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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'

#111

Post by lotsofpulp »

tpmoney wrote: post #109
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.

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, aga…

My HSA money is also available in the first pay period of the calendar year. It’s up to the employer to decide when they want to contribute it.

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

#112

Post by sensanaty »

some_random wrote: post #50
Pet_Ant wrote: post #29

Earlier quoted context omitted.

Man, it's almost like healthcare and human lives shouldn't be for profit...

You're welcome to come up with an alternative system of aligning interests, so far all of the other ones have failed horrifically.

I live in NL. I pay 130 euros a month for my health insurance, and a max of 375 yearly on deductibles should I accrue some costs. The only reason I pay 130 is because I earn above a certain number, otherwise it's discounted and even free at a certain level (and I opted into the more expensive tier to also have dental coverage). In my case, my employer even pays for my insurance so in reality I don't even pay anything monthly (that's rare here though).

I recently did an in-depth sleep study, got a CPAP machine prescribed to me, free replacement filters and replacement tubes + mask for it whenever I need them. I also got xrays and CT scans because of a foot injury around the same time. I also got comprehensive blood tests done.

None of it cost me a penny other than the ~100 euros a month, the doctors and GPs are paid well, the quality of care I received was exceptional, and in the worst case scenario possible I would've only paid 375 euros max.

My mother in law has osteoporosis and a number of other chronic illnesses, so she has to see specialists quite often. The quality of care she receives is similarly excellent to the one I received, and due to her disability her healthcare is partially covered as well.

It's not perfect of course, but it sure does beat all the horror stories you often hear coming from across the pond of people ending up in lifelong medical debt should, God forbid, something happen to them that they realistically have no control over. So I'm sorry, but I don't buy that the for-profit fucked up system you guys have going on over there is the best of the lot, especially if you're an average Joe and not someone from SV earning obscene amounts.

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

#113

Post by fph »

atomicnumber3 wrote: post #73
renewiltord wrote: post #55

People get annoyed at insurers who will deny treatment but most of the time you can just pay it yourself. The government has decided that everyone should pay for health insurance but you'll never be denied care if you pay for it yourself. So if you think you do require some care, just ask the medical practice whether they accept self-pay and then you can decide if it's worth paying or not. If you think it's not, it's…

>So if you think you do require some care, just ask the medical practice whether they accept self-pay and then you can decide if it's worth paying or not. If you think it's not, it's unlikely someone else will if they have to pay on your behalf. Ok, hear me out for a minute. What if I wanted to pool with several people, so that if any of us had unexpected medical needs, it wouldn't bankrupt any of us. Knowing that mo…

Aren't these basically mutual healthcare providers? We have them in Europe.

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

#114

Post by unyttigfjelltol »

salawat wrote: post #102
ratelimitsteve wrote: post #95

Earlier quoted context omitted.

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 app…

Turns out there are rational commercial players in these markets if you just go all-cash. The price is abandoning the incantations and local pharmacies, hospitals, ignoring your insurance. Harder to do that with services, but it’s coming as well.

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

#115

Post by themafia »

darth_avocado wrote: post #96
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.

It is a relatively easy fix tbh. You spend on medical bills through the account like you do right now, but the way you fund it is your post tax contributions. At the end of the year the account sends you a statement of what you used and you can use it to get the tax paid on the money back when you file the taxes.

And if you're wrong on your medical expense paperwork it could be a felony!

Why shouldn't the institutions that do this all day and claim it as their special expertise handle all of this? Why should I even be /capable/ of losing money due to my lack of experience with the system?

The money is forfeited back to the employer. There should be a law that money is now taxed and forwarded to the employee in their regular payroll.

This system is designed to screw over regular consumers.

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

#116

Post by renewiltord »

atomicnumber3 wrote: post #73
renewiltord wrote: post #55

People get annoyed at insurers who will deny treatment but most of the time you can just pay it yourself. The government has decided that everyone should pay for health insurance but you'll never be denied care if you pay for it yourself. So if you think you do require some care, just ask the medical practice whether they accept self-pay and then you can decide if it's worth paying or not. If you think it's not, it's…

>So if you think you do require some care, just ask the medical practice whether they accept self-pay and then you can decide if it's worth paying or not. If you think it's not, it's unlikely someone else will if they have to pay on your behalf. Ok, hear me out for a minute. What if I wanted to pool with several people, so that if any of us had unexpected medical needs, it wouldn't bankrupt any of us. Knowing that mo…

Yes, you can do that. HealthPartners[0] is such a consumer-governed non-profit. It is entirely opt-in. It is not illegal in America to do that and, as you can see, others have done that.

In HealthPartners' case, they do deny claims despite having the structure you mentioned. I think if you wanted to run such a pooled insurance company that advertised that it would pay any and all claims made to it and would deny precisely zero claims, you could and you would find it very easy to onboard both patients and providers to it, at least so long as its fund was solvent.

0: https://en.wikipedia.org/wiki/HealthPartners

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

#117

Post by themafia »

standardUser wrote: post #64

It's a system that supports two set of clients, doctors and patients, and fails them both. Yet, Congress has considered it sacred and infallible for a hundred years. Democrat's most earnest attempt ended up strengthening and expanding that system, and Republicans for their part have fought tooth and nail to stack the system even further against the people it's supposed to serve.

Congress has considered that the employees of this industry are wealthy enough to contribute generously and often to their "re-election campaigns." They couldn't care less if your medical bills bankrupt you or not.

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

#118

Post by themafia »

renewiltord wrote: post #55

People get annoyed at insurers who will deny treatment but most of the time you can just pay it yourself. The government has decided that everyone should pay for health insurance but you'll never be denied care if you pay for it yourself. So if you think you do require some care, just ask the medical practice whether they accept self-pay and then you can decide if it's worth paying or not. If you think it's not, it's…

> but you'll never be denied care if you pay for it yourself.

If you can pay. You're still required to have insurance anyways. Which is a regressive tax and harms the people most in need of these services. It's a cruel joke.

Those living paycheck to paycheck are screaming at you right now.

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

#119

Post by renewiltord »

elwebmaster wrote: post #60
renewiltord wrote: post #55

People get annoyed at insurers who will deny treatment but most of the time you can just pay it yourself. The government has decided that everyone should pay for health insurance but you'll never be denied care if you pay for it yourself. So if you think you do require some care, just ask the medical practice whether they accept self-pay and then you can decide if it's worth paying or not. If you think it's not, it's…

How about this one: - patient: wants to maximize care, money no object since it isn't theirs - medical practice: wants minimize care since money is based on number of patients not care - insurer (government): wants to minimize money spent on care while maximizing care because money comes from healthy citizens who pay taxes

There are two differently behaving conforming things in reality of these I think. Both Medicare and the UK/CA NHS in my knowledge conform to your description.

In Medicare, this incentivizes maximizing patients on 'recurring revenue procedures' like dialysis.

In the UK NHS (which I know better), it leads to the government denying certain kinds of care depending on the Adjusted QALYs / pound spent that the intervention will provide.

TANSTAAFL after all, but yes, perhaps the interesting thing about the government being in that model is that patients can control government in a way that they cannot control insurance companies (i.e. they're not strictly oppositional) and consequently when the insurer is the government you get spend-bias in the direction of who has government power. In the US, that turns out to be old people. Additionally, governments have non-health-related sources of revenue so a government health plan can be used as a redistribution mechanism.

But I think it leads to these outcomes predictably with a splitter placed on how much control the government exerts over the practice and how much control the patients exert on the government.

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

#120

Post by unyttigfjelltol »

arealaccount wrote: post #15
kotaKat wrote: post #8

Ah 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 it’s only human nature to complain about the people who aren’t in the room. Insurers are not only absent, they are economically adverse to the two parties making decisions in the room.
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