Of all the dysfunctions of the famously cursed US healthcare system, few are so obviously a total scam as "surprise billing." Here's how that works: you go to a hospital (often its ER) that is covered by your insurer, and then, despite this, you get a giant bill. Surprise!

How can a hospital covered by your insurer hit you - and not your insurer - with a bill?


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Simple. A private equity company has convinced each of the medical professionals you interact with to secede from the hospital's payroll and form an LLC.

The hospital contracts with your anesthesiologist's LLC, your trauma surgeon's LLC, the radiologist's LLC - sometimes the WHOLE ER is amputated from the hospital and then grafted back on in LLC form, under contract to the hospital as a standalone independent business.


Your insurer has a deal with the hospital, but all of these artificial persons that were Frankensteined together by private equity have no deal with your insurer. What's more, they can charge many multiples of the "negotiated rate" for your care and bill *you* for it.

So after the ambulance brings you, bleeding and unconscious to the hospital and you wake up and ascertain that they lucked into bringing you to an ER that has a deal with your insurer, you're still in for a surprise. Surprise!


The surprise keeps on coming. First you get a bill from the ER itself as a "facilities fee," like the cover charge at a bar, except it's hundreds or thousands of dollars and it applies whether you got any care at all.

Then you get the radiologist's bill, which might be $12 or $200, depending on some invisible, inscrutable negotiation between their LLC and your insurer. Then comes the aneasthesiologist. Then the orthopedist.


Despite outward appearances and the sign over the door, the hospital isn't a unitary entity. It's a colony organism, a kind of rich Galapagos of intertwined, symbiotic, standalone entities that somehow produce care as an emergent property.

It's like a hollow, rotten log, teeming with independent, variegated lifeforms that trickle bills into your mailbox without end, for months after your trauma, adding up to hundreds or thousands or tens of thousands of dollars.


Even the $12 invoices take an hour to pay as you set up an account with the exotic payment processor that contracts with the chiropodist's LLC, whose website and phone-tree were designed by a GPT-3 procedural dungeon generator.

This is a system of absolute and manifest terribleness, and it's also illegal. US medical practices are legally required to be run by licensed doctors, but the doctors who get sucked into these scams quickly discover that they're only nominally running the business.


The PE "investor" actually calls the shots, and any doctor "owner" who bucks the system gets fired from their own medical practice.

This worked well for PE companies during the pandemic, as they raked in millions in federal PPP loans while slashing doctors' pay and denying medical staff access to PPE.

All attempts to end surprise billing, were sabotaged by the PE giants who created it - Blackrock, KKR and co.


They were long on surprise billing and spending millions to keep the racket intact was a rational investment.

Surprise billing was a 2020 election issue. The same PE-backed LLCs (who'd cut doctors' pay and demanded billions in bailouts) found vast sums to spend on astroturf campaigns where "patients" insisted surprise billing was great, actually.


And they pumped huge amounts to support the campaigns of ghouls like Richie Neal, whose progressive primary challenger was sidelined via a homophobic smear campaign, and who rode to office on promises of maintaining surprise billing.

For those of us who despaired of ever being shut of this predatory scam, the news that the Biden administration is issuing an interim order barring surprise billing could not be more welcome.


"[The rule] bars surprise billing for emergency services and high out-of-network cost-sharing for emergency and non-emergency services... out-of-network charges for ancillary services like those provided by anesthesiologists or assistant surgeons..."


But the rule still offers a chance to do *some* price gouging. It follows the contours of the No Surprises Act (which passed the House in Dec 2020), "with baseball-style arbitration to settle payment disputes between providers and insurers."

We got hit by a wave of surprise bills last year after our daughter broke her wrist, with dozens of bills totalling thousands arriving in the mail for months after. The experience prompted us to switch from Cigna to Kaiser in January.


Kaiser is as close to the Canadian and British health care I used for most of my life, but every now and again you'll get a reminder that the best for-profit health-care in America is *much* worse than the state-run care elsewhere.

Just yesterday I got a letter from a private insurance investigator deputized by Kaiser to investigate the circumstances of an "injury" I experienced to see if someone else could be sued or threatened to pay for the resulting care.


Not only is this seven kinds of fucked up, but I don't have a knee injury. I woke up with a mysterious pain in my knee, and, after it persisted for a week, I had a telephone call with a Kaiser doc to determine whether I should be worried. He said it was fine.

The letter from Kaiser's bounty-hunters was plastered in dire warnings to the effect that I'd lose my health care if I didn't cooperate with them in their hunt for someone to terrorize into recouping the cost of this phone-call.


Ladies and gentlemen, the efficiencies of the free market.

An executive order is a nice start here, but we need actual legislative reform.


In the USA, Medicaid most certainly does this, and I think Medicare too. Many of the nasty things health insurance does was pioneered by Medicare and Medicaid.

@pluralistic Jesus. Canada's definitely got problems, but thank God we have socialized healthcare

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