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

I think the reason is that people know it is a problem but ideologically they really disagree about what to do about it. The impasse creates an opportunity for profit driven actors to fight reforms. Also, democracies do dumb things sometimes. See Brexit.

But also, sometimes people from other countries-- I am thinking parts of Europe-- underestimate how well paid people in the US often are. They compare the averages, like the US only makes 20% more per household, why do they put up with this or that. But that comparison is for the whole country, so imagine if you were comparing all of Europe or China.

I had a friend in Spain at a similar company as mine say, how can you put up with no safety net, etc. But I look at his company and every one at my company at any level gets paid 2-5x as much. So like these are less serious issues if you are paid an extra $1-200k/ year. It doesn't explain the inaction, but I believe it is why a lot of politically influential people don't care.

The United States is a democracy, but more specifically, a representative democracy. That means citizens don’t directly vote on most laws or policies—aside from certain state or local measures—but instead elect representatives to make those decisions on our behalf. The idea is that we trust them to act in our best interests.

You can probably see where the problem comes in. Take, for example, a politician who campaigns on Medicare for All or universal healthcare. To win an election, they often need massive campaign funding—much of which comes from wealthy donors, including those in the medical or pharmaceutical industries. And once in office, they’re targeted by powerful lobbying efforts worth billions of dollars from those same industries.

In the end, the issue is that politicians can legally receive millions in donations and support from industries whose interests might directly conflict with the needs of the people they’re supposed to represent.

Ultimately though, it is known by most people irrespective of party affiliation that medical costs are out of control. One recent example of this collective understanding was when the united healthcare exec was killed. Before there was even a suspect, people generally knew why he was assassinated. Most people in the U.S. have either been directly affected by the insanity that is our healthcare system, or one of their loved ones has. Those that haven’t yet, it’s just a matter of time. It’s just so pervasive.

No one is "putting up with it." We don't have a choice.

The way our government is designed right now, the populace doesn't really have elected representatives. More accurately, they have a corporate bought-and-paid for stooge that managed to be more likeable in a political race than their opponent, so we don't actually have anyone representing our interests _as a country_ at the federal level.

Scarcity is a fact of every country's health system and you'll quickly find stories with similar fact patterns with e.g. the NHS. There's not a lot to recommend the US system as implemented today, but the problem isn't "insurance-based health care"; lots of countries have insurance-based health care.

Without making a claim about whether it's what most people actually want or not, there's not much that an individual can do about this by changing their voting preference. The US doesn't have proportional representation, and the overwhelming majority of elections are "first past the post" rather than one of the more "modern" alternatives like ranked choice votes, so in practice very few elections ever swing to anyone outside of the two major political parties (neither of which have a particularly large contingent of politicians who have come out in favor of something like single-payer healthcare). Even for a purely single-issue voter who only cares about this, from a game theoretic perspective you're likely to be essentially throwing your vote away if you vote for someone outside of those two major parties because it's unlikely enough others will.

Presidential elections are even worse because they're determined by electoral college vote rather than popular vote. Even ignoring the potential for "faithless electors", all but two states allocate the entirety of their electoral votes to the candidate who wins the majority of their vote, which means that if you live in a state with a majority who reliably vote for a specific party's candidate every four years, your vote for president is effectively meaningless.

The only obvious way to fix these issues with how elections work would be to elect people who make different decisions about how to run them, which is hard to do because of the issues themselves. The system is self-reinforcing in a way that makes it extremely difficult for the average person to do anything about it, and any desire to do so gets weighed against the concerns about the policies that you might actually get to influence by voting for one of the two candidates who might actually win. At the end of the day, people who are concerned with the fundamental systemic flaws in things like elections and healthcare still likely end up picking pragmatism over principle (with the expected value of a vote for a candidate who is almost guaranteed not to win being lower than one who is might be less desirable than a third-party one but still has an actually realistic chance of winning and is preferable to the other major party candidate) or just check out of the system entirely (with people not bothering to vote at all already being a fairly common phenomenon in the US).

Ideologically, just enough voters in the right places believe that unless you’re old, or a military veteran, in which case government healthcare is just fine, your sickness should not be their problem, even if it means they pay more for their own care.

Also, if healthcare wasn’t tied to having a job, then the inherent laziness and moral degeneracy of people without jobs would be encouraged by letting them not be sick. (BTW, being self-employed does not count as “having a job” in this mindset.)

In part because hospital bills are monopoly money and most people just play a game of chicken with debt collectors, and the only actually sue a small fraction of the time and mostly either settle for a small fraction, give up besides annoying phone calls, or it gets discharged in bankruptcy.

Almost no one gets a bill from the hospital and just pays it, and in most cases if you do it's totally financially illiterate.

To the extent that U.S. voters want to maintain the status quo, which many (though not most) voters do wish to do, it's largely driven by an individualist mindset in which the worst thing that can happen is somebody else getting something that they didn't "earn".

>A code is not an artistic expression and so can't be copyrightable.

that was changed

https://www.bitlaw.com/copyright/database.html

Databases are generally protected by copyright law as compilations. Under the Copyright Act, a compilation is defined as a "collection and assembling of preexisting materials or of data that are selected in such a way that the resulting work as a whole constitutes an original work of authorship." 17. U.S.C. § 101. The preexisting materials or data may be protected by copyright, or may be unprotectable facts or ideas (see the BitLaw discussion on unprotected ideas for more information).

(I did not use AI, but this appeared at the top of my search and I think the search engine used AI to generate it):

In the European Union, databases are protected under the Database Directive, which provides legal protection based on the originality of the selection or arrangement of their contents...Some countries offer additional protections for databases that do not meet the originality requirement, often through sui generis rights.

Judging by Judge Alsup's ruling even if the codes were copyrighted it would most likely not be copyright infringement to train on them either, and as such even if they are copyrightable and they do own copyright on them it remains beyond their abilities to forbid training on them. (Also opinion, also not legal advice, I'm also not a lawyer and sort of doubt the person I'm responding to is).

Software I write at work is not artistic expression yet is covered by copyright.

This isn't a counter argument, just pointing out how absurd copyright is.

> The layout of a book of codes, for sure, but the information in it

Are you talking about copyright here? It sounds more like design protection.

Wouldn't the book be as copyrightable as any other non-fiction work?

And yet people are collectively paying $300M licensing these non-copyrightable codes? With that kind of money somebody must have looked into not paying for licensing

Any non-profit can always claim to inflate their expenditures up to (and above) their expenses and pay lavish bonuses to their employees, like you said.

Doesn't change what it basically is - aka Scamming the Public, and privatising the gains.

It has been forever, what planet are you on? Their official policy would be to make any native american cure (upon which many of the medications we use from big pharma, are based on in origin) to be illegal. They would want all profit going through them, whether that is good for you or not.

Anything related to healthcare (except some genuine minority of doctors and staff) is almost openly hostile to Americans.

I used to think American healthcare was in part expensive because Americans have poor health (e.g. high obesity).

Now I am beginning to think that Americans have poor health by design for the healthcare industry to be able to maximize their profits. Making some Americans healthy just seems to be a side product.

Yeah, US hospital billing is based on the idea that the patient has insurance and won't really care about what their insurer gets charged. (The wider implications of this are left to the reader.)

For the uninsured this sort of thing is actually really common. Had an online friend who had to get emergency treatment and they sent him a bill for $20k. His response was, "lol I'm uninsured and don't give a fuck about my credit score, so, fuck you basically." The bill was revised to $500, which he paid just to not have that debt on his record.

We are self-employed in the US and buy our own high deductible plan on our state's marketplace. One of my family members needed a fairly routine planned surgery, so I went through the effort to try to determine in advance how much I would be billed. What a waste of time. My favorite was the hospital who told me the fee for a one night stay would be 73k. But, good news! Your insurance has a contracted discount that brings it down to 13k. So what does the 73k price even mean? At this point I shelved the effort as I correctly concluded we would hit our household max out of pocket for the year, so anything above that would not affect us.

And hey! Silver lining: in a year when we max the out of pocket limit, no more cost-sharing on any other services for that calendar year! Time to pack in some care we have been deferring mostly due to cost. Except the care providers and insurance company are well aware of this, so they don't bill you for up to a year from the date of service, so you can't be sure you "hit your max" until the subsequent year.

It is enough to induce strong negative emotions.

> What the author calls criminal is the way hospitals typically bill Medicare and private insurance providers.

Interestingly enough, the FBI considers double billing and phantom billing by medical providers, to be fraud.

https://www.fbi.gov/investigate/white-collar-crime/health-ca...

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.

double charging on purpose systematically sounds slightly criminal to me

This! People underestimate the extent to which lawyers are negotiable also. “I’m not paying that” is a surprisingly effective method; they’re often willing to compromise on payment terms, work at-risk subject to a successful outcome, significantly reduce their rates, etc.

Not just arcane subject matter, but numbers so high any sane person panics.

Hospital: "Here's your bill for $1,000,000." (a figure which is 100% fictional) Patient: <panic> "Oh shit, I don't have $1,000,000!" Hospital: "Oh, we'll reduce it to $30,000. Aren't we nice!" Patient: <slightly less panic> "I don't have $30,000 either, but it might not bankrupt me immediately, so I guess that'll do..."

Never mind that the same procedure in most of the EU was either "free" (to consumer at time of care) or a fraction of the cost.

The whole system is fucked.

I've found LLMs helpful for figuring out what I don't know, then I can go and look up how those things work, again together with an LLM.

But in the past, once I got to the point where I know I could maybe do something about it, but not exactly what, and I don't know any of the domain words used, you got pretty much stuck unless you asked other people, either locally or on the internet.

At least now I can explore what I don't know, and decide if it's relevant or not. It's really helpful when diving into new topics, because it gives you a starting point.

I would never send something to a real human that a LLM composed without me, I still want to write and decide everything 100% myself, but I use more LLMs as a powerful search engine where you can put synonyms or questions and get somewhat fine answers from it.

"But fight with knowledge. My $20/month subscription to Claude more than paid for itself. Yes, AI assistants can hallucinate and give you garbage. So I didn’t rely on it. I spot checked by looking up its big findings myself and found it was right. I also had ChatGPT, to which I subscribed for one month just to do this, read the letter and fact check it. No notes."

Old poker adage: "The more wild cards and crazy rules, the greater the expert's advantage."

Poker has nothing on Commercial Lawfare.

I suppose a saving grace there is that Medicare is incentivized to help people or at least not incentivized to provide the minimum amount of value for maximum profit.

So what you're saying is we've injected a whole smorgasbord of electrical dumbasses into a system already rife with corruption, greed and exploitation that provides services no person can do without and is frustrating to use at every juncture.

Yaaaaaaaaaaaaaaaay.

The funniest bit about all this is that this is all just laziness all the way down. People complain about AI-written articles. When the article is written about a human, they fall over themselves to point out potential flaws, like "well it looks like AI hallucinated" and it gets voted to the top. Then it turns out that they themselves did not read the article. Just a damning indictment of the quality of online discourse in year 2025.

I don't know, I don't run an ambulance company- what should the cost be (either to me, my insurance company, or to the government)? Can't be cheap to fully staff an ambulance with EMTs.

Hard to believe you say we aren't subject to rationing when pre-authorization is as big as it is.

You should see some of the proposed rules. Pre-authorization will start to use a medical language called CQL and there will be literally thousands of queries EHRs will need to implement to ensure their customers can get the care they need.

The idea of an injured patient having to pay at all for an emergency ambulance ride to a hospital should stun any normal human being living in a civilized society.

I’ll look into it. From what I can tell it’s not a simple hero vs villain story. It feels more like an industrial disaster or the AWS outage where there are like a dozen compounding system failures leading to where we are today.

Medical billing is like a massive centuries-old tenement building with a patchwork of legacy plumbing, electrical , framing, sewage all patched together with decades of duct tape, wood shards, and rusty couplings. But in this case there’s massive incentives to keep it all bodged because each pipe and crevice hides billions of un-audited income.

Matt Stoller is properly described as an insane person who thinks every single problem in the world is caused by monopolies (yes, including whatever random problem you're thinking of now).

His most notable attributes on Twitter are he constantly lies about everything and that he spends all his time promoting Republicans who are clearly not going to implement his anti-monopoly agenda.

> one where medicare prices are the set prices for everything, but that is nearly a political impossibility given the amount that these middlemen spend in keeping politicians who support that from winning primaries.

You're missing the part where the Stated and objective goal of popular politicians from one party is not to let that happen.

They don't get elected because someone scheming to control their funding (though that is a proximal cause of Republican candidates getting more extreme: Align with MAGA or get primaried)

They get elected because a huge portion of the USA are divorced from reality and utterly deny said reality. They say "government is less efficient" as we sit on top of this atrocious system, a system where we already have the government version and it's radically cheaper and we could literally just sign up everyone for that, save everyone time, money, and headache, and then improve service quality.

These people deny that nearly all developed countries and lots of undeveloped countries have vastly better healthcare outcomes than the USA, extremely better healthcare access, and pay way way less overall, taxes included.

These people just consume propaganda, and purposely refuse to engage with any clear or obvious evidence that contradicts said propaganda.

thank you for saying that and I share your sadness / anger . A lot of people do. It’s not your fault, or ours. Healthcare is a truly evil bureaucracy staffed with some of the most loving and capable people I’ve seen. So I’ve been able to admire the beauty of the situation while remaining angry at “the system”.

1. There are assistances available for low-net-worth and low income individuals. Have you tried those options?

2. Refuse to pay. Medical debt doesn't count against your credit and, based on my own experience, is almost impossible for the other party to collect, except some annoying phone calls.

It's probably unsaid that she died with a good credit rating as well.

You don't necessarily need to pay back those loans, and most of the time the hospital has to negotiate a feasible repayment plan.

Medical bills have to lowest life-improvement rating of them all. That is to say paying off someones medical bills will have one of the lowest impacts to their lives compared to another financial intervention.

We had felt invulnerable until we weren’t. I’m sorry about your friend’s mom it’s vile and even more infuriating that there’s no clear “villain”. But you reach a point where you focus on what you have. Good doctors, admirable and compassionate nurses , loving and supportive family. The money is toilet paper really – we conceded that a long time ago. Make the most of it while you can but you can’t hold onto too tightly.

There are two “provider networks” in our region: BCBS & The United Healthcare network. BCBS is supposed to be better. Were we to switch, let’s say they did cover the 1/10 out of network cases, we risk losing the 9/10 that we currently have . The “whack a mole” is a good example. In this case it’s whack a mole and one could be $50-$100k worth of coverage gone. And more importantly, when you find a good doctor, you need to hold onto them. The difference between a good doctor and a bad one is life or death for this condition.

Does that

- turn into whackamole every year?

- expose someone to "preexisting conditions aren't covered" issues?

It’s just so insane that the entire industry accepts that no one knows how much things are. Even the “financial services” team will just say “yeah that estimate is wrong” and not blush. What are you guys all doing?

That’s exactly what we experienced. There is no way to be an informed customer or “vote with your wallet”. For many diagnostics and services, the “provider” is 2 referrals downstream – the patient never elects or engages with them.

Plus, your life is on the line. If they don’t run the test, it means the wrong treatment and your prognosis goes from 80% survival to 80% mortality

> I got an eye roll, a lengthy and exasperated lecture...

This is the part that is galling to me. Apparently no healthcare worker I've ever spoken with about billing has ever had the same considerations I do re: finances. My inquiries have almost always been met with zero empathy and contempt that I would even be so gauche as to ask.

(It's 1000x worse when you're talking to them about your child's medical care. My daughter, at 3 y/o, had a short fall and received a small cut on her face. It bled profusely so we took her to the ER. We ended up with x-rays because I couldn't successful "negotiate" that we didn't want that. The shaming was intense.)

in every single case those estimates have been wrong. In most cases by 200% or more. And a many case there are no figures.

You’re right and there are some provider segments like MRIs that have succeeded with this model.

From our perspective the real blocker is the “lock in” due to timing and the referral process. We’re paying bills to providers like specialized labs that are 2-3 degrees down the chain from our doctor (e.g. radiologist refers pathologist refers lab1 refers lab2 – we only see radiologist) .

Even if there was a “amazon for labs” we wouldn’t be able to order this stuff because the decision is 2 degrees away.

Fun fact is that most such obvious innovative solutions are prohibited by law. There are many layers of turtles the lowest two are: corrupt politicians and, population that doesn't care about corrupt politicians.

To a lot of people, that's out of the fire and into the frying pan.

Their brother presumably didn't have insurance, and it sounds like some pretty major procedures involving specialists, equipment, and hospital intake. While the outcome was horrible, all of those people need to get paid for the services rendered somehow if we want folks in the US to continue receiving this standard of care.

$30K NOT counting some expenses (cardiologist, ER docs)???

> Bills were a few thousand here for the cardiologist, another few there for the ER docs, a bit for the radiologist. I helped my sister-in-law negotiate these down but they weren’t back breakers. Then the hospital bill came: $195k. This is a story about that.

Hospital billing involves the 'mafia'-like influence game of having good insurance (which means being hired at the right company, with the right 'influence' over the hospital network in question) and covering the costs of the other patients who cannot afford it and refuse to pay. Hospital billing has the least teeth of any debt in the US. If you haggle a billing department long enough, they'll desperately take anything you give them.

Look at when all the "No Kings" protests are happening: on the weekend. Because there is no way the vast majority of Americans can go on strike, because healthcare is tied to employment. This is why healthcare is never getting "fixed" in America--it's doing its job quite well.

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.

the medical insurance industry and the hospitals do this whole song-and-dance charade where they pretend that they are charitable, public-protecting institutions who serve noble goals of helping sick people.

in truth, they are doing nothing but racketeering.

I'm getting that most people don't know the sticker price is fraudulent (e.g. the overlapping "master procedure" and component codes) and/or are so relieved to have the charity out that they agree to it without any further questions. But OP points out that the charity out is just further fraud, victimizing tax-payers.

Where are the class action law suits?

I assume it'd get sold to a collection agency for something like $500, which would then try to get you to pay as much as possible, possibly settling for as low as $2000).

So the hospital is still getting paid something, and the billee has the option to take a bigger credit hit or to negotiate down