There appears to be no bottom to the deception, self-dealing and criminal behavior that is the US healthcare system. In Never Pay The First Bill, healthcare investigative reporter Marshall Allen has collected a well-rounded and well thought-through range of stories to understand the enemy, and successfully fight back. His advice could save numerous bankruptcies, both corporate and individual.

Allen doesn’t mince words. He calls the system a “moral travesty” and “a predatory industry built on deception and price gouging.” It thrives on customers’ continuing ignorance , and operates on the bulldozer principle of running over customers repeatedly and universally, so they all think this is normal and the only way it could possibly be.

First of all, the patient is not the customer, Allen says. Insurers really don’t care what happens to patients. Their interest is milking those payers to feed their real interest: the hospitals and the doctors. Without them, there is no golden egg. Their networks would shrink along with their credibility. So they cater to and side with the medical establishment as a first principle. This is why people with billing issues have such an incredibly hard time with their own insurers.

The other point is that everything, absolutely everything, comes from the pockets of the payers. Even if you are relieved that your insurance has covered the entire cost of something, the inflated price you avoided and it paid will simply be billed back to everyone in double-digit premium increases next year. It’s the main reason insurers don’t have to care; no one is going to stop them raising prices as desired. They pay (very) good money to elected officials to keep it that way. Allen hammers at this one point repeatedly, throughout the book. Be vigilant, because they will (over)charge for every little thing.

Amazingly to normal people, insurers don’t even bother to go after fraudsters. Allen cites a repeat offender, racking up tens of millions of dollars posing as a doctor, offering services he called different names to fit the coding scheme, attracting new patients for services not covered. Rather than bring him to justice, they eventually asked for some of the money back, threatening to take it out of his future billings(!). He simply defaulted on the agreement and carried on. Once again, insurers don’t care how much they pay out; they will get it all back and more next year. No need to bother the police with these things, and the police confirm it in the book.

Some 600,000 payers undergo treatment they don’t even need every year. Hospitals charge what they want, different for each case, for whatever they feel like charging at the moment. Nothing will be agreed to in advance. Price lists on websites are fluid numbers the hospitals can veer from at will. A surgeon offered to pierce a little girl’s ears as long as he was performing another procedure anyway. Sure, said her mother, why not. The bill came to $1187.00 and she had to have the job redone at Walmart because the surgeon botched it.

Hospitals don’t care how much they charge patients for drugs they could have purchased themselves with a GoodRX card for less than ten bucks. Drug pricing is a well-known scam, with Americans paying the highest prices in the world – a captive audience of suckers. Prices on decades-old drugs can multiply overnight for no reason except bigger profits. Middlemen like pharmacy benefit managers (which have all merged so there is nowhere else to go) have intricate programs of payoffs to keep the merchandise moving, and those commissions come from higher than necessary prices.

The tactics Allen recommends to fight back are fairly classic. They include researching codes to verify you are being billed for the right thing. The system is justifiably famous for upcoding – claiming higher payment for a more involved test or procedure. Then there is turning the tables and demanding an immediate refund for services that were not performed or absurdly charged. There is also media pressure, as Allen has discovered: when he calls, a bill is suddenly cancelled out of “compassion”. Pestering higher ups can work, for the simple reason that it only takes one “yes” to walk back a bill. Allen has a comprehensive, six-point list of tactics that sadly, everyone should internalize.

Allen wants you to know that if your bill is sent to collection, all is not lost. Debt collectors, he says, pay no more than five cents on the dollar for the past-due accounts they purchase. So if debtors negotiate, say, 50 cents on the dollar, that’s a huge windfall and case closed. Work with the agent, he says. Get to know them. Make them understand they will be successful in their case. And avoid dings to your credit score or a trip to court by executing a decent settlement before it comes to that.

Medicare is the standard everyone refers to. It has payments for every code, adjusted for location. Hospitals and practices are comfortably profitable on Medicare schedules of payment. For them to charge ten times the Medicare rate is an obscenity they get away with at will.

Payers can go to Small Claims Court and show how unreasonable the charges are, that the hospital refused a reasonable offer of say, twice the Medicare rate, and that the payer only paid under protest. These things can work, depending on the judge, the circumstances, and if the hospital bothers to send a lawyer or not.

There is no reason you can’t add your own codicil to the stack of paperwork you must sign in order to have an operation or procedure. Allen suggests: “I consent to appropriate treatment and (including applicable insurance payments) to be responsible for reasonable charges up to two times the Medicare rate,” on the Informed Consent Agreement. It’s supposed to be a contract between two bodies; there is no reason why the patient can’t modify it.

It is an absurdity of America that the quality of your healthcare depends on the quality of your job. Lousy jobs force people into lousy healthcare (if any at all) with gigantic deductibles in the thousands of dollars every year. God help you if you get injured in December.

Employers are up against it as well, if not worse. They are ripped off by the consultants and administrators as well as by the insurers. They have to fight to see bills they must pay, often with no success, even when they are the payer. The bonuses and chargebacks in the system keep the brokers and consultants happy, and make employees’ healthcare more expensive. A single company account for fifty employees could mean $50,000 a year, every year to the broker. The add-ons, additional options including dental, vision, life insurance, disability and upgrades can earn the broker over 50% of the additional annual premium. The money is definitely not going towards better service to the patient. The average worker pays $4000 to the broker over their career at the company.

Allen cites several company success stories, where audits were successfully made, where companies set the new rules, refused to pay extreme multiples of Medicare rates, beat back unnecessary treatments and fraudulent programs. They save millions. One gave it back to employees in major company outings. Another wrote a check to everyone. The rape and pillaging of employers keeps them from hiring (say, more teachers) or paying more (to keep employees solvent and loyal). It can be stopped, but it takes bullying as bad as the insurers’ bullying.

The most impressive story is about the State of Montana, which hired a woman to straighten out their public employee healthcare mess, which cost taxpayers millions every year. She spent years trying to obtain her own data, and then arm twisting and shaming the medical establishment into a more reasonable payment scheme, never knowing if she would succeed. She broke it down to incremental steps, for small incremental victories that rolled upwards into finally beating back the biggest players themselves. One very large hospital refused, and of course was furious to be cut out of public employee business as a result. It took all her smarts to push them over the edge, but she did it, totally restructuring healthcare as a reasonable and still highly profitable service in Montana. It can be done.

And for all this, the American Healthcare establishment is the laughingstock of the world. Everyone knows what a miserable failure it is. It is the third largest cause of death in the country, a country where life expectancy has been falling in recent years – unprecedented in western countries (until COVID dented everyone’s stats).

The nonsense seems to extend to every branch. Currently, COVID-19 vaccines are free, and in many instances not even an appointment is necessary. Yet COVID-19 tests require a prescription (Why? Are they a danger to the patient?), which might require a visit to the doctor, involving payments, co-pays, billing and collections. How does that make sense? Things like this and the ugliness examined throughout the book are a terrible indictment of the whole sector such that it needs an entire manual for people to defend themselves against healthcare.

The final twist is that nearly every story Allen tells is about a victim who works in healthcare. They are healthcare workers’ own fights for justice. From nurses to doctors, lawyers and administrators, the healthcare system rips off anyone who comes in for help. It’s not just the public at large. If there’s a sickness to be cured, it’s the healthcare system itself. Never Pay The First Bill will bring back ugly memories from times you too were ripped off and never achieved satisfaction. It is unfortunate, but absolutely everyone needs to have a copy of this book for emergencies brought on — by the healthcare system.

David Wineberg ( )