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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'

#161

Post by salawat »

ceejayoz wrote: post #133
unyttigfjelltol wrote: post #114

Earlier quoted context omitted.

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.

It’s deeply frustrating that the $12 doesn’t go towards the deductible. I just saved the insurer a bunch of money!

You did nothing from their point of view except waive having them cover the claim, thusly leaving more money on their hands to be managed longer. Your "price discovery" isn't something they aren't aware of. On the contrary, their surveillance/clinical team have been crunching the numbers and making unilateral decisions on how the population is best guided to drugs based on their bottom line benefit to the insurer.

You don't really factor into it except as an actuarial data point. But you might have kicked off an overpayment check back to the consumer in 12 months because golly gee, those pesky regulations! Don't worry though, you can hand it back because the premiums went up again!

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

#162

Post by potatoicecoffee »

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…

In Australia I just take my blood test form to any pathology place and they do it for free (for me) and bill the government a set price from the medicare benefits schedule.

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

#163

Post by senderista »

As long as providers have an incentive to overtreat and overcharge, I don't see how we can control costs without an adversarial system, as infuriating and dysfunctional as it is. I never had to deal with any of this while enrolled in a nonprofit HMO (there must be some internal adversarial dynamics there, though).

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

#164

Post by remus »

greenchair wrote: post #147

It's pretty obvious to everyone that doctors have been abusing these levels. See doc for 20 minutes for a low complexity item but get charged for a 30 minute medium complexity. The insurance companies aren't blind. They've got the stats in hand for each doctor. I mean some of the ranking data is already built into the portal tools they give consumers for finding a doc.

It's a huge system with a lot of people involved so no doubt there is abuse, but there is also natural and expected levels of variation in the complexity of patients that doctors doing notionally the same job will actually encounter. If you're doing an honest job and happened to have seen more complex patients than average I think you'd rightly be pretty angry if you were then forced to do more paperwork to justify yourself to an insurance company who starts downcoding your patients.

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

#165

Post by JumpCrisscross »

iamnothere wrote: post #160
JumpCrisscross wrote: post #104

Earlier quoted context omitted.

> reasonable wage or salary isn’t usually considered “profit” in a legal sense This is a semantic punt to the word “reasonable.”

The IRS has some guidelines that they use to decide what is “reasonable” but they don’t give out whatever actual formula or process they use to determine this. It’s supposed to be based on industry averages (more or less) but in reality it’s hard to determine what exactly that means. Generally you are “safe” paying in an industry average range, but if outside that range you need legal and accounting support to back u…

> you are “safe” paying in an industry average range, but if outside that range you need legal and accounting support to back up your own assessment

What? The IRS doesn’t regulate wages. They just care about getting their money. If I pay you $10bn a year to yell at my cat, the IRS is fine so long as I pay payroll and you income taxes.

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

#166

Post by testing22321 »

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.

…. So you pay many thousands a year for insurance, but it’s easier not to use it?

Ummm

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

#167

Post by testing22321 »

lotsofpulp wrote: post #63
hypeatei wrote: post #54

Earlier quoted context omitted.

> No one knows, do the test and insurance will decide Oh, someone knew but the doctors office wanted to do the expensive thing and get paid (either by you or the insurance) Not saying the blood test was unnecessary but we have no idea what communication happened between the doctor and insurance company. Did they possibly recommend a less expensive test and the doctor decided that'd make him less money so he went forw…

Health insurance companies have told me, on the phone, that they will not tell me the codes the doctor needs to charge for preventative visits in order to for my visit to be covered as preventative care (meaning I don’t have to pay anything). However, I could tell the insurance customer service person a code, then they could tell me if it was classified as a covered preventative service. So I, the insurance company’s…

> However, I could tell the insurance customer service person a code, then they could tell me if it was classified as a covered preventative service.

Malicious compliance engaged.

Start with code “1” and go to “99999999999999999” until they tell you it’s covered.

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

#168

Post by testing22321 »

m101 wrote: post #158

For those looking for a fix to US healthcare I think it's something like this: - (user incentive to reduce cost) insurance is structured as co-pay of [20+]% on all expenses, no exceptions - (price transparency) require healthcare providers to quote upfront for care, via API/website/phone/in-person. Price paid by anyone is the same except for expenses related to billing. E.g https://surgerycenterok.com/ - (create comp…

You don’t need to attempt something that has never been done before with no guarantee of the outcome.

This is a solved problem in two dozen countries and it’s been working for many, many decades.

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

#169

Post by testing22321 »

827a wrote: post #148
costcopizza wrote: post #137

What, if any, alternative framework other than single payer could be put into place instead of our current hellscape? Have health sharing plans been successful? Those require a religious affiliation IIRC. I exclude single payer solely because it’s impossible with our current leadership. I’m surprised there isn’t a Costco like medical group that’s nationwide, has a membership, and works solely to provide care efficien…

Where I live, we have three major hospital chains. Imagine one of them is Kaiser Permanente. My primary care is through Kaiser. When I needed to see a podiatrist to get a toenail removed, they were through Kaiser. When I went to an ER a few years ago for some abdominal pain, it was a Kaiser ER. It is beyond me why my employer is paying an insurance company anything at this point. Kaiser should be selling me an annual…

> Kaiser should be selling me an annual plan where everything at Kaiser is covered, maybe up to a point, and then they have insurance-like network relationships with e.g. other ERs in the area, if you need them, plus out-of-area addons for when I'm traveling.

If you’re trying to solve them problem, why on earth do you propose such an expensive, convoluted and strange solution?

Two dozen countTies have solved this. It works very, very well. People pay less and get better outcomes. What more do you want?

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

#170

Post by standardUser »

hibikir wrote: post #146
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.

This would all be well and good if the doctors weren't also profiteering. When you visit one, you still don't know if their recommendations are good for me or for them. I have seen allergists which are no less slimy than used car salesmen. See also studies on dentists and their varied recommendations for the same patient. The US insurance system doesn't seem to be giving us low prices, but let's not pretend it's all…

I'd argue the problem is that doctors and insurance companies are two for-profit entities fighting it out for every penny, whereas the people who ultimately pay for the services aren't part of that conversation. If making me an afterthought makes you (the doctor) more money, I become an afterthought (assuming I don't have other options, which most people don't). I can't imagine it working any other way, aside from magical altruism.

The dental industry gets no defense from me as I've been subject to attempts at swindling and coercion more times than I can remember, as if it's standard practice.

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