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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'

#121

Post by darth_avocado »

themafia wrote: post #115
darth_avocado wrote: post #96

Earlier quoted context omitted.

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 p…

Like I said, you don’t have to do anything. It’s would be like your W2 as long as you use your account.

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

#122

Post by alphazard »

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…

The biggest problem with the American system is that it's just illegal for me to sell you good, simple insurance.

Let's say I draft an insurance contract that says for any treatment if >5 of 10 randomly selected doctors agree that the procedure was warranted, then I have to pay out the cost of the procedure, no questions asked. This contract is less hassle, clear, and doesn't require arguing with an insurance company since it specifies how disputes are resolved.

But I'm not going to give it to you for free. I need to know the expected payout in order to come up with a price and sell it to you. You know, like how all other insurance works. There is a price that is positive EV for me, but better aligns with your risk tolerance, and is therefore positive utility for you as well. In America, pricing it is illegal. I cannot, by my own methods, determine a fair price and sell it to you.

That's why we can't have nice things, because it's illegal for two people to agree on a price and terms and create a good deal for themselves.

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

#123

Post by anigbrowl »

Apreche wrote: post #3

If 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…

I'm 90% certain that submitting claims to an insurer subjects doctors to resolving any disputes via an appeal followed by an arbitration process, and that the right to sue or handle the debt in the regular way is severely attenuated.

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

#124

Post by xhrpost »

supportengineer wrote: post #77
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.

HSA requires a high deductible health plan, not everyone could afford that deductible. "To contribute to an HSA, you'll need to be enrolled in an HSA-eligible health plan, also called a high-deductible health plan (HDHP)."

Yup, I agree HSA is superior but depending on your situation (and plans offered), the HDHP can be much more expensive out of pocket[1], even if you're paying with after tax dollars. Sweet spot I think is using a good low deductible plan when it makes sense but having a spouse with an HSA which both spouses can use for expenses.

[1]: or so it seems, I tried to figure this out earlier in the year and the data is just lacking in order to make a perfect decision.

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

#125

Post by mschuster91 »

mbb70 wrote: post #110
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.

A lack of lawsuits can just be an off the record agreement that no one benefits from the entire mess being dragged in front of the courts with public record laws, because that is how you give future Luigis ideas.

The more shady the industry, the more everyone involved is shying awaa from sunlight.

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

#126

Post by myko »

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.

In years of working in the medical industry it is rare for health systems to purposefully upcode a patient's visit (this is taken extremely seriously) while insurers attempting not to pay the bill and sticking it to the patient and health system is standard practice

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

#127

Post by anonymars »

i80and wrote: post #70
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.

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.

Cue that tuba/horn motif from "The Price is Right" (famous for "guess as close as you can without going over")

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

#128

Post by jimbokun »

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.

"What is the cash price?" magically puts you back in the land of Classical Capitalism, where the service provider wants to keep you as a customer and knows their internal costs and you as a consumer of the service can evaluate their reputation for quality and cost vs other providers.

It's adding 3rd parties like "insurance" (which only works as insurance in very limited catastrophic circumstances) and government plans that create the nightmare of the Mystery Price Only Knowable After Service Has Been Rendered.

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

#129

Post by tptacek »

spiffytech wrote: post #34
Apreche wrote: post #3

If 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…

Insurance companies hold tremendous leverage over care providers, up to and including the power to effectively put them out of business on a whim. Care providers don't like picking fights with insurance companies.

Care providers make massively, massively more money than insurance providers.

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

#130

Post by prasadjoglekar »

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.

Sorta. The reason to go thru insurance is to count the money paid against your deductible. If you pay cash outside insurance, it doesn't.

And if you have an HSA, you have a high deductible plan.

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