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Notes -
Again, the entity extracting more money and surprise fucking over the patient isn't the hospital or the healthcare provider it's the insurance company.
OP paid the insurance company for a service (covering healthcare needs) and then the insurance company was like lol nah we aren't going to do that, and instead of refusing to pay the insurance company or complaining about the insurance company they take it out on essentially a third party with no control.
If I wire transfer some money to 419 scammers and then walk into a bank and punch an employee in the face for allowing me to get scammed then I'm the asshole.
The ED is literally required by law to provide care regardless of insurance status, ability to pay, or appropriateness of that level of care. There's literally nothing the ED can do to stop this, it's OP's job to go to an appropriate level of care, think critically about whether an ED visit is required, investigate his insurance, or get new insurance.
OP and the Hospital are both victims of the insurance company being an asshole.
But if, hypothetically, the OP didn't have insurance and just wanted to pay cash, do you think the bill would have been any lower? My impression is that paying cash for healthcare in the US is strangely difficult, expensive, and prices just as (if not more) opaque.
Short version: costs are weird, sometimes outright unknown (the accounting for some stuff gets bizarre), charges are generally inflated as a result an annoying dance with insurance companies and the federal government to get things paid for (ex: for a lot of stuff medicaid and medicare pay less than cost so things get...creative and the insurance company goes "we'll pay you 1.05 times the cost...").
Professional fees are like likely to do this because it's a little more obvious to pay out a portion of a staff members salary based off of how long the encounter is supposed to go (very doctors, NPs, or PA are self-employed these days, almost everyone is "owned" sometimes by a hospital but also by....).
Based off the absurdly inflated price and and the lack of willingness to negotiate (most health systems will be flexible with cash pay) (and also the fact this is the ED) the PA was probably owned by a practice management group which is when a PE firm buys a physician group and does things like cut salaries, raise prices, and be an asshole (and give the money back to whoever is invested in it). It's a huge problem right now.
It is also possible that this primarily driven by what happens when your insurance company just refuses to pay for things but that's less likely.
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again, the healthcare industry and hospital systems are participants with agency in this game which designed this setup as part of the negotiating game with insurance companies
this new bank employee analogy is even worse than your car mechanic one
Negotiating prices for services is not "extracting" money unexpectedly, being unaware of what the insurance will cover is not "surprising fucking over," the insurance knows what they will pay for and we often don't and have to fight them, even for clearly necessary stuff.
Hospitals can't know (as in knowing and changing your decisions as a result is illegal, specifically for emergency medicine) what the insurance is going to do, the agency is extremely limited.
In response to this sort of fuckery places have literally closed their EDs. Hospitals are going out of business at record rates and posting record lows for profit. Meanwhile the insurance companies are posting record highs.
What are they supposed to do? Break the law and not treat the guy? Just not get paid and then go out of business? Stop victim blaming.
And that's completely ignoring the other layer of this which I can't verify with the details OP provided, but the PA is probably owned by a third party - a private equity group that does enjoy the revenue associated with skull fucking patients and everyone in healthcare would love for that behavior to get banned but we don't have any control...
I don't know how the fuck the scummy companies won the psyop where they blame everything on doctors who have zero administrative or financial control.
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