For what it's worth, this sort of gaming works both ways.
Many medical administrations do everything they can to upcode in order to bill for more money.
The whole system is a mess.
The fight between doctors and insurance companies over 'downcoding'
11–20 of 354 posts
Re: The fight between doctors and insurance companies over 'downcoding'
#12I wonder how this plays out with Kaiser and other integrated practices.
Re: The fight between doctors and insurance companies over 'downcoding'
#13This doesn't surprise me: The "fee for service" system encourages doctors to perform as many services as they can so they can bill for more. I've certainly had my fair share of tests and procedures where I wonder if the provider was just trying to find something to bill for.
I'm also not surprised that some providers will try to figure out which codes they can use to get the most revenue. ("Hey, if I do procedure A instead of B, I get paid more, so why would I do B?")
That being said, I also wouldn't be surprised if many of these turn into lawsuits, or ultimately push to revise the whole "fee for service" system.
Re: The fight between doctors and insurance companies over 'downcoding'
#14Ah yes, this is a fight between the practices (sometimes not the doctors!) upcoding their visits and the insurance companies wanting to push back and downcode the visits to what they actually entailed. Healthcare practices want to maximize revenue and push up the “level” of a doctors visit and they can do it with just adding one or two extra little questionnaires or an extra test or two that you might not pay attenti…
There is immense pressure on insurance companies to lower costs, as they get blamed for the "American health care system". The only one on the side of the payer is the insurance company, they're the only one who wants to keep costs down for the consumer. Given the massive amounts of fraud in government health insurance (medicare) it would of course be prevalent in the private insurance market.
https://www.azcentral.com/story/news/local/arizona-health/20...
Re: The fight between doctors and insurance companies over 'downcoding'
#15Ah yes, this is a fight between the practices (sometimes not the doctors!) upcoding their visits and the insurance companies wanting to push back and downcode the visits to what they actually entailed. Healthcare practices want to maximize revenue and push up the “level” of a doctors visit and they can do it with just adding one or two extra little questionnaires or an extra test or two that you might not pay attenti…
I never understood why insurers get all the flack while the providers get a pass.
Re: The fight between doctors and insurance companies over 'downcoding'
#16If someone invoices me, and I don’t pay the full amount in a timely manner, what do you think will happen? Late fees, reports to credit bureaus, collections agencies hounding me, maybe even lawsuits? If insurance companies underpay, doctors should treat that no differently. Don’t appeal through the insurance company itself. Imagine I go to a store and pay less than the full amount at the register, and then the grocer…
Doctors have extensive contracts with insurance companies, and often have employees dedicated to billing. I wouldn't make assumptions here, other than "downcoding" is probably just subtle enough to not be worth it to fight.
Re: The fight between doctors and insurance companies over 'downcoding'
#17If someone invoices me, and I don’t pay the full amount in a timely manner, what do you think will happen? Late fees, reports to credit bureaus, collections agencies hounding me, maybe even lawsuits? If insurance companies underpay, doctors should treat that no differently. Don’t appeal through the insurance company itself. Imagine I go to a store and pay less than the full amount at the register, and then the grocer…
So what should happen when Docs lie about what procedures they did? Because it happens quite frequently and for some reason is always left out of these discussions.
Re: The fight between doctors and insurance companies over 'downcoding'
#18Good startup idea would be to work with medical practices to use AI to automate the disputing of the "downcoding" by insurers.
Hate it, thanks
Re: The fight between doctors and insurance companies over 'downcoding'
#19Ah yes, this is a fight between the practices (sometimes not the doctors!) upcoding their visits and the insurance companies wanting to push back and downcode the visits to what they actually entailed. Healthcare practices want to maximize revenue and push up the “level” of a doctors visit and they can do it with just adding one or two extra little questionnaires or an extra test or two that you might not pay attenti…
I never understood why insurers get all the flack while the providers get a pass.
Because the common interaction people have with their insurers is "We are denying this because of " which they have to fight to get healthcare.
When a provider rips off an insurer it's invisible to the general public.
Also, incidentally, when people talk about fraud in Medicare/Medicaid, the providers are almost always where that happens (yet that's often not pointed out).
Re: The fight between doctors and insurance companies over 'downcoding'
#20For what it's worth, this sort of gaming works both ways. Many medical administrations do everything they can to upcode in order to bill for more money. The whole system is a mess.
It's beyond our control, says only country where this happens daily.