health care providers in the USA are padding the bill (that $9,000 that "just disappeared") and getting away with it. Apparently [...] the way the current American two-tier health care system works is that customers with clout -- the ones that buy wholesale, as it were -- get a discounted rate, while ordinary shmucks who pay all of their own bills are handed an inflated bill with an artificially high sticker price.

I think the term for that -- and maybe this is how you guys down south should go after those vultures! -- is fraud.

It's not fraud, it's hedging their bets.

Here's how medical billing works:

Each physician or physician's group negotiates payment rates *per billing code* (of which there are thousands) with every single insurer, and with insurers like BCBS, which have a million different sub-plans, they have to negotiate on a plan by plan basis. Every insurance company will pay a different rate, some will pay very low (Medicare -- which just announced another rate cut, just in time for the tip of the boomer population iceberg to go into retirement and move onto Medicare coverage) and some will pay very high (any indemnity plan). In order to ensure that they can collect as much as possible from the high-paying insurance companies to offset the low reimbursement they receive elsewhere, they set the price per code artificially high. They know it's a shell game; they never intend to collect those high prices, so the money never really exists to them in terms of setting their own budget (rent, salaries, utilities, equipment, etc.) Forget about Medicaid. By the time you jump through the hoops of requirements, authorizations, specialized billing forms, etc., you've spent more money than you'll receive.

You would be stunned to see how low some reimbursement is, especially when you start subtracting all the bills that have to be paid with that money. Without getting in to a dollar by dollar breakdown, I'll tell you that primary care doctors in this country are getting a pretty raw deal, especially if they have a high geriatric or Medicaid population. One of my doctors told me she takes home less than her secretary ("good thing I married a neurologist!" she said, I think only half-kidding).

By federal law, all payers have to be handed the same amount on the bill, including includes self-pay patients, and on top of that nobody can handed a bill that is lower than the reimbursement rate for Medicare (I believe is how it works.)

Here's the important part: if you are self-pay, ask for a discount. I can all but guarantee that your doctor or the facility will slice a substantial portion off that bill, especially if you can pay them on the spot (obviously not the case for emergent or inpatient care, but more reasonable for standard office visits) because they can just deposit the check and have the money that day, rather than wait 30-45 days or longer to have a claim processed, only to have it denied 30% of the time for missing some arcane piece of information, and dragging out their payment date another two months beyond that.

This is nonsense. Why even have these "pools"? When I read today about young folks having left college having to buy insurance I am aghast. When I left in the late 60s, I had NO insurance. El zippo.

When I had an accident, serious illness ....I went to see a dr. He billed me for the treatment. Case closed.

When I returned, all I hear about is this insurance claptrap. Why could the same pay-go system we had before not be used again? WHY was it ever changed?

To distribute risk, now that major medical costs are in the tens and hundreds of thousands of dollars. I am slender, very active, I eat well (and properly!), I don't smoke, I wear my seatbelt, I have all my vaccines so I guess on the main those insurance premiums don't really seem worth it, if you assume that my cash medical expenses would only include two office visits a year, at $200 each. If my employer didn't kick in a share of my insurance, that would be less than a half a year's worth of premiums, so not really worth it assuming I stayed healthy and didn't have an accident.

But I didn't stay healthy, I wound up having two massive PEs last summer that nearly killed me, and the total hospital bill (48 hours inpatient: 1 ER consult, 1 CT scan, 24 hours of heparin drip, 10 PT/INRs, plus bed and board) cost $20,000 -- 20 year's worth of the premiums I currently pay.

I was one of the lowest risk patients my vascular doc had ever seen, I had people running down to sign me up to be included in medical studies because they couldn't believe this happened to me. If I had taken the gamble that my general health level would suffice to keep my medical costs low, I would have lost and lost *big*. You really don't ever know what could happen to you (really: my uncle who is also very healthy was in a horrible car wreck the night before I went into the hospital, also not his fault. His family probably would have lost their home if he was uninsured.)

Okay, he did a few mildly funny things now and again. But some crimes are unforgivable.

Really? You don't think his turn as his own crazy Scottish da in "So I Married an Axe Murderer" sort of preemptively redeems all the crap that's come since? I thought that was hilarious.

Ah go crrry yerself tae sleep on yaer HUUUUGE pellow!

[a la The Electric Company]

I am a whoooore! I am your muzzah!

Whooore! Muzzah!

Whoore! Muzzah!

Whore-muzzah!

According to Wikipedia, David Hasselhoff was supposed to be in the movie. Damn!

Hammer. Not "hummer"