[HN Gopher] Launch HN: Certainly Health (YC S23) - Book doctors ...
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Launch HN: Certainly Health (YC S23) - Book doctors without
surprise bills
Hi HN! We're Kevin and Daryl from Certainly Health
(https://certainlyhealth.com/), a marketplace that lets you shop
for doctors and compare your out-of-pocket costs upfront (currently
only in NYC). Using each patient's insurance and machine learning,
we predict and guarantee out-of-pocket costs to prevent surprise
bills. We grew up in immigrant families, and for both of us, our
parents would honestly tell us to not trust doctors because of
unexpected medical bills. They really believed that doctors were
adding on unnecessary things that didn't help in order to make more
money. As adults, we've both had first-hand experiences receiving
surprise bills even with good insurance while working at tech
companies, so solving this problem is personal to us. It turns out
38% of Americans delay medical care for fear of the bill while
prices vary 2-10x across health providers, even when using
insurance. This led us to believe that creating a marketplace with
transparent out-of-pocket costs could be a solution. However, it
wasn't until the July 2022 Transparency in Coverage Rule
(https://www.cms.gov/healthplan-price-transparency) that we had the
payer pricing data (that's actually high quality compared to
hospital data) to create this marketplace. Certainly is the first
company to use this data to predict and guarantee prices for
consumers to book doctors. We know the HN community has been
interested in applications of healthcare price transparency data
(https://news.ycombinator.com/item?id=32738783), so we're excited
to share how we're using this data to predict and guarantee prices
for a consumer application. With Certainly, patients can enter
their insurance, compare guaranteed out-of-pocket costs across
doctors, and book an appointment with price transparency. For
providers, we guarantee any patient we send them will always pay.
Partner providers pay us any time we send them a new patient.
Eventually, we'll convert providers to using our SaaS platform to
guarantee payments from existing patients. We are currently
focused on shoppable services - anything that can be scheduled in
advance. Our solution falls between two ends of the spectrum for
consumer shopping experiences. At one end is healthcare, where the
status quo is you go to a doctor and you have no idea what will
happen and you have no idea how much it will cost. At the other end
is going to a restaurant, having a menu of items with corresponding
prices, and deciding which items you want to order. Certainly
Health lets you see what services could happen during your visit
and how much they will cost. We guarantee that if those services
happen, you will not pay more than the out-of-pocket costs you saw
upfront for each of those services. But it is ultimately the doctor
who decides which services you end up getting (like a chef deciding
which dishes you will be served). As a result, you can compare
upfront out-of-pocket costs specific to your insurance and book a
provider without worrying about surprise bills. A common
misconception is that patient out-of-pocket costs are set by
doctors. Prices of healthcare services are actually the result of
negotiations between providers and insurance companies. Groups with
more negotiating power, like large hospital systems, are able to
command higher rates than private practice physicians. This
variance in cost is enormous across almost all procedures we've
looked at, even between providers a few blocks from each other. It
might cost $105 to get an orthopedic consultation with one doctor,
and $550 to get a consultation with another doctor across the
street, for example. This price variance means the out-of-pocket
cost also varies for patients with high deductible plans or plans
where the copay does not cover all services (which we've
encountered very often). We do not use hospital price data which
is inconsistent and messy (https://www.kff.org/health-costs/press-
release/analysis-inco...). Instead, our guaranteed prices are based
on three things: (1) health insurance published rates for
procedures, as required by regulation; (2) patient
eligibility/benefits information (e.g. deductible, copay,
coinsurance); and (3) an online learning model to account for
variance across thousands of plans and patient conditions. As we
process payments and claims, we create an accurate platform for
predicting out-of-pocket costs by accounting for variations such as
whether certain procedures are covered by an insurance plan/copay,
and how the rate changes based on diagnosis code (we discovered
V97.33XD is for "Sucked into jet engine, subsequent encounter"),
number of units, medical coding modifiers, and other factors.
Certainly is currently available in NYC where you can choose from
over 5k doctors to book without surprise bills for free at
https://certainlyhealth.com/. We plan to expand to other cities
once we prove that we can establish a low CAC on both the supply
and demand sides in NYC. Although we're early, we're starting to
see intended results. One patient saved $850 on a podiatrist visit
booked through us compared to a previous visit with a different
doctor for the exact same services. Another was charged for an
annual physical, but we identified the mistake and got a refund
issued to him. Most of our customers have had surprise bills in the
past and are happy to have peace of mind with our upfront,
guaranteed prices. We'd love to hear your ideas, experiences,
feedback and any feature requests!
Author : blastbking
Score : 177 points
Date : 2023-08-02 12:45 UTC (1 days ago)
| kevmo wrote:
| America is eventually going to move to a socialized healthcare
| model like the rest of the developed world. I hope.
| pkaye wrote:
| I think you mean universal healthcare. Most of the countries in
| Europe have universal healthcare systems, not socialized. For
| example Netherlands and Switzerland don't have single payer
| healthcare. Its basically compulsory private insurance with
| subsidies and highly regulated.
| lotsofpulp wrote:
| I would predict rest of the world will move to an American
| model, based on lowering fertility rates and demand from people
| who cannot afford to pay for healthcare exceeding supply of
| healthcare.
|
| Managed care organizations (MCOs, aka health insurance
| companies) are the mechanism by which you can provide different
| groups of people with different levels of healthcare, while
| still having plausible deniability that you provided healthcare
| for political purposes.
|
| Example: Medicare and Medicaid are both subsidized healthcare
| programs in the US. But the people who receive Medicare are
| more valuable to leaders, so Medicare pays more, and hence
| Medicare recipients get better healthcare. Medicaid recipients
| are less valuable to leaders, and so it pays less, so Medicaid
| recipients have to travel farther and wait longer for
| healthcare.
|
| MCOs can even be used to implement different levels of
| healthcare for different groups of employees based on how well
| the coverage for that group of employees pays providers. You
| can delineate all the way from President and staff, to
| legislators, to military, to civilian employees, and private
| businesses can delineate between employees of low profit
| margin, low pay businesses, and high profit margin, high pay
| businesses.
|
| On the provider side, poorer people will get seen by NP/PA,
| while richer people can be seen by MDs. Or richer people can
| skip the line or get access to MDs via concierge medicine or
| direct primary care.
| messe wrote:
| > I would predict rest of the world will move to an American
| model, based on lowering fertility rates and demand from
| people who cannot afford to pay for healthcare exceeding
| supply of healthcare.
|
| The US pays more per capita for healthcare than most of
| europe. Why do you believe that lowering fertility rates--
| leading presumably to an increase in the proportion of the
| population needing access to healthcare due to age, and a
| similar decrease in the amount of tax payers--would lead to a
| shift towards a US-model that costs more overall?
| robertlagrant wrote:
| If you make it to the UK, don't forget to account for SCTID
| 74105006! [0]
|
| [0]
| https://termbrowser.nhs.uk/?perspective=full&conceptId1=7410...
| danielmg wrote:
| this is more important:
| https://termbrowser.nhs.uk/?perspective=full&conceptId1=2379...
|
| SCTID 23791009
| robertlagrant wrote:
| Very good. Your cover, like your head, extends for 2 seconds
| before dropping off.
|
| We trawled SNOMED extensively for fun, er, I mean, data model
| research in my last company. But we didn't spot that one.
| arnonejoe wrote:
| We created a similar product in 2014 and closed 18 months later
| (openhospital.com). Our team landed an interview with YC for the
| S2014 batch. I will say number of doctors were very interested in
| this, especially the concierge docs. We ran in to a number of
| issues but the gist was that medicine needs to be sold as a
| product. Anything surgical is typically billed against a dozen or
| more CPT codes for a single procedure and often involves more
| than one provider.
|
| Finding consumers is going to be difficult. You guys are also
| going up against an entrenched multi billion dollar health care
| industry. We found that the providers were all required by their
| contracts with the health insurance companies to ask for an
| insurance card. If a patient had disclosed that they have health
| insurance, the provider was not allowed to offer a cash price
| (which is often cheaper).
|
| Since you are building a marketplace I would strongly recommend
| reading The Coldstart Problem by Andrew Chen. I wish this book
| were available back when we launched our marketplace.
|
| Good luck. I hope it works out.
| i_like_pie1 wrote:
| thank you for sharing. good learnings +1 strong recommend to
| that book
|
| curious what you do now?
| arnonejoe wrote:
| The Cold Start Problem? I have listened to it on Audible 3
| times. It's on par with Zero to One in terms of an important
| startup book (imho). Chen goes in to strategies for building
| the hard side and easy side of a new marketplace. Product
| strategies for building networks (ex. come for the tool, stay
| for the network). He gives examples of how to get to a
| minimum viable network and discusses why Slack spread so
| fast. I could go on and on. It's a pretty good on Audible.
| cddotdotslash wrote:
| > to ask for an insurance card
|
| Are patients required to disclose this? Or can I simply decline
| to provide insurance?
| codegeek wrote:
| You can decline but then you have to deal with people on the
| desk who may not even know what to do without insurance. They
| may have to call their boss to figure out if there is even a
| cash price possible. You will get crazy looks and stares.
| DOn't let someone tell you otherwise. I have done this dance
| for 10+ years with 3 kids now.
| gymbeaux wrote:
| Do you not have insurance or do you just prefer to pay the
| cash price where possible? It's interesting that you might
| be voluntarily uninsured despite having 3 kids. The system
| is such that your kids' health is a bargaining chip to
| employers. I know people who have stayed at jobs just for
| the health insurance, and then there are the H1-B folk who
| are effectively indentured ("yeah we're paying you $20k
| below market rate but we _are_ sponsoring you so... try to
| be a little more grateful")
| codegeek wrote:
| I do have insurance because that's the game. I don't like
| it though. Btw my Insurance Premium is $24k/Year and
| $5k/Year for deductible. So I am almost $30K out of
| pocket BEFORE insurance pays a dime. If thats not a scam,
| what is.
| vxNsr wrote:
| Yikes! That's horrifically bad insurance, I'm paying $10k
| in premiums for a $2k deductible. And I was paying (until
| my company cheaped out on insurance) $15k/yr on a
| combined in/out $1k deductible and combined in/out $3k
| OOP. Which might seem worse but we were using fantastic
| OON providers that normally would barely be covered but
| instead were essentially the same as in network.
| ceejayoz wrote:
| Why is that a scam?
|
| My house has never burned down, but I pay homeowners
| insurance every year. My dad has never had a car
| accident, but pays every year. Both have deductibles
| awaiting us if we need them.
|
| It's insurance, not a prepaid debit card.
| zaroth wrote:
| There's nothing wrong with the concept of an insurance
| premium or even a deductible.
|
| The problem is the sheer magnitude of the cost. It's an
| extraordinary sum of money to be paying out of pocket as
| an annual family expense for a non-discretionary basic
| living expense.
|
| And more or less every single family in the US is doing
| the same? It's totally untenable.
| ceejayoz wrote:
| My kids had about a million dollars in NICU costs from
| being three months early. I take a $18,800 shot every
| twelve weeks.
|
| Now, I think a single-payer national health service would
| be better, but that $30k/year doesn't surprise me at all.
| Our monthly premium is $2,700. It sucks, but this stuff
| is _expensive_.
| haldujai wrote:
| > Now, I think a single-payer national health service
| would be better
|
| This isn't the panacea it sounds like, single payer
| doesn't work that well in Canada. Having worked in both
| systems the quality of care and accessibility is far
| better in the US, assuming you have good insurance of
| course, but it's hard to get access to things in most of
| Canada until you're actively dying. Primary care is also
| challenging to access in most places not Toronto.
|
| I've seen conflicting reports on the math of how this
| plays out while trying to maintain quality and options.
|
| I fully realize I am saying this from a privileged
| position that an OOP max wouldn't be financially
| challenging but I would much rather get care in the US
| than Canada.
|
| I'm not sure what the best system is. Perhaps a two tier
| system would work better and have a better safety net,
| although that's controversial as well. I do think single
| payer is overrated, of course the US might do it better
| (and obviously has more resources + economies of scale).
| ceejayoz wrote:
| > This isn't the panacea it sounds like, single payer
| doesn't work that well in Canada.
|
| They pay about half as much per-capita with similar
| health outcomes.
|
| > the quality of care and accessibility is far better in
| the US, assuming you have good insurance of course
|
| Well, yes. Homelessness isn't a problem for people who
| own houses, either.
|
| > Primary care is also challenging to access in most
| places not Toronto.
|
| This is not unique to Canada.
|
| https://www.health.harvard.edu/blog/why-is-it-so-
| challenging...
|
| https://www.newyorker.com/science/medical-
| dispatch/americas-...
|
| "Experts have long warned of a shortage of doctors
| providing foundational forms of outpatient care,
| especially in rural areas. Last year, the Kaiser Family
| Foundation estimated that more than fourteen thousand
| primary-care physicians were needed to eliminate existing
| shortages."
| haldujai wrote:
| You're missing the point, I said it's not a panacea.
|
| I doubt adequately insured in the US (69%) would tolerate
| lower quality care and being prohibited from paying for
| better care like in a single payer system, both socially
| and legally although I am not a lawyer.
|
| There is a growing movement towards privatization and two
| tiered systems in Canada. It's already available in
| Quebec, British Columbia (illegally as recently
| determined by the Supreme Court) and Saskatchewan. It's
| starting to happen in Ontario.
|
| > They pay about half as much per-capita with similar
| health outcomes.
|
| Health outcomes is very misleading as it's confounded by
| baseline population characteristics, lifestyle, and non
| healthcare related morbidity. It isn't very useful as a
| single measure to determine system efficiency. The
| simplest example is Americans have more chronic
| conditions than Canadians.
|
| Paying more is only a problem if you get the same level
| of care, which you don't.
|
| As compared to the US more Canadians use the ER for
| primary care, are unable to get same-day or next-day
| appointments and wait longer for procedures.
|
| https://www.cihi.ca/sites/default/files/document/how-
| canada-...
|
| > Well, yes. Homelessness isn't a problem for people who
| own houses, either.
|
| Uninsured rate is 9% acknowledging underinsured is 23%.
|
| The main point here is in the Canadian single payer
| system quality of care for adequately insured declines
| relative to what the US has now.
|
| Whether that sacrifice in single-payer (as opposed to
| two-tier or privatized) is worth it is a complicated
| political question depending on social values and the
| legal system.
|
| Using your analogy, people don't want to and aren't
| giving up their luxury homes to fix homelessness.
|
| > This is not unique to Canada.
|
| No but it's significantly worse in Canada than the US
| (see reference in point 1).
| FireBeyond wrote:
| > My kids had about a million dollars in NICU costs from
| being three months early.
|
| Except the true cost of that NICU stay was not a million
| dollars.
|
| > I take a $18,800 shot every twelve weeks.
|
| The true cost of that medication is not $80,000 a year,
| including R&D. Particularly for patients who needs meds
| like that indefinitely.
|
| Pfizer claims that it effectively is profitable
| everywhere in the world but the US, its base: That of its
| nearly $40B profits last year, less than $5B was earned
| in the US, despite its US sales being nearly $50B of it's
| $100B global revenue (do that math, they say that selling
| $50B of drugs in the ROW earned them $40B in profit, yet
| the same sales in the US netted only $5B in profit...) -
| they're offshoring all their finances, basically.
|
| Big Pharma likes to peddle the myth that all their R&D
| takes place in the US, hence the costs. That's all it is,
| a myth. They do significant R&D in the US, sure, and
| about the same elsewhere in the world. And most of their
| R&D isn't from first principles, but often leverages
| publicly funded research in universities and
| government/quasi-government orgs.
| codegeek wrote:
| "If a patient had disclosed that they have health insurance,
| the provider was not allowed to offer a cash price (which is
| often cheaper)"
|
| Sums up the problem with our Health Industry in America. The
| middle-man Health Insurance mafia is too powerful to let
| anything else happen.
| shellfishgene wrote:
| I don't understand how this works. So if you have insurance
| the procedure is 120$, which you pay as the patient because
| it's not covered, but if you paid cash it's 100$? Where does
| the 20$ go, and why does the insurance want this?
| avgDev wrote:
| To be fair is not like providers are hurting either. Nobody
| wants better pricing.
|
| "Physicians in the United States are among the best paid in
| the world (Bodenheimer, 2005). The average U.S. specialist
| physician earns $230,000 annually--78 percent above the
| average in other countries, as shown in Table 2. Primary care
| physicians earn less (they earn $161,000 on average), but the
| same percentage more than their peers in other countries." -
| sauce https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4511963/
| FireBeyond wrote:
| That number is higher now. $351,000 for physicians across
| the board, $382,000+ for specialists.
|
| Source: https://www.whitecoatinvestor.com/how-much-do-
| doctors-make/ (actually a MedScape survey, but that
| requires a login, so I found this which summarizes the
| survey).
| Calavar wrote:
| Insurance based reimbursement is not financially lucrative
| for physicians. That's why plastic surgeons, who take
| almost entirely out of pocket payments, are the highest
| paid physicians.
|
| As for why US salaries are so high, it's because the
| training it so much longer and more expensive than it is in
| other countries. The most common training scheme for
| general practitioners internationally is 6 years of medical
| school + 1 year of internship. In the US, it is 4 years of
| undergrad + 4 years of medical school + 3 years of
| residency. Add on the ridiculous pricing for higher
| education in the US (public medical schools charge about
| 50k/year, and since medical school is a type of graduate
| degree, med students do not qualify for subsidized Stafford
| loans) and it would be financially untenable to be a
| physician in the US if salaries were the same as they are
| in Europe.
| haldujai wrote:
| Not sure how accurate those numbers are. "Physician" is not
| a singular job even within a single specialty and varies
| significantly based on practice pattern so averaging the
| numbers like that doesn't make a lot of sense.
|
| For similar job descriptions most equivalent physicians
| would have higher compensation in Canada than the US,
| contrary to what that dated study says.
|
| Definitely agree the majority of physicians aren't hurting
| in either country although I think the US/Canadian
| compensation is fair given the years
| sacrificed/intensity/work hours/stress (disclosure: I'm a
| physician). Some specialties like primary care and
| pediatrics remain very underpaid.
| hn_throwaway_99 wrote:
| I think this comparison misses the impact of Baumol's cost
| disease in the US. I mean, your link says a primary care
| physician earns $161k in the US. That's after going into a
| ton of debt with 4 years of medical school, and then making
| slave wages and horrendous hours as a resident for 4-5
| years.
|
| Meanwhile, it's pretty easy for a software engineer in the
| US to make that much not long after graduating college (I
| don't want to over reference something like FAANG salaries,
| which relatively few engineers make, but still, it's
| totally reasonable for a software dev to make that much
| somewhere between 0-10 years after graduation). That's
| after going into much less debt, and software jobs are way,
| way, way easier than medical jobs - honestly I think anyone
| who says otherwise is just full of shit (I'm a software eng
| for what it's worth).
|
| So most people who can go on to be doctors have at least a
| similar level of intelligence/work ethic etc. as software
| devs (or lots of other careers in business, etc.) There is
| no way doctors are ever going to get paid significantly
| less than similarly credentialed professionals in the US.
| lotsofpulp wrote:
| The provider entered an agreement to give the health insurer
| the lowest publicly available price, which is usually how all
| insurance companies operate.
|
| How would it work if the insurance company's vendors charged
| the insurance company more than they charged random people
| off the street?
| TheJoeMan wrote:
| I can tell you haven't ever received a self-pay bill,
| waited a month, and unrequested a cheaper bill shows up and
| mysteriously Dr. Popped-in-for-5-minutes got dropped from
| billing. Sure it's the "cheapest rate" but they're billing
| for every tiny thing.
| lotsofpulp wrote:
| No, I have seen that. I have even called and asked why I
| was charged $15 for a towel to wipe the ultrasound gel
| off my wife's belly, when it was just paper towel, and if
| I knew it was going to cost me $15 I would have done it
| myself. And I was told to ignore it.
|
| But that seems irrelevant to my point. If you worked at
| an insurance company (not just health), and were tasked
| with contracting vendors (such as doctors or mechanics or
| construction), would you not want to stipulate that your
| vendor is giving you the lowest price publicly available
| from that vendor to avoid paying more than necessary,
| which would then allow you to offer your customers lower
| insurance premiums and compete with other insurance
| companies?
| amluto wrote:
| Health insurance companies have weird incentives. For one
| thing, they are not permitted to charge more in premiums
| than what they pay out times a small multiplier. So
| health care being expensive is good for insurers.
| lotsofpulp wrote:
| This is tempered by the fact that they have to compete
| with each other on pricing of premiums.
|
| And if they had such amazing power to unilaterally
| increase healthcare costs, there would not be many people
| complaining about healthcare not being covered.
| blastbking wrote:
| Thank you for the support! I think it is a challenging product
| to build for sure. We're focusing with simpler procedures that
| involve a few CPT codes and a single provider to make the
| problem easier but definitely want to figure out a way to make
| those complex procedures shoppable.
|
| I didn't know that they weren't allowed to offer cash rates to
| insured patients! Definitely a bummer from the patient's
| perspective (why pay for insurance if it will just cost you
| more...).
|
| Have heard a lot about the book, will check it out!
| arnonejoe wrote:
| If you are using CPT codes they are licensed by the AMA. I
| remember calling them to see if we could use them on our site
| and at the time I think they wanted a $15 fee per practice to
| use them. It was too cost prohibitive for us to use them. We
| ended up coming up with our own CPT code equivalents to get
| around this. One of the surgeons on our team pulled together
| a few hundred new codes and wrote new titles for them. We
| came up with a rosetta stone that we would use to set up
| providers. If you end up doing the same, it would be nice to
| publish a set of open source CPT codes for small start ups.
| I've included the link to the AMA CPT licensing page below.
| Good luck! I really hope you make it.
|
| https://help.practicefusion.com/s/article/CPT-License-
| FAQ#:~....
| NTDF9 wrote:
| > Anything surgical is typically billed against a dozen or more
| CPT codes for a single procedure and often involves more than
| one provider.
|
| This is the real startup gap. There are thousands of CPT codes.
| When a medical provider is trying to give an estimate, it
| should be easy for Medical providers to have packaged, template
| CPT codes for template procedures. Then, they should be able to
| add/remove CPT codes from the package (like drag and drop), and
| the prices should change automatically.
|
| The template packages could even be put on a social marketplace
| for doctors so that the information is shared.
| reureu wrote:
| That was what Nuna (nuna.com) was originally trying to do ~10
| years ago (put together bundled payments for value-based care
| models). I think they've since pivoted to more general
| healthcare data tools.
|
| One of the difficulties is that in many systems medical
| billing is done by coding specialists based off the
| provider's note. They may recommend CPT codes, but that may
| not be what's actually billed. In addition, most providers
| are too swamped to do things like put together an estimate or
| drag and drop CPT codes. Hell, many providers will literally
| count the clicks they have to make in an EHR and will LOUDLY
| let you know if your proposal will increase their number of
| clicks by even one.
|
| I don't mean to be a downer on this, and I do think there are
| solutions... but I think 90% of the problems in healthcare
| aren't technological ones but are navigating large,
| entrenched systems that have very little incentive to change.
| jmye wrote:
| > I don't mean to be a downer on this, and I do think there
| are solutions... but I think 90% of the problems in
| healthcare aren't technological ones but are navigating
| large, entrenched systems that have very little incentive
| to change.
|
| Having led provider operations and data systems in various
| settings for the last decade, this is absolutely true. I
| find a lot of the 'healthcare is ripe for disruption'
| comments miss that most of the work isn't going to be fixed
| by some neat javascript or whatever.
|
| To your note on CPT codes, I'd also bet that, if a given
| provider is seeing ACA or MA patients, their billing
| systems and payer interactions will also be more
| complicated, in terms of coding (diagnosis and procedure),
| in order to satisfy risk adjustment needs. It's effectively
| impossible to incent a provider to use two entirely
| different systems, depending on who the patient is.
| dboreham wrote:
| [flagged]
| dang wrote:
| Please don't fulminate or post in the flamewar style. You're
| welcome to make your substantive points thoughtfully.
|
| https://news.ycombinator.com/newsguidelines.html
| hospitalJail wrote:
| I think 10-25% of Physicians are part of the American Medical
| Association, if you put them all in jail, we'd have a
| healthcare crisis.
|
| We really need an alternative system for certifying doctors
| that isnt under the thumb of the private AMA and the private
| ACGME.
| dr_ wrote:
| What I like about this idea, as opposed to pure cash payment
| models, is that this allows the patient to remain in network, so
| that all payments are applied to their deductible (at least I
| think that's what you are doing). Pure cash models make little
| sense - depending on the severity or complexity of your
| condition, which you can't always tell in advance, there may be
| no end to the amount you ultimately owe.
|
| What concerns me however is the guarantee part of it. It's a bold
| move that is fraught with risk, especially as you get into higher
| ticket items, such as various surgical procedures. It's not clear
| to me how you spread this risk out (you take the downside risk,
| but what's the upside - just the referral fees?)
| whiddershins wrote:
| I don't understand this at all. My understanding is that in New
| York State a healthcare provider cannot bill you over your
| insurance.
|
| Once they agree to take your insurance you are liable for out of
| pocket or copays as per your agreement with your insurance
| company.
|
| Unless you deliberately go to a doctor who doesn't take
| insurance, which is generally only something very wealthy people
| do.
|
| What situation is this attempting to address?
|
| Edit: I've read the explanation in more detail above and I still
| don't get it.
| kchiu20 wrote:
| Great question! So particularly if you have a high deductible
| health plan (which has become the most popular plan for
| Americans over the last decade) or a plan with a copay that
| doesn't cover every service (which is most plans), it's common
| to receive unexpected medical bills.
|
| A simple example for me is I had a high deductible health plan
| (while working as a software engineer at Uber) where I went to
| see a dermatologist to remove a wart, but I had no idea how
| much it would cost until weeks or months after the visit. It
| turns out that cost of seeing a dermatologist and getting
| liquid nitrogen treatment can vary by hundreds of dollars
| depending on where you go, even if you use your insurance.
|
| So Certainly shows you the upfront price that is specific to
| your insurance and lets you compare prices across providers.
| And if you book through us, you don't need to worry about
| surprise bills since we guarantee that you won't owe more than
| the prices we show upfront.
| whiddershins wrote:
| What's odd is I think you might provide 90% of the value by
| just taking over the role of disputing random illegitimate
| bills.
|
| The majority of surprise bills are errors and stuff that
| verges in fraud. And even though the patient doesn't legally
| owe it, they may not understand this and even if they do it
| is super stressful.
|
| At minimum it is a time consuming nuisance to respond to all
| the random BS bills.
|
| I feel like you could accomplish that with a tiny fraction of
| the infrastructure.
| fifteenforty wrote:
| Let me get this straight: you are selling a guarantee of maximum
| price for a medical service?
|
| You are selling health insurance.
| krob wrote:
| Years ago, back in like 2011, I worked for pricedoc.com, this was
| our primary goal as well. Doctors wouldn't talk to us. Legally
| they're bound to not due to their insurance contracts. The only
| doctors we gained some traction with were plastic surgery, and
| dental. Because these doctors tend to deal more with cash
| patients. We didn't survive long. Maybe 14 months. Then sold our
| IP to some other startup called greatvets.com and we struggled
| like crazy to get exposure by vets to want to use our product.
| Same goal to provide cash prices. Good luck.
| blastbking wrote:
| Oo that's a good domain name! I think this space is pretty
| challenging. We actually wanted to work on this before the
| regulation came out and ran into similar issues - however
| thanks to the transparency in coverage rule, we have access to
| their pricing info without having to speak to a single doctor!
| Although we still need to make relationships with doctors in
| order to get the business part to work.
|
| We did hear from some dentists that their insurance company
| forbids them from sharing their rates, which makes it tough to
| add dentists to our platform.
| calderwoodra wrote:
| If you want dentists on your platform, try to find dentist
| who are "fee for service", that's what the no-insurance shops
| call themselves.
|
| If you have any other questions about working dentist, feel
| free to email me and we can setup a call. My wife is a
| dentist and we've learned a thing or two over the years.
| ethbr0 wrote:
| Thing I've always been curious about -- what's the process when
| an ICD-10 code for a specific scenario doesn't exist?
|
| Is there a catch-all bucket that "other things" go into?
| RobotToaster wrote:
| I assume "MH2Y Other specified symptoms, signs or clinical
| findings, not elsewhere classified"
|
| https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int...
|
| There's a lot of "other specified" or "unspecified" categories
| in the ICD-11
| rmorey wrote:
| Congrats! This is a desperately needed product. I'm really
| curious as to how you onboarded the 5k providers that you have
| now. That is a sizable number, and in NYC, the market most
| saturated by Zocdoc, whom you've identified as your only real
| competitor (who don't currently provide price predictions). I'm
| sure any provider familiar with ZD will have had their eye caught
| by "Only pay a patient booking fee when a patient books through
| Certainly _and shows up._ "
| blastbking wrote:
| Thx for the encouragement! Right now we don't have
| relationships with a lot of these providers, but we do use the
| only charge when a patient shows up thing as a selling point
| when selling to providers - providers HATE getting charged for
| no shows. We wanted to list more providers (even those we don't
| have relationships with) because with only a handful of
| providers the shopping experience doesn't really work.
| rmorey wrote:
| Hmm, so you are saying, most of these providers listed on
| your site have no relationship with you? They don't know they
| are being listed?
| blastbking wrote:
| Yep, since the pricing data is publicly available, we list
| mostly non-partnered providers. Eventually we would want to
| convert all of them to partners, but that's a years long
| journey.
| vxNsr wrote:
| Maybe it's changed but back when I used zocdoc, they charged a
| flat rate and the only issue was being downranked once someone
| booked with you. Initially we had all appointments going
| through ZD (because why not, it was free and we didn't need to
| spend time/money building our own appointment booking system,
| plus I think it integrated with our CMS), but changed that when
| it became clear there was no organic appointments because we
| were at the bottom of the list despite being highly rated.
|
| It's been nearly 10 years since I was involved in that practice
| so I have pretty stale info
| rmorey wrote:
| Yeah, it has changed. In 2019, they adopted a fee-per-booking
| model, in which the flat yearly fee is nominal (like, a
| hundred, not thousands) and providers pay ZD a fee (varies
| per speciality) per each new patient booking via the
| marketplace (i.e. not returning patients, and not patients
| who book via an embedded Zocdoc widget on the provider's
| site) The idea being, now they grow as providers' business
| grows, aligning incentives. There can be issues with that
| model as well, including the rules around no-shows.
| alecst wrote:
| This is the future. I also know that in-advance EOBs* happen to
| be on the agenda for the CMS.
|
| I'm curious about how you solved a couple of problems because
| it's becoming clearer to me that healthcare operates in a
| probabilistic way, which makes price prediction hard. Here's a
| simple timeline of how an average person interacts with the
| healthcare system.
|
| 1. A patient has a symptom
|
| At this point, the patient can see a primary care doctor, or see
| a specialist themselves.
|
| 2. Patient sees a doctor and receives a diagnosis
|
| Depending on the symptoms and the doctor, they'll receive a set
| of diagnoses with some probability.
|
| 3. Patient receives a treatment
|
| The patient, based on their symptoms and doctor, will get some
| set of treatments with some probability.
|
| I guess here's the rub with outpatient data. Even if you
| completely figure out the pricing problem, it's not obvious (at
| least not to me) that when a patient goes in for an outpatient
| procedure that they're going to be billed for exactly the
| shoppable service they think they're getting, because it's based
| on probabilities. I think your tool alludes to this actually --
| more below.
|
| A meniscus repair is an outpatient procedure, and part of CMS's
| shoppable services list*. But I'm not sure that it's the case
| that when you see an orthopedic surgeon for a meniscus repair
| that you'll be billed for CPT code 29880, or 29881, or something
| else. It might depend on the surgeon and what they see when they
| dig into your knee. They also might X-ray your knee, which may or
| may not be covered.
|
| (I'm not actually sure of the possibilities here, but I think
| David Gaines at CareIgnition (https://www.careignition.com/)
| might know, if you want to discuss with him.)
|
| Anyway, to test how you solved this, I searched "meniscus tear"
| in my area (zip 11377). What I saw was the rates for first
| consultations with orthopedic surgeons. I did not see rates for
| the procedure itself, so I couldn't easily see what you do in the
| case that a person is shopping for a 29880/29881. However, I did
| notice that the price variation for a consultation can vary up to
| a factor of 3, depending on whether the consultation is graded as
| low or high complexity. You do a good job of explaining this in
| the drop-down, and noting that most visits are low-complexity,
| but I suspect that as you expand to more outpatient procedures,
| the probabilistic parts will become nontrivial and more
| important...
|
| I suppose one approach is to limit procedures in your search
| engine to ones where 1) the patient _knows_ exactly the procedure
| they're getting and 2) there's a low probability that they
| patient expects to pay for anything but that procedure. Or maybe
| you could say something about this? I'm genuinely curious.
|
| Finally, one more comment on guaranteed pricing, which I'm sure
| you've thought about. My alarm bells go off when I see
| "guaranteed" because I know, for sure, that some of these rates
| are wrong. Not all, but some decent fraction of them, and it
| depends on the carrier -- Aetna's rates tend to be more reliable
| than United's for example. I know this because I compared them to
| internal contracts, and know other people who have done the same.
| You might be able to pressure the carrier to honor the rate that
| they published (and I know this has been done on the hospital
| side) but that's a different story, and I'm not sure how that
| process shakes out. I also know that sometimes the carrier
| published multiple rates for the same service, without
| disambiguating information. I'm not sure how common this is with
| the subset of codes/plans you've pulled.
|
| * "Explanation of Benefits", i.e. the bill. The insurance company
| would tell you, before your procedure, the patient's portion of
| the bill, which parts would be denied, etc.
|
| * https://www.cms.gov/healthplan-price-transparency/resources/...
| blastbking wrote:
| Yeah, it's definitely based on probabilities. I will definitely
| check out careignition as this is a problem we've been
| struggling with for sure! For orthopedics we're aware that the
| range of care and CPT codes are super complex and we're holding
| off on adding complex procedures for now until we get a better
| handle on the data side.
|
| We are taking the approach, as you suggested, of limiting
| procedures in the search engine to ones that patients know what
| they're getting. Our initial focus is actually Dermatology for
| this reason, from a combination of popular demand and us seeing
| that the procedures billed are often very simple and easy for
| us to model / predict.
|
| For us, our goal is to guarantee the rates that we show on the
| site, and we're building a model that figures out what the
| correct rates are as claims get adjudicated. At scale,
| internally we will have the most accurate model of what costs
| will be, figuring out which of the carrier rates is real. This
| part is definitely challenging as well and we expect to lose
| money on the guarantee (paying out to patients) for some time
| until we figure it out, but we're limiting the losses by not
| listing the more complex high variance stuff.
|
| RE in advance EOBs, we think that we can help providers comply
| if/when that regulation goes into effect!
| alecst wrote:
| Thanks for the reply, and great work on making a cool
| product. It's really impressive, and I hope it does well.
| codegeek wrote:
| "using each patient's insurance...."
|
| I usually commend anyone trying to fix our Healthcare system in
| America but every time I see a startup in this space, no one can
| dare to fight against the main culprit: the middle man Health
| Insurance Mafia. I wish someone could do something where Health
| Insurance mafia is no longer in picture except for catastrophic
| insurance. Watch how prices drop for everything when
| Doctors/Hospitals can bill patients directly in cash.
| mbesto wrote:
| > I wish someone could do something where Health Insurance
| mafia is no longer in picture except for catastrophic
| insurance.
|
| This is not a technological/startup problem to be solved, but a
| regulatory one.
| codegeek wrote:
| Agreed. But our politicians are too much in bed with the
| Health Insurance mafia and the only alternative is people
| like Bernie Sanders advocating for things like Medicare for
| All which I am not quite sure about. Best solution would be
| for Doctors/Hospitals to work directly with Patients without
| requiring Insurance company contracts.
| lotsofpulp wrote:
| No one is forced to use health insurance. Everyone is able to
| try to negotiate with healthcare providers.
|
| This is a surgery center in Oklahoma that offers pricing
| without insurance.
|
| https://surgerycenterok.com/
| codegeek wrote:
| Yes there is that 1 center or may be a couple like that. But
| are you really arguing in good faith that people can just
| live without Health Insurance in America ?
|
| Btw you are forced as well because of Obamacare but even if
| you were not forced, you would still need it unless you are
| an excellent salesperson/negotiator where you go a Doctor's
| office and negotiate Cash Price.
|
| Tell me what's the first question you are asked when you call
| a Doctor's office other than your name ? It is "What
| Insurance company do you have" ?
| lotsofpulp wrote:
| The root problem is most people cannot afford the
| healthcare they need/want. That cannot be solved by simply
| getting rid of health insurance. Absent taxes, it is the
| mechanism by which you get other people to pay for your
| healthcare (at a certain point in time).
|
| You are correct that prices should fall if demand was
| reduced, but that would mean a period where people go
| without healthcare. And you are correct having a middleman
| does increase prices. But in this case, you also have the
| high cost of highly specialized people doing difficult
| work, medicinal patents, and extremely high liabilities
| involved.
| codegeek wrote:
| I pay $24,000/Year Premium + $5000 deductible for my
| family before Insurance will pay anything. So I am almost
| out of $30K out of pocket before Insurance pays. My point
| is that if we can get rid of that $30K, I am sure the
| doctors and hospitals bill will be less than than and
| this is just for 1 year. Now, if something catastrophic
| happens like a cancer surgery, let Insurance cover that
| but it shouldn't cost me $30K/Year in
| premiums/deductibles.
|
| Now I know you will say "Oh get a better insurance
| through your employer". If You don't see the problem with
| that, I have nothing to add. I should not be dependent on
| an Employer to provide a good neogitated Health Insurance
| Rate. The job of an employer is not to provide Health
| Insurance. It adds overhead for them and employees as
| well.
|
| This is purely on the cost side. NOw let's talk about the
| inefficiences that are added due to Insurance middle man
| mafia. I had a Doctor's office bill incorrectly and it
| took me days to fight with them and the insurance company
| just to correct a bill. I know I am not alone in this.
|
| We need to get rid of Insurance companies and rethink the
| concept of Health Insurance. Thats my opinion and if I
| had the power, I would do it today.
| lotsofpulp wrote:
| >My point is that if we can get rid of that $30K, I am
| sure the doctors and hospitals bill will be less than
| than and this is just for 1 year.
|
| Your assumption is incorrect. You are not paying for your
| doctors and hospital bills, and you are not paying for
| just the 1 year. You are paying for the NICU baby that
| costs $1M, or the anemic person that needs medicine that
| costs $100k per month, etc. And the chance that you might
| be one of those people.
|
| >Now I know you will say "Oh get a better insurance
| through your employer". If You don't see the problem with
| that, I have nothing to add. I should not be dependent on
| an Employer to provide a good neogitated Health Insurance
| Rate. The job of an employer is not to provide Health
| Insurance. It adds overhead for them and employees as
| well.
|
| No, I will not say that. Employers are involved in health
| insurance because it gives big employers an advantage
| over small employer by being able to compensate employees
| with pre tax dollars, and it helps prevent people from
| being able to compare compensation from different jobs so
| it incentivizes employees to stay put.
|
| A further benefit is that employers with relatively
| healthy and young employees such as higher paid desk job
| firms can sequester their health risks into a healthier
| pool of lives so that they are not subsidizing healthcare
| for older/less healthy people.
|
| >This is purely on the cost side. NOw let's talk about
| the inefficiences that are added due to Insurance middle
| man mafia. I had a Doctor's office bill incorrectly and
| it took me days to fight with them and the insurance
| company just to correct a bill. I know I am not alone in
| this.
|
| Absolutely, there is inefficiency. But doctors are among
| the smartest, most well paid people in the US, and have
| been for a long time. There is a reason that most agree
| to the terms of insurance companies, and that is because
| they know their customers cannot afford to pay them as
| much as they get via insurance companies.
|
| See also this comment.
|
| https://news.ycombinator.com/item?id=36972991
| smcl wrote:
| According to this same user you should be individually
| negotiating with your healthcare provider (or going to
| like one center in Oklahoma). You're talking to someone
| who is probably insulated from the worst of this (i.e. is
| young and/or well paid and insured and/or hasn't had a
| major healh scare) and therefore does not see what all
| the fuss is about.
| lotsofpulp wrote:
| I see perfectly well what the fuss is about. I am simply
| trying to elucidate that eliminating health insurance
| companies from the chain is not the panacea that many
| people think it is, which is due to people not being able
| to afford the services they want/need, and hence being
| subject to a mechanism of cost sharing not unlike taxes.
|
| In order of descending profit margins in the healthcare
| chain, you have:
|
| Pharmaceutical companies, medical software companies,
| medical hardware companies, hospital companies, nursing
| home companies, doctor companies, individual doctors,
| nurses/other staff, pharmacists, health insurance
| companies, and pharmacies.
|
| Somewhere in there is also costs due to liability due to
| tort laws, probably reflected in liability insurance
| companies. But let us say you got rid of the health
| insurance companies, who have medical loss ratios of 80%
| to 90%. Which means you are still left with quite a bit
| of the current system's costs.
| atonse wrote:
| Also you're then making a tradeoff between time and money.
|
| Do you want to spend hours calling and faxing various
| places to save $50 on a bill? The people on the other end
| of the line are getting paid to talk to you, they'll
| happily talk to you for hours. But you have other things to
| do.
| codegeek wrote:
| Exactly.
| blastbking wrote:
| Yeah, it's really hard to go head up against companies with
| 100B+ revenue (united healthcare etc) who essentially write the
| laws.
|
| I think this is a good space for the government to step in with
| progressive policies, and there are a lot of supporters that
| aren't as easily influenced by lobbying and under the table
| bribery.
|
| Our approach is to make something that makes the existing
| system easier to use for patients, under the assumption that
| that system continues to exist as-is. We do think there is
| bipartisan support for price transparency. Something like
| single payer healthcare is much less likely to get passed and
| health insurance companies would fight for their lives to
| prevent it from happening.
|
| There is a ridiculous amount of overhead that the whole
| insurance dance adds to providers and I think it's unfortunate
| how much that inflates pricing for everyone.
| otikik wrote:
| From outside the US this reads like "Pay protection money to the
| Mob without surprise bills"
| haldujai wrote:
| Couple comments:
|
| 1. I tried searching colonoscopy in the UES and the experience is
| a bit confusing.
|
| Although it says "showing price for colonoscopy" I had to expand
| the price breakdown to see that some of the quotes (the cheaper
| ones) don't include the procedure and are just for a consult.
|
| 2. _If the provider performs any services not listed in your
| Certainly Price Protection package, you will be liable and have
| to directly pay the provider for those services._
|
| This is going to be challenging as you scale up. What you're
| doing/saying works for predictable encounters like derm as you
| state in comments but thinking of my own procedural days I often
| don't know what I'll be billing (or doing) until I'm starting the
| case. I'd imagine it's worse for my surgical colleagues.
|
| It's a good idea, it'll be interesting to see how you tackle the
| bigger problem in surprise billing/price transparency which is
| the more complex work and encounters rather than the easy stuff
| like a consult, makes sense to start there though.
| nostrebored wrote:
| I've lived in countries where medical pricing was extremely
| upfront. You could go in, pay for your services, and walk out
| without any uncertainty. Even for ER visits, the maximum that
| you'd pay was clearly denoted, for everything short of a hospital
| stay.
|
| After moving back to the US, I had a huge amount of culture clash
| after an ER visit. I was leaving the hospital and asked the front
| desk where I could pay, and they looked at me like I was a
| lunatic.
|
| I'd be really curious if you have plans to tackle these types of
| visits if you get enough bargaining power.
| avn2109 wrote:
| Out of curiosity, what countries are those?
| remyp wrote:
| I went a private hospital ER in Portugal and it worked
| exactly this way since I didn't have (Portuguese) health
| insurance. I was there a couple hours, they gave me an IV,
| ran a blood panel, and wrote me a prescription. I then paid
| the cashier EUR250 and that was the end of it.
|
| Additionally, the visit actually solved the problem, which is
| something that rarely happens when I go to the doctor in the
| US.
| MandieD wrote:
| Emergency rooms in cities like Frankfurt often have a table
| of basic fees for visitors without German/EU health
| insurance.
| codegeek wrote:
| Most countries except USA.
| lowercased wrote:
| Can't say for certain, but I had a US citizen relative living
| in Belgium. He was vacationing in Scotland. Got kidney stone
| attack... was taken immediately to local hospital in
| Scotland, then airlifted to larger hospital. Was there for
| ... several days, then went back to Belgium. No cost from him
| at any point in Scotland. Had another attack while getting
| back to Belgium, and ended up in a Belgian hospital for
| several more days.
|
| Went to leave hospital after days of being there (and tests,
| and whatnot), and was told "well... you'll have to submit
| this to your insurance - we can't deal with it. It's going to
| be expensive(!)". They were sort of visibly ... agitated
| (possibly just because they don't deal with many overseas US
| people?). His total they were making him pay was around $200
| USD.
| kchiu20 wrote:
| Yes, we do! There is a procedure code and corresponding rate
| for each type of medical procedure/service that can be done,
| and that includes ER visits. For example, when I went to the ER
| for an ankle issue, I was billed for
| https://www.aapc.com/codes/cpt-codes/99284 which had a
| corresponding rate of $1072.50 for my insurance.
|
| So we can predict what the cost of the visit is. However,
| emergency care is much more difficult to predict the total cost
| of in terms of what gets done during the visit. For my visit, I
| also had x-ray imaging done, but it can be more difficult to
| predict the full scope of services that could be done during an
| ER visit.
|
| So it is something we plan to address later. But it should be a
| tractable problem that we plan to solve.
| lcnpc1848 wrote:
| Do you happen to be hiring for customer service roles?
| [deleted]
| ryanianian wrote:
| 1. If there's ML and a "guarantee" involved, what actually
| happens if the bill is larger than predicted?
|
| 2. I've been to medical appointments where doctors have clearly
| ordered tests to pad the bill. E.g. a lung capacity test to
| prescribe stimulant medication. Or doing many blood panels "just
| in case" (conveniently when they have an in-house blood scanner
| and phlebotomist). Some practices offer dozens of such tests and
| procedures. They are judgment calls but doctors are perversely
| incentivized to order them. What is the patient/doctor experience
| in these situations? Having the menu of services+prices readily
| visible and available and the doctor walking through the options
| and risk/reward?
|
| 3. Will you publish the pricing information over time? Perhaps
| comparing the transparency/hospital-published data versus your
| experiential and predicted data?
| blastbking wrote:
| If the bill is larger than predicted, we end up covering the
| difference (assuming that the services we showed the user are
| the ones the user ended up getting). We match the prices shown
| in the table of 'All Covered Services' that we show to the
| user, so if you go to a derm to have a mole looked at, it might
| be $150 for a consultation, and we'll tell you it'll be $70 to
| have a biopsy done, and if you get the biopsy, we'll guarantee
| all you owe is $220, and if you don't we guarantee it's $150.
|
| In terms of padding the bill, we think that doctors tend to pad
| it in order to get reimbursed more by insurance, but they're
| pretty soft on holding patients liable to these padded things,
| and also they will get in trouble if they do it too much. We do
| need to figure out the patient experience though, our goal is
| that patients know the cost of procedures a doctor is
| recommending (for ex if my doctor says I should get an
| arthroscopy and an x ray, I want to know ahead of time how much
| it costs), and can make an educated decision on whether they
| want to get the procedure done or want to see a different
| doctor.
|
| The pricing information, we're likely to publish broad
| analytics level information, but from a business perspective
| we're thinking that the discrepancies between the published
| data and our experiential data are really our 'data moat' for
| the business, so that's likely to be our IP (as it's what
| prevents someone from easily copying us by scraping our site).
| We want consumers to have to go through our site in order to
| get the pricing info, otherwise if it's just an informational
| site and people use us to look up pricing then end up going to
| competitors, we wouldn't be able to financially support the
| site existing long term.
| darkclouds wrote:
| So an insurance hedge for insurance schemes, with an AI as
| the hook?
| [deleted]
| FireBeyond wrote:
| Diagnostic Imaging is one of these areas. All of the big
| imaging manufacturers (Siemens, GE, Philips, Toshiba) have
| physician-specific financing assistance to help doctors buy CT,
| MRI, etc. They also offer consulting to assist obtaining
| Certificates of Need (generally required when opening certain
| new practices/facilities). They discuss break-even numbers of a
| couple of years, if not less.
|
| Studies show that physicians who own/part-own a DI facility
| tend to refer their patients for imaging substantially more
| than their peers who do not.
| itissid wrote:
| > Groups with more negotiating power, like large hospital
| systems, are able to command higher rates than private practice
| physicians.
|
| A thought: I wonder if this also mean that large hospitals will
| have doctors that earn more and somehow correlated with better
| care in _certain cases_? For example, In NYC I have found better
| care with Beth Israel and NYU Langone for Preventative and
| Diagnostic Health care than private practices.
|
| I have *not* had experience for injury treatment/surgery at
| hospitals, but WSJ has reported extensively on wacky Hospital
| billing practices for such patients.
| haldujai wrote:
| >A thought: I wonder if this also mean that large hospitals
| will have doctors that earn more and somehow correlated with
| better care in certain cases?
|
| No, usually lower. Especially academic hospitals.
|
| Better care because it's academic which draws the type who want
| to the best and are willing to forego higher pay for prestige.
| Also because billing matters a lot less and generally doesn't
| go into physician pockets at these hospitals so you can see
| more complexity and spend more time.
|
| >For example, In NYC I have found better care with Beth Israel
| and NYU Langone for Preventative and Diagnostic Health care
| than private practices.
|
| Mount Sinai and especially Langone are amongst the best
| academic hospitals and health systems in the US right now.
| rwissmann wrote:
| How do you handle the interaction with insurance plan information
| like accrued deductible? Certainly aims to guarantee the patient
| responsibility, right?
|
| Love to see innovation in this space!
|
| The challenge of not knowing what other services might end up
| being done seems daunting from a UX perspective. Hopefully you
| guys can find a solution.
|
| (I was early on the Data team at Oscar Health, so have more than
| my fair share of experience with thorny health care pricing
| data.)
| blastbking wrote:
| When patients enter their insurance, we have an API we use to
| retrieve their deductible remaining info, and then we use that
| to calculate their out of pocket cost that we show. And yes, we
| guarantee the patient responsibility!
|
| Definitely a challenge timing wise if a patient does other
| services with other doctors off platform between when we quote
| them and they see the doctor though.
|
| Would love to trade notes on the pricing data!
| rwissmann wrote:
| Getting timely, accurate data from the insurance companies on
| this intuitively feels hard. What are the guarantees around
| those APIs? There are so many path-dependent factors, like
| outstanding claims, readjudication of old claims, or "revenue
| optimization" games on the backend.
|
| Happy to connect if it would be helpful for you!
| runako wrote:
| > outstanding claims, readjudication of old claims
|
| I was going to ask about these in particular. I am very
| curious how you can assign an accurate number to these so
| that you can guarantee an out-of-pocket number.
| blastbking wrote:
| Sure! This is something we're still figuring out as we're
| quire early. Would say that the APIs don't guarantee a lot,
| so it's up to us to piece together the story for a patient
| and figure out these edge cases.
| thallium205 wrote:
| I am an industry veteran and can assure you this fact
| alone kills your guarantee. Pivot immediately.
| colinmorelli wrote:
| I say this not to discourage you, but what's being
| described here is far from an edge case. Providers have
| often up to ~90 days (when in network with the plan) to
| submit a claim. Then payers have time to process the
| claim and adjudicate it. If the claim is denied,
| providers have more time to appeal the claim, etc.
|
| Again, this isn't intended to be discouraging at all.
| Just don't operate on the assumption that eligibility
| APIs showing out-of-date deductibles is normal and not an
| edge case!
| paulgb wrote:
| Nice, congrats on the launch!
|
| I'm probably your ICP -- I live in NYC and have been burned by a
| surprise bill that was frustrating enough that I'd try a service
| like this. But after I entered some details to try it out, you
| hit me with an email wall, so I bounced immediately.
|
| It's not just that I don't want to give my email until I've seen
| more of a product; the fact that you string me along until I get
| to the payoff is destructive of user trust. There was an article
| about this phenomenon on the front page just yesterday:
| https://news.ycombinator.com/item?id=36962502
| kchiu20 wrote:
| hm so you shouldn't have been required to submit an email after
| the initial search (there's a check box to dismiss it).
|
| When you say you entered some details, are you saying after you
| searched, saw results, and tried to book someone? If so, we are
| not collecting email, but actually are collecting your
| insurance information. We need that to get your specific out-
| of-pocket cost (e.g. copay, deductible, out-of-pocket max,
| etc.)
|
| Do you mind trying again or emailing us at
| support@certainlyhealth.com with some more details?
| legitster wrote:
| > But it is ultimately the doctor who decides which services you
| end up getting (like a chef deciding which dishes you will be
| served). As a result, you can compare upfront out-of-pocket costs
| specific to your insurance and book a provider without worrying
| about surprise bills.
|
| This is the problem though. 9/10 when I get a surprise bill, it's
| because the hospital tacked on billing codes. So unless your
| model can spit out a likelihood that a clinic is going to
| classify an ear cleaning as a surgery, it will not prevent the
| worst surprise bills.
|
| You should also include cash-price options. Since switching to an
| HSA, I have saved _tons_ of money. Some hospitals even have
| across the board 60% discounts for cash. Pretty often the cash
| price can be lower than the out-of-pocket expenses when going
| through insurance! And I have never yet gotten a surprise bill
| when I settle the bills immediately.
| blastbking wrote:
| That's a great suggestion, we are planning on adding cash
| prices! It's a bit harder to collect them as we have to
| manually call all these places (not covered by the regulation).
| paulddraper wrote:
| > You should also include cash-price options
|
| This is an amazing hack.
|
| Also, it's harder for them to include it, because those aren't
| available like insurance rates are.
| legitster wrote:
| In our area there is a somewhat new chain of clinics
| (ZoomCare) that has all of their prices listed on their
| website.
|
| They have been SUPER awesome. I have had to play 0 games with
| their billing department and I think everyone should demand
| the same for all clinics.
| atlasunshrugged wrote:
| This is really interesting, I'm curious what made you decide to
| focus on U.S. doctors versus a medical tourism style marketplace
| if you're targeting price-sensitive folks? What are your
| expectations on the customer acquisition costs? It seems like
| that's one of the most difficult pieces as you'd get folks for
| one-off purchases or maybe once in a great while, but it seems
| unlikely you'd get a strong recurring revenue stream from a
| single customer.
| kchiu20 wrote:
| Good question - so the problem we're focused on solving and
| that we've personally experienced is surprise medical bills,
| which generally only happen if you have health insurance. The
| Transparency in Coverage Rule that went into effect in July
| 2022 is the unlock to solving this since it required all
| insurance companies to publish prices in public machine
| readable JSON files that could be ingested.
|
| Medical tourism is definitely something we'd want to eventually
| add, though that pricing data is not accessible in one place
| like the insurance company data, so it seems to be a bit harder
| starting place.
|
| With that said, you are absolutely correct that CAC is probably
| the biggest challenge with this marketplace. Healthcare is
| generally infrequent and unpredictable (unlike travel or
| groceries). But the market is huge (probably biggest in the
| US), and there's only been one company that's made any kind of
| dent in becoming a consumer marketplace (Zocdoc). Our
| hope/belief is that being the first place to allow consumers to
| see prices creates the product-market fit to lower that CAC and
| gain traction over time, but time will tell!
| healthapiguy wrote:
| > (2) patient eligibility/benefits information (e.g. deductible,
| copay, coinsurance);
|
| How are you retrieving this? Typically eligibility is only
| available through clearinghouses to providers - not directly to
| consumers.
| siva7 wrote:
| [flagged]
| dang wrote:
| " _Eschew flamebait. Avoid generic tangents._ "
|
| https://news.ycombinator.com/newsguidelines.html
|
| (I know it's hard to resist such things because people
| understandably have strong feelings about them, but when you
| react to a generic provocation like this, it's likely to lead
| to a generic flamewar, and that's not a good thing in any HN
| thread, and when nationalistic feelings are sprinkled in, it
| all gets much worse...)
| itissid wrote:
| A Question. NYC has a law regarding surprise medical
| bills:(https://ag.ny.gov/resources/individuals/health-care-
| insuranc...). If I understand that law correctly
| hospitals/facilities can't bill both in and out of network
| piecemeal billing for care if they are supposed to be in network.
|
| Would this mean the app is less useful once you are already
| admitted to a hospital in NYC that I know has a lot of care in my
| network? How does it help in such situations if we assume the law
| may not always do so?
| eek2121 wrote:
| Note that all emergency visits are always "in-network" regardless
| of your location and/or diagnosis/duration. It is the law. If you
| receive a bill saying not covered or out of network, contact your
| insurance.
| midenginedcoupe wrote:
| Seen from outside the US this is wild. Yet more middlemen to deal
| with middlemen. And you wonder why US healthcare is so expensive
| with such relatively poor outcomes.
| louwrentius wrote:
| I feel it's predatory to try to make a profit on something that
| is already so profoundly wrong. Yet this is the kind of company
| that the YC billionaires want to fund.
| SkyMarshal wrote:
| It's predatory to make obscene profits bankrupting people
| over unavoidable healthcare costs. But YC didn't create this
| problem, Private Equity did. YC is just trying solve it with
| a new business model. Ideally the US govt would solve it, but
| since they aren't, a private sector approach is the next best
| thing.
| louwrentius wrote:
| The YC billionaires are part of the same problem and belong
| to the same class as private equity.
| SkyMarshal wrote:
| Unless they're investing in PE then that's not
| necessarily true. There's a difference between creating
| wealth via innovation and production, vs extracting
| wealth. I know everyone wants to hate on billionaires
| these days, but it's worth keeping mind that the ways in
| people create wealth and make money are not necessarily
| equivalent. Some are a non-zero-sum game that create
| extraordinary social good and lift all ships, some are a
| zero-sum-game that merely extract wealth from others.
| Let's try not to throw out the baby with the bathwater.
| midenginedcoupe wrote:
| This isn't trying to solve that problem at all. It's yet
| another flavour of insurance to add to your existing
| insurance. Yet another layer of the same guff that exposes
| ill people to bankrupcy in the first place.
| ryanackley wrote:
| I don't understand your logic. This is addressing a real
| problem faced by people in America. I think what you're
| saying is YC billionaires should be fixing everything about
| our healthcare system instead?
|
| First, other billionaires have tried and failed[0].
| Billionaires don't stand a chance against a trillion dollar
| industry. Second, did you ever consider that a more realistic
| approach is to start with easily addressible problems like
| this one rather than trying to boil the ocean.
|
| [0] https://www.cnbc.com/2021/01/04/haven-the-amazon-
| berkshire-j...
| louwrentius wrote:
| Billionaires haven't tried at all. They only tried to
| create a new profit center. They are 100% part of the
| problem.
|
| The key issue is for-profit healthcare and capitalist
| methods isn't going to solve it.
| pcurve wrote:
| Believe me, things whole thing is wild to someone who worked
| for one of the big healthcare 'cartel' for a very long time.
| It's tragic, and it's by design.
|
| And the CMS 9915-F isn't going to fix this problem.
| hospitalJail wrote:
| Its not middlemen that is the problem. The service providers
| have done a complete regulatory capture of the industry.
|
| See the healthcare cartels among the top bribers of all time:
|
| https://www.opensecrets.org/federal-lobbying/top-spenders?cy...
| doctortheow wrote:
| This is nice and I hope it becomes standard. I have basically not
| been to the doctor in 7 years because of medical bill fears.
|
| I work at a big tech company and have theoretically very good
| insurance, but I have heard stories where the insurance gets
| declined even though they say they take it... or some lab
| specialist is using a different insurance network and you have no
| control over using them. If I don't have coverage then there is
| nothing stopping them from billing me like $1m as far as I can
| tell, _after the fact_ , when I can't just decline the service.
| It's insane that they can't say what it will cost up front.
|
| My company switched insurance _name_ but not _network_ and
| doctors didn't understand it and started denying the claims...
| even though they were technically in the network! That's when I
| gave up, after reading other employees' reports of that.
| chrisgd wrote:
| If you get a bill you don't agree with, just don't pay it. If
| you want to spend the time on it, you can ask for full itemized
| bill and when they send you something, tell them you want more
| detail. You can let it go to collections and settle for a
| lesser amount. Or just ignore it, unlikely anyone is going to
| credit bureau or garnishing wages over less than $5k.
|
| Only do above with doctor you don't plan to see again or
| anesthesia/lab company. Your insurance company will have a list
| of doctors in network, print it out and ask for front office
| staff to verify over email.
| danenania wrote:
| I've had a delinquency on my credit report for years from
| Verizon Fios for ~$200. It was a clear error on their part,
| but I still wasn't able to get it removed. I wouldn't be so
| sure ignoring a $5k medical bill won't have any consequences.
| jrockway wrote:
| I mean, the consequence is that you won't be able to borrow
| money. On Big Tech salary, you can pay cash for things that
| a lot of people borrow for.
|
| If you already own your primary residence and you bought in
| 2021, then you're pretty much locked into that home for 30
| years. Interest rates will never be 2% again. So, what is
| your credit even going towards?
|
| On the same note, you can just show up at your favorite
| doctor and say you'll pay cash and not tell them your
| insurance information. My doctor tends to bill my insurance
| company $200 for an office visit. This is unlikely to be a
| significant hardship for a software engineer.
| danenania wrote:
| Well sure, if you're going to construct a scenario where
| a credit score hit will have no impact on someone because
| they have no need for credit in the next decade, then
| they can certainly go ahead and ignore bills.
|
| You're making a lot of assumptions though. What if they
| don't own a house yet? A bad credit score will make it
| harder to get one, increase the interest rate if they can
| even get approved, and also make it harder to get
| approved for a rental lease too. Or maybe this person is
| all set like you describe, but they want to guarantor a
| loan or a lease for one of their kids? I think credit
| scores are a borderline scam, but it's hard to avoid
| relying on them for one thing or another for most people.
| chrisgd wrote:
| You paid and had a credit problem. I didn't and haven't had
| any issues. Seems like the better solution is to ignore it
| until you can't
| danenania wrote:
| Sure, people can roll the dice if they want. It might
| work out like it did for you. Or they could end up with
| an unremovable delinquency that gives them poor credit
| for years. Unless you have data to back it up, I wouldn't
| be telling people that the risk is low based on a single
| experience you had.
| TylerE wrote:
| Or just call the hospital's financial office. I've got a stay
| from a several years ago I'm still paying off. They offered
| me $50/mo. at 0% interest without me even asking, and why
| not? Free money, $50 5 years from now certainly being worth
| less than $50 today.
| ceejayoz wrote:
| > Or just ignore it, unlikely anyone is going to credit
| bureau or garnishing wages over less than $5k.
|
| They absolutely will do so. https://www.reddit.com/r/CRedit/s
| earch/?q=ambulance&restrict...
| HarryHirsch wrote:
| _If you get a bill you don't agree with, just don't pay it._
|
| That is the way. A couple of years back, a physician tried
| the out-of-network labs scam with me because they try it with
| everyone. It does like this: you piss in a jar at the intake
| visit, the physician sends it off to an out of network lab
| for high-complexity drug screening, and you get presented
| with a 4-digit bill.
|
| Everyone is innocent, the physician said "you peed in the
| jar", the insurance says "out of network", and the scam lab
| says "services were rendered". When you make it clear that
| any bill will be disputed and attempts to collect will end up
| in court, they settle for 0 dollars.
|
| They still tried the same on my wife, a few months later. All
| physicians are scum of the earth.
| runako wrote:
| Just coming to add that if it's been 7 years of no checkups,
| you are possibly getting into the age bracket where routine
| checks can make meaningful differences in longevity and quality
| of life.
|
| Highly recommend not going through middle adulthood without at
| least having annual physicals.
|
| There are a lot of things that happen to bodies that are easy
| to treat if you know about them soon enough.
|
| It sounds like you may need help using your insurance; call the
| insurer from the physicals office if the office won't call the
| insurer. Healthcare in the US is a tremendous administrative
| burden on us all, but overall it is still necessary.
| staticman2 wrote:
| "I have basically not been to the doctor in 7 years because of
| medical bill fears."
|
| I mean this kindly, but your concerns are not rational. Every
| middle class person I know goes to the doctor from time to time
| and has somehow avoided $1m dollar bills for providers listed
| as covered by their insurance.
|
| While our system is bad, you are greatly overestimating the
| probability of something very bad happening to you.
| bhelkey wrote:
| If you live in California this practice of out-of-network
| providers giving surprise bills at in-network facilities was
| ended in 2017 [1].
|
| Federally, this practice was ended January of 2022 [2].
|
| Go to a Doctor and get a checkup.
|
| [1]
| https://www.insurance.ca.gov/01-consumers/110-health/60-reso...
|
| [2] https://www.help.senate.gov/chair/newsroom/press/senator-
| mur...
| [deleted]
| zerkten wrote:
| Did you consider the impact of missing out on preventative
| care?
|
| Have you seen a dentist? The dental coverage from employers
| feels much more limited (except for preventative cleanings) and
| you can expect some not so fun problems if you miss so many
| cleanings.
| blastbking wrote:
| Good to hear from you. I hope that we can offer you peace of
| mind on pricing! We want people to not have to worry about
| surprise bills. We are working on sorting out the in-
| network/out-of-network lab situation soon as that's been a
| common complaint we hear from patients.
| ImHereToVote wrote:
| [flagged]
| dang wrote:
| Nationalistic flamebait will get you banned here, as will
| other flamebait, so please make your substantive points
| without that.
|
| https://news.ycombinator.com/newsguidelines.html
| ImHereToVote wrote:
| Thanks, I'll keep this in mind. This this apply to actual
| opinions one would hold?
| dang wrote:
| I'm not sure I understand your question but most opinions
| are fine on HN as long as they're expressed in a way that
| fits the site guidelines, i.e. thoughtfully,
| respectfully, curiously.
| JimtheCoder wrote:
| HN taught me that checkups aren't really useful...
| callalex wrote:
| Then you weren't reading properly. The articles that make
| the rounds here every now and then simply posit that the
| way checkups frequently end up being conducted is not very
| useful, but there is absolutely no doubt in the value of
| primary care checkups in scientific consensus.
| JimtheCoder wrote:
| "The articles that make the rounds here every now and
| then simply posit that the way checkups frequently end up
| being conducted is not very useful, but there is
| absolutely no doubt in the value of primary care checkups
| in scientific consensus."
|
| So, the way they are conducted aren't very useful in
| reality. But, in theory, they should work, so we should
| keep on doing them anyways?
|
| Got it.
| Aaronstotle wrote:
| You have healthcare and good insurance and presumably make a
| good amount of money working for a big tech company.
|
| A checkup will not end up with thousands of dollars of bills,
| schedule a routine health-check, you can also call your
| insurance first to check what is covered.
| ceejayoz wrote:
| The 2022 No Surprises Act (https://www.cms.gov/newsroom/fact-
| sheets/no-surprises-unders...) reduces the occurrence of
| this, but huge bills from a simple checkup have definitely
| been a thing.
|
| https://www.npr.org/sections/health-
| shots/2018/02/16/5855481...
|
| > After Elizabeth Moreno had back surgery in late 2015, her
| surgeon prescribed an opioid painkiller and a follow-up drug
| test that seemed routine -- until the lab slapped her with a
| bill for $17,850.
|
| https://www.npr.org/sections/health-
| shots/2019/12/23/7874035...
|
| > The visit was quick. Kasdan got her throat swabbed, gave a
| tube of blood and was sent out the door with a prescription
| for antibiotics. She soon felt better, and the trip went off
| without a hitch. Then the bill came. Total bill: $28,395.50
| for an out-of-network throat swab. Her insurer cut a check
| for $25,865.24.
| howon92 wrote:
| This is a problem worth solving. Congrats on launch!
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