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The fight between doctors and insurance companies over 'downcoding'

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Re: The fight between doctors and insurance companies over 'downcoding'

#101

Post by lotsofpulp »

delecti wrote: post #80
lotsofpulp wrote: post #76

Earlier quoted context omitted.

I don’t understand why any decision maker in any business in the USA chooses to offer their employees (and hence themselves) health FSAs at all, especially when the much superior in every way Fidelity HSA is available.

HSAs are only available alongside high deductible plans (HDHP), which aren't necessarily ideal in all situations. FSAs are the only option like that if you don't have an HDHP.

Surely, that is offset by having to forfeit or waste any FSA money not needed by the end of the year. It really only makes sense if you have a minimum amount of guaranteed healthcare expenses every year.

Re: The fight between doctors and insurance companies over 'downcoding'

#102

Post by salawat »

ratelimitsteve wrote: post #95
supportengineer wrote: post #68

Earlier quoted context omitted.

Here are the magic words in US Health Care: "What is the cash price?" It's usually less than you think and often worth avoiding the insurance company hassle. Then you can just get reimbursed with your FSA or HSA anyway.

Pharmtech: "With your current insurance we can't sell you this medicine at any price. We're under an agreement." Me: "Okay, what if we don't go through insurance?" Pharmtech: "$45 for the prescription." Me: "That's a bit higher than last time." Pharmtech: performs some sort of incantation "Okay, $12." Me: "How did we go from not at any price to $12?" for those of you keeping score at home, the medicine was generic co…

Medicine not in formulary. Their clinical department decided it was not worth covering for $reasons. The Pharmacy, likely to be considered a preferred pharmacy, signed a contract to be bound by that company's clinical formulary for policyholders.

$45 was probably cash price, the they can let it go for if they do their ordering through a pharmacy supply group.

$12 may be a price with a discount program like GoodRx applied. Data changes hands behind the scenes to make the lower price at the till possible. Don't know how GoodRx works, but been around long enough to know you're probably the product.

You'll be amazed the complexity of the pharmacy benefits management complex.

t. Been there, seen it, tried to fix it best I could, left in abject horror.

Re: The fight between doctors and insurance companies over 'downcoding'

#103

Post by andrewmcwatters »

supportengineer wrote: post #68
3D30497420 wrote: post #46

This sort of thing gets to two critical problems of the American system: 1. It is largely designed to make money, not actually help patients. So every step in the healthcare chain that can extract a bit of value will do so, largely to boost profits. 2. Insane complexity with limited transparency. How much will something cost? Hard to tell. Will it be covered? Who knows? On the opacity, I have one informative anecdote…

Here are the magic words in US Health Care: "What is the cash price?" It's usually less than you think and often worth avoiding the insurance company hassle. Then you can just get reimbursed with your FSA or HSA anyway.

This is absolutely unacceptable when per employee healthcare employer costs are basically now something like, I don't know, 20,000-25,000 USD?

Re: The fight between doctors and insurance companies over 'downcoding'

#104

Post by JumpCrisscross »

iamnothere wrote: post #57
philipallstar wrote: post #51

Earlier quoted context omitted.

Eventually everyone works for profit if they get paid. Spending time only is pure profit in money.

A reasonable wage or salary isn’t usually considered “profit” in a legal sense. This is why nonprofits can still pay employees. Any money that is left over after costs (including wages/salaries) needs to be reinvested, spent on the organizational mission, or held for future use, not distributed through dividends or other distributions as in a for-profit enterprise.

> reasonable wage or salary isn’t usually considered “profit” in a legal sense

This is a semantic punt to the word “reasonable.”

Re: The fight between doctors and insurance companies over 'downcoding'

#105

Post by lotsofpulp »

lozenge wrote: post #86
hypeatei wrote: post #74

Earlier quoted context omitted.

> An insurance company's only goal nowadays is to make as much money as possible How can that be true when their profits are capped on collected premiums? Look up the Medical Loss Ratio (MLR) rule to see what I'm referring to. If you wanted to squeeze money out of people, health insurance would be the least appealing industry to do that in since you're required to spend 80-85% of premiums on medical care.

So increase the health care spending, then you can raise premiums. An issue the ACA drafters already knew about, and tried (and failed) to deal with.

The linked article is about insurers trying to reduce spending by downcoding.

So which is it? Insurers unfairly denying reimbursement for what should be valid claims, or insurers unfairly increasing spending on claims so they can increase their profits.

Also, go look at 5, 10, and 15 year returns for the big insurers (UNH/Elevance/CVS/Cigna/Humana/Molina/Centene) if you think health insurance is a good business for earning money. Spoiler alert: they’re less than desirable, stick with SP500.

Re: The fight between doctors and insurance companies over 'downcoding'

#106

Post by darth_avocado »

eigencoder wrote: post #28

My pediatrician always charges us for an office visit + preventative care when we go in for a preventative care visit. It's obviously to get more $$ from insurance. I feel like this goes both ways...

Yeah enough gets talked about insurers acting in bad faith, but let’s not forget hospitals also acting in bad faith for their end. Some personal examples:

1. Sitting in a Urgent care. They get you in the exam room. You sit there for 15 mins, doctor comes and sees you for 5 mins (mostly rushes the exam), do a blood draw, ask me to sit around while they run the test, doctor leaves, as soon as 45 mins are over the nurse comes over to let me know it’s taking longer to run the test so I can go home and they’ll call when the results are out. A month later charge thousands of dollars to insurance for a 45 min Urgent Care visit that doesn’t cover the lab work.

2. Go to PCP with cold symptoms that haven’t cleared in 10 days. I insist it’s a sinus infection, they send me back with no antibiotics and ask to schedule and online appointment in 2 days. I insist I come in in person, but they schedule an online appointment anyway. Nothing gets better and I see the doctor online after 2 days, they say I’ll have to come in so that they can evaluate me in person and prescribe antibiotics. I go in person, get antibiotics and get cured. Insurance gets charged for 3 separate hour long visits ($750 each and none of them lasted more than 10 mins).

Re: The fight between doctors and insurance companies over 'downcoding'

#107

Post by wat10000 »

hypeatei wrote: post #74
danaris wrote: post #59

Earlier quoted context omitted.

No, I assure you, it is very common for doctors' offices not to know whether a particular procedure will be covered. This is not just because of the capriciousness of insurance adjusters, but because they have to deal with all the 273 different variations of insurance plans that people who come through their offices might have. In general , a doctor's primary goal will be to get you good care. An insurance company's…

> An insurance company's only goal nowadays is to make as much money as possible How can that be true when their profits are capped on collected premiums? Look up the Medical Loss Ratio (MLR) rule to see what I'm referring to. If you wanted to squeeze money out of people, health insurance would be the least appealing industry to do that in since you're required to spend 80-85% of premiums on medical care.

A 25% margin is pretty good, and companies aren't hitting the limit currently.

Re: The fight between doctors and insurance companies over 'downcoding'

#108

Post by djoldman »

hypeatei wrote: post #71
djoldman wrote: post #61

Earlier quoted context omitted.

Health insurance companies are not immediately insolvent because they 1. pay out claims slowly and/or 2. deny or downcode claims outright? Really? That to me would imply that doctors/patients are submitting a huge amount of incorrect claims.

Doctors/patients are human too and your proposed system would be ripe for abuse. If you're well versed in submitting claims, and you know they have to pay out, then you could inundate them with fraudulent ones. > That to me would imply that doctors/patients are submitting a huge amount of incorrect claims UnitedHealthcare says that 10% of claims go through additional review for various reasons[0]. I don't know if the…

I'm not proposing that all guardrail responsibilities be shifted to the insurer. Just the "medically necessary" provision.

Doctors would still have a Duty to Code Services Accurately and a Duty to Maintain the Medical Record (which would clearly enable an insurer to prove a non-medically necessary therapies). There would be plenty plenty of evidence for an insurer to immediately respond.

So claims could be rejected on the basis of failing to code accurately or lack of record.

Re: The fight between doctors and insurance companies over 'downcoding'

#109

Post by tpmoney »

lotsofpulp wrote: post #76
i80and wrote: post #70

Earlier quoted context omitted.

FSAs are insane, conceptually. "Guess how much money you're spending in a year on healthcare! But beee caaareful: if you guess too high, YOU LOSE IT" I still used mine while I still had access to one, but it was grumpy-making and was usually almost more trouble than it was worth.

I don’t understand why any decision maker in any business in the USA chooses to offer their employees (and hence themselves) health FSAs at all, especially when the much superior in every way Fidelity HSA is available.

All the FSA money in your account is available immediately at the beginning of the year. Ironically that would make it a better choice for anyone with a lot of medical expenses on an HDHP if it wasn’t for the fact that FSAs are capped by law.

As someone who does deal with enough medical stuff to clear the deductible (and sometimes the OOP max) on their normal health plan annually, it’s still much more convenient, again because the money is all there at the beginning of the year when the expenses are highest

Re: The fight between doctors and insurance companies over 'downcoding'

#110

Post by mbb70 »

gwbas1c wrote: post #13

This 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 i…

"Figure out which codes they can use to get the most revenue" is a billion dollar industry with many players, subspecialties and surprisingly few lawsuits.
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