Using AI to negotiate a $195k hospital bill down to $33k

For folks who aren't healthcare tech nerds, what happened in this case is called "unbundling" which is a fraudulent practice that can have steep penalties from CMS.

CMS maintains a service and set of tools to help prevent payers from getting hit with this called the National Correct Coding Initiative (NCCI) [1]. NCCI only applies to provider services and outpatient billing codes, but is still applicable for emergency room services.

There are a bunch of technical details for implementing the edits in the NCCI, but I think it's worth taking a moment to reflect on this.

It's pretty popular to point to the insurance company as the "bad guy" in healthcare, but this is the sort of stuff they deal with thousands of times per day.

As frustrating and horrible as this story is, it's not unique to an uninsured individual. A big problem in US healthcare is provider overbilling.

One of the most tragic jobs I held in healthcare tech was developing software for billing negotiation between providers and insurance companies. It was pretty eye-opening how terribly everyone behaves, and I learned to have a lot more sympathy for what insurance companies/government payers have to deal with.

As a patient trying to have necessary treatment paid for, it's incredibly frustrating to have a claim denied, and these are what we see in the news and experience personally.

As an insurance company, building robust systems that authorize necessary care while catching overbilling, overutilization and outright fraud is unfathomably complex and error prone.

This one of the reasons I've become a fan of DPC (direct primary care) models [2] with HSAs and supplement high-deductible catastrophic insurance to protect against hospital stays. It puts primary care back into a direct relationship with the patient, and lets insurance companies do what they are good at: pricing risk.

Some of the unintended consequences of how insurance companies are currently regulated is that in some states it can be difficult or impossible for an insurance company to provide a low cost, high deductible plan. They are forced to cover things that drive the costs up, so it's hard to do a DPC + catastrophic insurance option.

[1] https://www.cms.gov/national-correct-coding-initiative-ncci

[2] https://www.aafp.org/family-physician/practice-and-career/de...

I understand. The different meanings of "code" in this conversation is why I said "software" in my comment instead of code.

Copyrighting software is as absurd the other things you listed.

True of the UK, not true of Canada (where providing services covered by the public sector is illegal AFAIU). I think this is exactly the sort of model to move to, price sensitivity for routine care - government insurance and forced saving for the catastrophic. Healthcare should be entirely untied from jobs.

US healthcare is a mess and I'm not defending the cost - but it does have the highest number of top specialists in the world & strong R&D.

Are the outcomes in the US worse? Not that long ago (a couple months ago in fact), I looked at public data comparing cancer survival rates, which put the outcomes in the US at least 10% better than those in the UK. That was additive, such that a 20% survival rate in the UK for a type of cancer is at least a 30% survival rate in the US. The 10%+ better outcome in the US applied to all types of cancers for which I found public data.

I believe the reason for higher US success rates was that the US used more aggressive treatments that the UK would not, since neither does the NHS pay for them nor do their doctors offer them. It is easy to complain about the US system, but the reason that the per capita cost of health care in the US is high could be because the US will try expensive things that the UK’s NHS never would have attempted (since spending exorbitant amounts on aggressive treatments with low chances of success to attain US success rates would drive the per capita cost of medicine to what could be US levels). The high US pricing of those treatments could be further amplified by attempts to take advantage of ignorance. Amplification to take advantage of ignorance was clearly the case in the article author’s case.

I feel like the opposite viewpoint in favor of the US system is not well represented in online discourse, which could very well be because those who were not served well by the UK’s NHS are dead. There are anecdotes about people coming to the US for treatments that they could not receive in the UK or Europe, which is consistent with that.

That said, I have only looked at data for cancer survival rates and not other illnesses, but the cancer data alone contradicts what you wrote. Perhaps reality is in the middle where the UK system is better for routine issues (i.e. you avoid sticker shock), but the US system is better for anything that falls outside of that (i.e. you have a better chance to live). There is evidence both systems have plenty of room for improvement.

We don’t have to imagine how Medicare works because it exists, so I don’t see the use of such analogies.

I suspect that it’s mainly doctors who need to be more responsive to cost incentives as they’re often the ones recommending unnecessary tests or treatments.