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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'

#181

Post by throwaway2037 »

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…

    > One (social) system that may work well is the South Korean one: private provision of healthcare services; government run insurance scheme with mandatory payments by those that can afford to pay
Do you know if SK govt owns hospitals? Or are they all private? In Japan, it has a similar system, but lots of the larger facilities are owned by govt, or associated with a public university.

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

#182

Post by khuey »

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.

Good luck a) actually getting a price named and b) having that price be honored.

Outside of certain procedures which are used to cash payers (dentists, lasik, plastic surgeons, imaging) this is nearly impossible in my experience.

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

#183

Post by Braxton1980 »

danaris wrote: post #59
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…

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 for as little effort as possible.

That's the goal of almost every business and person

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

#184

Post by Braxton1980 »

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…

>"And for God's sake, get the government out of it!!"

But then you suggest using the South Korean system where the government runs the insurance.

And you say; "so I think it might make sense to make it govt run."

So which is it?

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

#185

Post by 827a »

testing22321 wrote: post #169
827a wrote: post #148

Earlier quoted context omitted.

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…

What I want is simple: For change to actually happen. You don't need to convince me; your choice is either to convince 100M+ unreasonable people, or make a reasonable path. Direct to consumer billing is that reasonable path; that's why we're seeing it take hold in the dental, vision, and pharmaceutical industries. Core medical is next. Specialty medical will follow. Emergent medicine might never change, but that is absolutely an area where insurance does make logical sense.

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

#186

Post by Interesco »

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…

Does your dental insurance not reimburse you? My dentist is also direct pay but submits for reimbursement on my behalf. They get paid up front and I get a check a few weeks later.

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

#187

Post by tonymet »

I'm on the side of the insurance companies. they are likely the only "responsible adults" keeping providers in check. Providers are extremely wasteful and "creative" with their billing. Staff are generally idle, and staff-to-patient ratios are 10-20:1 if not more. There is little urgency around the clinic, staff take off at 4pm and are impossible to catch on a Friday. Every procedure bills a redundant and pointless "consult"-- a $1500 meeting that could have been an email.

Providers benefit from possibly the best PR of any industry. Insurance companies are the "Ticketmaster" of the healthcare industry. Their entire objective is to be the punching bag for wasteful healthcare providers.

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

#188

Post by empressplay »

hintklb wrote: post #171
potatoicecoffee wrote: post #162

Earlier quoted context omitted.

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.

Hmm sure, but there must similarly be things that are denied right? I lived in both systems. In a single payer system, the state essentially decide what is allowed and what is not. And with the state as a single payer, they also go back and forth on price with the hospitals. It still is a better system overall but there is no places where you can just spend as much as you want on healthcare without some type of centr…

Yes, in Australia what and how much of it a doctor can prescribe is tightly regulated. Many medications require a specialist referral and approval. Any medical procedure requires a specialist to sign off on it.

That and there is often a 'gap' that needs to be covered for GP and specialist services, although that tends to be balanced out by much cheaper prescription costs. (Prescriptions in Canada for example easily cost 2X as much).

However, Australia has a two-tier system where you can buy private insurance cover that can cover the costs of gaps and allow you access to private hospitals. This insurance is much cheaper than the equivalent US versions.

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

#189

Post by empressplay »

aduffy wrote: post #90
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…

I've had numerous encounters where doctors (and dentists) attempt to charge me for services they've already been reimbursed for from the insurance company. It's only after hours of scouring my EOBs and being on the phone with my insurance that I then come back to the practice's office with evidence in hand, and they dismiss the charges. I'm pretty sure this is just a racket because they expect most people not to put…

Where do you live, so people know not to move there? Jesus.

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

#190

Post by cogman10 »

khuey wrote: post #180
cblum wrote: post #152

Earlier quoted context omitted.

> FSAs are insane, conceptually. Indeed. I don’t understand why they cant just make medical expenses tax-deductible up to a certain amount. The effect would be the same. Why do I need a separate account for it, and why do I have to guess how much I’ll need every year (as you pointed out)? I guess at least part of the answer is that the companies administering FSAs make money out of this system. Sigh.

> I don’t understand why they cant just make medical expenses tax-deductible We have that, although the deduction only starts after a certain amount which makes it useless to almost everyone.

The issue is that it only kicks in when you itemize your deductions and it has something like a $10k cap. The standard deduction is 15k for a single and 30k married.

Unless you have a bunch of other things to deduct, it's often the right choice to just use the standard deduction.

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