I wrote the book on hospital bills. I got three things wrong.

Hi friends,

It took me five months to write Your Hospital Bill Survival Guide. Five months of nights and weekends and a lot of takeout containers.

Last Sunday I sat down with a stack of this year's healthcare news on one side of the table and my own book on the other, and I read them against each other.

I got some things wrong.

Not the how-to parts. Those still hold up, and I'll get to that at the end so nobody panics. But there are three things I either missed completely or only told you half of, and you deserve to hear that from me instead of finding out the hard way when a bill shows up.

So let's do this.

Miss #1: I wrote a whole chapter about losing coverage and skipped the biggest way people are losing it

Chapter 3 of my book goes deep on Medicaid. Work requirements, eligibility checks, what happens to rural hospitals, all of it. I used Ohio as my example because Ohio is near and dear to me.

Here is what I did not write a single word about: the extra help that made insurance affordable on the ACA marketplace ran out.

If you buy your own insurance instead of getting it through a job, you may have gotten a monthly discount that made your premium possible. That discount is gone. The Congressional Budget Office projects marketplace enrollment dropping from about 22.4 million people in 2025 to about 13.1 million in 2027.

That is nine million people. Most of them are not going to plan for it. They are going to find out at a doctor's office.

And this is not a forecast anymore; it is already showing up in hospital numbers. Community Health Systems reported last week that half of their growth in admissions came from patients with no insurance at all. Their self-pay share of visits went from just under 5% to over 6% in a single year. HCA raised its own estimate of the damage from $600 million to more than a billion dollars.

Here's why that matters to you and not just to a hospital's investors.

Chapter 5 of my book is called "What If I Don't Have Insurance?" It is six pages long. It is the shortest chapter in the whole thing, because when I wrote it I thought of uninsured readers as a smaller group who needed a smaller section.

Chapter 5 is now the most important chapter in the book, and I wrote it like an afterthought. That one stings.

If you are newly uninsured or about to be, the two moves that matter most are asking for the self-pay discount before you pay anything, and asking for the financial assistance application even if nobody offers you one. Those are both in Chapter 5. They just deserved more room.

Miss #2: My AI chapter told you half the story

In Chapter 8 I wrote about artificial intelligence in healthcare, and I focused almost entirely on the ways it can be used against you. Biased data. Automated claim denials. Private equity money funding tools built to save money rather than help patients.

All of that is still true. I stand behind every word.

What I did not tell you is that some hospitals have started pointing the same technology at the insurance companies on your behalf. MaineHealth in Portland is using software to spot patterns in how insurers deny claims, compare those denials against the insurer's own written policies, and challenge the bad ones faster. They say it has overturned improper denials for thousands of patients.

I wrote about AI like it was one thing. It is not one thing. It is a tool, and what matters is who is holding it and who they are pointing it at.

One more piece of this that nobody has told you yet: the American Medical Association is building new billing codes so that hospitals can bill for analysis done by AI without a doctor doing the work. Comments are open until August 10. I am not going to tell you how to feel about that. I am telling you because in a year or two you may see a line item on your bill for work no human being performed, and I would rather you recognize it than be surprised by it.

Miss #3: I never told you how to use AI on your own bill

This is the one that actually keeps me up.

I wrote a whole book to help you decode a confusing document, and I never once mentioned the free tool that more than 300 million people a week are already using to ask health questions. As of this week, ChatGPT's health feature is open to every adult in the United States, and it can connect directly to medical records from Epic and Oracle systems.

Some of you are already pasting your bill into it. I know because you have emailed me about it.

In the very same week, a man in Florida filed suit claiming the chatbot told him his symptoms were not dangerous and encouraged him to stay home. He says he ended up in the ICU with blood clots in both lungs.

So here are my rules, and I would put these in the book tomorrow if I could:

• Use it to translate. Never use it to decide. "What does CPT code 99285 mean" is a great question. "Do I need to go to the emergency room" is not a question for a chatbot, ever. Not once, not even a little.

• Do not paste your full name, date of birth, address, member ID, or medical record number. Black those out first. You do not need them there for the tool to explain a charge.

• Check every dollar figure yourself against the bill and your Explanation of Benefits. These tools make arithmetic mistakes with total confidence, and confidence is not accuracy.

• And when it gives you an answer that sounds too good, treat that the way you would treat a stranger at a party telling you about a great investment. Verify it before you act on it.

Smaller corrections, quickly

I said hospitals were already posting their prices and mostly getting away with doing it badly. Still true, but a bill moving through the House would extend those rules to imaging centers, surgery centers and labs, and would require an actual estimate before your service. If it passes, my Chapter 6 advice about not prepaying gets a lot more teeth.

My Medicare Advantage section could use a note that the prior authorization reform bill cleared its committee 42 to 0. That is about as close to unanimous as anything gets in Washington right now.

My cyberattack section stops at Change Healthcare in 2024 and Kettering in 2025. There were two more disclosed in a single week this month, one of them a company whose billing software runs at more than 2,000 hospitals. The lesson has changed from "this happened" to "expect this," and the new risk to you is fake bills and scam collection calls.

And my Federal Poverty Level table says 2025 right on it. Use this year's numbers instead; I have a free worksheet for that on the website.

What did not change

Every practical thing in Chapters 4 through 7 held up.

Nonprofit hospitals still have to have a financial assistance policy and still have to tell you about it. IRS rule 501(r) still requires four communications over 120 days before they can come after you. You still have between 120 and 240 days to apply. Appealing a denied claim still works far more often than people believe. Waiting for the final bill instead of prepaying is still the right call. Asking for an in-person meeting still gets results that phone calls do not.

None of that moved an inch. If anything, it all matters more this year than it did last year.

I told a friend once that my book would be boring to read. Flashlights are boring too. We keep them for the emergency when we need them.

Turns out even a flashlight needs new batteries now and then.

More next week,

April

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