What the author calls criminal is the way hospitals typically bill Medicare and private insurance providers.
If the OPs brother-in-law had had insurance, the hospital would have billed the insurance company the same $195k (albeit with CPT codes in the first place).
The insurance company would have come back and said, "Ok, great, thanks for the bill. We've analyzed it, and you're authorized to received $37k (or whatever the number was) based off our contract/rules."
That number would typically be a bit higher for private insurance (Blue Cross, Blue Shield, United Healthcare, etc), a little lower for Medicare, and even lower for than that for Medicaid.
Then the insurance would have made their calculations relative to the brother-in-law's deductible/coinsurance/etc., made an electronic payment to the hospital, and said, "Ok, you can collect the $X,XXX balance from the patient." ($37k - the Insurers responsability = Patient Responsibility)
Likely by this point in a chronic and fatal disease, the patient would have hit their out-of-pocket maximum previously, so the $37k would have been covered at 100% by the insurance provider.
That's basically the way all medical billing to private and government insurance providers in this country works.
"Put in everything we did and see what we can get paid for by insurance" isn't criminal behavior, it's the way essentially every pay-for-service healthcare organization in the country bills for its services.
I don't say that to either defend the system, or to defend the actions of the hospital in this instance. It certainly feels criminal for the hospital to send an individual an inflated bill they would never expect to pay.
Yes. Though I think technically none of that happened here.
If I sound like I'm defending the morality of the hospital for billing a private individual $190k for services they'd expect to be paid $37k for, please know that I'm not. But it helps to understand WHY the hospital billed that much, and whether it's legal for the hospital to bill that much.
The biggest semantic "mistake" the author makes in their thread is saying, "Claude figured out that the biggest rule for Medicare was that one of the codes meant all other procedures and supplies during the encounter were unbillable."
The Medicare rule does not make those codes "unbillable" - it makes them unreimburseable.
The hospital can both bill Medicare for a bigger procedure code, and the individual components of that procedure, but Medicare is gonna say, "Thanks for the bill, you're only entitled to be paid for the bigger procedure code, not the stuff in there."
Neither the FBI nor Medicare is gonna go after the hospital for submitting covered procedure codes and individual codes that are unreimbursable under those procedure codes. That's not crime, that's just medical billing.
Actual double billing would occur if, say, your insurnace paid the hospital for a procedure, and then they came after you for more money, or billed a secondary insurance for the same procedure. Or if they'd said, "Oh no, the OP's brother in law wasn't here for just 4-hours, they were here overnight so now we're billing for that as well."
NOW - a much better way for the hospital to handle this scenario would be to see that the patient is cash-pay, and then have separate cash-pay rates that they get billed that essentially mirror Medicare reimbursement. That's essentially what the author got them to do, and it absolutely sucks that's what he had to do.
I briefly worked in adjacent space. While I hate the way it works, it makes a lot more sense when you understand that the billed amount is essentially just a negotiation tactic that represents a price well above what they ever expect to be paid (and a bit added to that for safety).
Then, they negotiate with all of the in-network providers for some number that’s well below the billed amount. That number varies a bit based on how effective various negotiations are.
Realistically, OP simply found the number that insurance was going to pay out anyways.
I think the argument is that it’s criminal to take advantage of the patient without insurance and ask them to ruin their life trying to come up with 195k when your system is setup to reasonably profit off the 37k you get from the insured patients. I firmly believe that even in a capitalist society the idea of profiting off of anything let alone healthcare in the thousands of percentage points is criminal.
The hospital double billed for over $100k worth of services on the original invoice.
At a certain point a pattern of issuing inaccurate invoices crosses the line into negligence.
If a business just have a habit of blasting out invoices that bill for services never received, and they know that they keep doing this, and only correct it when the customer points it out, at a certain point it turns into a crime.
From a quick Google query, it says that ~%90 of Americans have health insurance (which seems higher to me than I'd expected). I'd be very interested in knowing the number of uninsured, negligent/nefarious, and exorbitant invoices that are issued as a percentage of all invoices, for the purpose of determining the scale of criminality with respect to your description.
If the OPs brother-in-law had had insurance, the hospital would have billed the insurance company the same $195k (albeit with CPT codes in the first place).
The insurance company would have come back and said, "Ok, great, thanks for the bill. We've analyzed it, and you're authorized to received $37k (or whatever the number was) based off our contract/rules."
That number would typically be a bit higher for private insurance (Blue Cross, Blue Shield, United Healthcare, etc), a little lower for Medicare, and even lower for than that for Medicaid.
Then the insurance would have made their calculations relative to the brother-in-law's deductible/coinsurance/etc., made an electronic payment to the hospital, and said, "Ok, you can collect the $X,XXX balance from the patient." ($37k - the Insurers responsability = Patient Responsibility)
Likely by this point in a chronic and fatal disease, the patient would have hit their out-of-pocket maximum previously, so the $37k would have been covered at 100% by the insurance provider.
That's basically the way all medical billing to private and government insurance providers in this country works.
"Put in everything we did and see what we can get paid for by insurance" isn't criminal behavior, it's the way essentially every pay-for-service healthcare organization in the country bills for its services.
I don't say that to either defend the system, or to defend the actions of the hospital in this instance. It certainly feels criminal for the hospital to send an individual an inflated bill they would never expect to pay.