It sounds more like the rack rate. I think there is a good chance that in the end the charges will be in line with what you expected. Unfortunately, the system has evolved into one where often neither the provider or patient can provide an accurate estimate before the procedure when insurance and layers of hospital billing departments are involved.

boglesmind
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Re: shocking hospital fee estimate

Post by boglesmind » Sat Nov 09, 2019 4:22 pm

sawhorse wrote:
Sat Nov 09, 2019 12:16 pm
HoosierJim wrote:
Sat Nov 09, 2019 9:16 am
Triple check that EVERYTHING is going to be in your network.

The other risk is that your anesthesiologist calls in sick the morning of the surgery and another anesthesiologist stands in. EXCEPT this doctor is not in your network, now you get to pay the $3k that you thought would be $2k PLUS an out of network bill of $5k that the insurance company refuses to pay.
About 1 in 7 patients received a surprise bill despite obtaining care at an in-network hospital, according to new data that fuels the momentum behind potential fixes to the fragmented billing process.

The share of in-network hospital admissions with at least one out-of-network claim ranged from 1.7% in Minnesota to 26.3% in Florida, according to the Health Care Cost Institute's analysis of nearly 620,000 in-network inpatient admissions and associated claims across 37 states and the District of Columbia in 2016.

Anesthesiology accounted for the largest share of out-of-network professional claims associated with an in-network admission at 16.5%. Independent labs were the most likely to bill out of network at 22.1%.
You might also get hit with a $117k bill for an out-of-network "assistant surgeon" you've never met and were never told about and whose presence was dubious. Or a $250k bill for two surgeons called in just to stitch up the incision. Or a $94k out-of-network bill for neuromonitoring services that insurance companies value at $816.

https://www.npr.org/sections/health-sho ... ackbreaker

https://www.nytimes.com/2014/09/21/us/d ... bills.html (requires subscription)

https://www.aol.com/article/2014/09/22/ ... /20965696/
1. Thanks to CA AB-72 , balance billing and drive-by out of network charges should be reduced or eliminated in CA. Other states I heard are drafting similar consumer protections modeled after CA AB-72 law. I hope all states do so.

2. Thanks to Kaiser Permanente where one doesn't have to worry about such scams (IMO). One of my ex-colleagues had successful open heart by-pass surgery and a few days of hospital stay, diagnostic tests, pre-op, post op care and visits etc and all he has to pay was $3000 for the year.

Boglesmind

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Re: shocking hospital fee estimate

Post by whodidntante » Sat Nov 09, 2019 4:24 pm

sawhorse wrote:
Sat Nov 09, 2019 3:50 pm
Startingover2019 wrote:
Sat Nov 09, 2019 2:58 pm
HoosierJim wrote:
Sat Nov 09, 2019 9:16 am
Triple check that EVERYTHING is going to be in your network.

The other risk is that your anesthesiologist calls in sick the morning of the surgery and another anesthesiologist stands in. EXCEPT this doctor is not in your network, now you get to pay the $3k that you thought would be $2k PLUS an out of network bill of $5k that the insurance company refuses to pay.
About 1 in 7 patients received a surprise bill despite obtaining care at an in-network hospital, according to new data that fuels the momentum behind potential fixes to the fragmented billing process.

The share of in-network hospital admissions with at least one out-of-network claim ranged from 1.7% in Minnesota to 26.3% in Florida, according to the Health Care Cost Institute's analysis of nearly 620,000 in-network inpatient admissions and associated claims across 37 states and the District of Columbia in 2016.

Anesthesiology accounted for the largest share of out-of-network professional claims associated with an in-network admission at 16.5%. Independent labs were the most likely to bill out of network at 22.1%.
As an anesthesiologist, I don’t know what to say about this. I know a doctor in Dallas who does this full time and makes an insane amount of money. But it is coming to an end soon.
Is there anything patients can do?
If it all possible, stay healthy. :happy

Big Dog
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Re: shocking hospital fee estimate

Post by Big Dog » Sat Nov 09, 2019 4:28 pm

2. Thanks to Kaiser Permanente where one doesn't have to worry about such scams (IMO).
I still don't see any "scam" in the OP's description (since we are missing facts, such as real EOB's), but second the idea about joining an HMO, such as Kaiser.

Startingover2019
Posts: 29
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Re: shocking hospital fee estimate

Post by Startingover2019 » Sat Nov 09, 2019 5:30 pm

1210sda wrote:
Sat Nov 09, 2019 4:07 pm
Startingover2019 wrote:
Sat Nov 09, 2019 2:58 pm
HoosierJim wrote:
Sat Nov 09, 2019 9:16 am
Triple check that EVERYTHING is going to be in your network.

The other risk is that your anesthesiologist calls in sick the morning of the surgery and another anesthesiologist stands in. EXCEPT this doctor is not in your network, now you get to pay the $3k that you thought would be $2k PLUS an out of network bill of $5k that the insurance company refuses to pay.
About 1 in 7 patients received a surprise bill despite obtaining care at an in-network hospital, according to new data that fuels the momentum behind potential fixes to the fragmented billing process.

The share of in-network hospital admissions with at least one out-of-network claim ranged from 1.7% in Minnesota to 26.3% in Florida, according to the Health Care Cost Institute's analysis of nearly 620,000 in-network inpatient admissions and associated claims across 37 states and the District of Columbia in 2016.

Anesthesiology accounted for the largest share of out-of-network professional claims associated with an in-network admission at 16.5%. Independent labs were the most likely to bill out of network at 22.1%.
As an anesthesiologist, I don’t know what to say about this. I know a doctor in Dallas who does this full time and makes an insane amount of money. But it is coming to an end soon.
[ quote fixed by admin LadyGeek]

Can you explain what you mean
States are starting to eliminate this option and make it illegal. Of course if as a doctor, you don’t want to take a certain rate, you can always refuse to treat those patients. I bet what’s eventually going to happen should it be a whole blanket statement on “never out of network” then maybe doctors will move, become employed by very large groups with good insurance rates or surgeons and patients will be left hanging? IDK?
I however don’t like the idea of an insurance company offering one group different rate than the next though. I don’t have the right answer, but the docs who “always” bill OON are simply greedy.

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Re: shocking hospital fee estimate

Post by MathIsMyWayr » Sat Nov 09, 2019 5:54 pm

whodidntante wrote:
Sat Nov 09, 2019 1:33 am
surfstar wrote:
Sat Nov 09, 2019 12:26 am
This is our healthcare system.

Its also why many of the well-off Bogleheads, "coincidentally" are physicians.
I've always thought tech was a better honeypot than medicine. You can get started younger, and with less debt and less overhead. Plus no one dies or sues you. Plus the hours are better and you can dress like you just woke up and you never have to wash your hands. Although doctor pajamas are not so bad.

The site does seem surprisingly thin in rich attorneys, however.
I usually stay away from young doctors fresh out of training. In medicine, experience counts. In a fast changing tech sector, workers become "experienced" and obsolete in no time. I see so often that their core expertise downshifts to a freshman level several years after school. Doesn't matter whether BS or PhD.

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Re: shocking hospital fee estimate

Post by deltaneutral83 » Sat Nov 09, 2019 6:07 pm

Hitting an OOP max of $3k for any hospital admission and pre arranging all of the healthcare provided to be in network is a victory, to think anything less is to be unaware of the current healthcare climate. OP should have no other bills the rest of the plan year as long as OP stays in network. The $3k sticker shock (if that's what we're calling it) isn't even in the top 1,500 nightmare articles I've read on health care the last 15 years. And yes, the OOP max is by far the most important thing I look at when deciding between plans. Co insurance is very cute, but I always plan on a hospital admission and blowing right through the OOP max as far as worst case. In fact, I plan on hitting the OOP max just by asking for a glass of water from the ER for a sprained ankle. And that's hoping the water isn't served by an out of network anesthesiologist because the in network one called in sick.

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Re: shocking hospital fee estimate

Post by KingRiggs » Sat Nov 09, 2019 6:25 pm

Startingover2019 wrote:
Sat Nov 09, 2019 5:30 pm
1210sda wrote:
Sat Nov 09, 2019 4:07 pm
Startingover2019 wrote:
Sat Nov 09, 2019 2:58 pm
HoosierJim wrote:
Sat Nov 09, 2019 9:16 am
Triple check that EVERYTHING is going to be in your network.

The other risk is that your anesthesiologist calls in sick the morning of the surgery and another anesthesiologist stands in. EXCEPT this doctor is not in your network, now you get to pay the $3k that you thought would be $2k PLUS an out of network bill of $5k that the insurance company refuses to pay.
About 1 in 7 patients received a surprise bill despite obtaining care at an in-network hospital, according to new data that fuels the momentum behind potential fixes to the fragmented billing process.

The share of in-network hospital admissions with at least one out-of-network claim ranged from 1.7% in Minnesota to 26.3% in Florida, according to the Health Care Cost Institute's analysis of nearly 620,000 in-network inpatient admissions and associated claims across 37 states and the District of Columbia in 2016.

Anesthesiology accounted for the largest share of out-of-network professional claims associated with an in-network admission at 16.5%. Independent labs were the most likely to bill out of network at 22.1%.
As an anesthesiologist, I don’t know what to say about this. I know a doctor in Dallas who does this full time and makes an insane amount of money. But it is coming to an end soon.
Can you explain what you mean
States are starting to eliminate this option and make it illegal. Of course if as a doctor, you don’t want to take a certain rate, you can always refuse to treat those patients. I bet what’s eventually going to happen should it be a whole blanket statement on “never out of network” then maybe doctors will move, become employed by very large groups with good insurance rates or surgeons and patients will be left hanging? IDK?
I however don’t like the idea of an insurance company offering one group different rate than the next though. I don’t have the right answer, but the docs who “always” bill OON are simply greedy.
[ quote fixed by admin LadyGeek]

Our anesthesia practice makes every effort to stay in-network with all major carriers. Eliminating the threat of going out-of-network during contract negotiations puts all the power on the side of the insurance carriers. There are two sides to every coin.

I don’t know any anesthesiologists who are intentionally out of network as a permanent state of affairs. Hospitals would not tolerate that behavior.
Advice = noun | Advise = verb | | Roth, not ROTH

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Re: shocking hospital fee estimate

Post by LadyGeek » Sat Nov 09, 2019 6:26 pm

I removed a number of posts comparing the UK healthcare system to the US. Also, a few posts complaining about the US healthcare system. This thread has run its course and is locked (contentious, derailed). See: Locked Topics
Moderators or site admins may lock a topic (set it so no more replies may be added) when a violation of posting policy has occurred. Occasionally, even if there are no overt violations of posting policy, a topic (or thread) will reach a point where the information content of the discussion has been essentially exhausted and further replies are much more likely to cause distress to the community than add anything of value.
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