231–240 of 354 posts
The obvious solution: doctors need to start upcoding their cases by default.
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Are you calling it the magical land because it doesn't exist? I doubt your doctors office can commit a cash price for the lab they sent you blood too. And try doing that at a hospital and see where it gets you
The lab does the blood draw. You pick the lab and negotiate with them.
You go to your doctor, you have a suspected tick bite with a bullseye pattern around it and a red streak running away. Your doctor is concerned about tick born illnesses and the red streak suspecting the start of sepsis. They need to determine asap if they can treat you with docycline or if you need IV antibiotics. They need to assess your blood for a CBC to determine immediate risk factors like sepsis. They also need to asses for pathogens like Lyme disease, alpha-gal syndrome or that other tick disease I can't remember. This will determine what antibiotics will be effective, and if eating red meat will make you anaphylaxic, and you need to see an allergist if you ever want to eat red meat again
There's a place in town that can do the CBC, the test for alpha-gal is only done by two labs in the country, nearest one is in south Carolina two states away. There's more, but not many more that test for the other two diseases, the closest one is almost the whole country away in salt lake city.
You have to know ASAP to determine your next course of action.
In your proposal, do you call south Carolina and then fly there? Do you do the same to salt lake city? You've still got to find and negotiate with someone local for a CBC. Salt lake city doesn't have the same balance billing law your home state does, you could pay more than your cash price there if they involve another provider.
What do you do? Gotta act fast, or you could wind up with life long neurologically symptoms or even die.
There need to be more companies solving this from first principles like Yuzu Health. They have a cool blog at https://yuzu.health/blog that gets into the dynamics of this stuff. Legacy insurance is cooked.
Good startup idea would be to work with medical practices to use AI to automate the disputing of the "downcoding" by insurers.
I recently created an application called EMpowerAI that uses AI to analyze clinical notes and assign appropriate billing codes based on medical complexity or documented time. It also can enhance the Assessment/Plan to justify higher billing codes if the note content supports it.
I presented it at the HRX conference in Atlanta on 9/4/2025 in the top 5 abstracts session. Here is the abstract: https://www.heartrhythmopen.com/article/S2666-5018(25)00291-...
As a Cardiac Electrophysiologist, I optimized the application for cardiology and EP, though it is scalable to other specialties. I am looking for beta testers and would appreciate any feedback. Here is a link to the app:
http://em-billing-assistant.onrender.com/
Leave your name and email here if you would like to receive updates:
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I never understood why insurers get all the flack while the providers get a pass.
Because the common interaction people have with their insurers is "We are denying this because of " which they have to fight to get healthcare. When a provider rips off an insurer it's invisible to the general public. Also, incidentally, when people talk about fraud in Medicare/Medicaid, the providers are almost always where that happens (yet that's often not pointed out).
Of the multiple times my insurance has declined to cover one thing or another, not once have I ever gotten a reason. The claim is just billed to the patient, directly. I'm then left wondering things like "Hey, your plan documentation says 'preventative care is 100% covered'. This was preventative care. Why is it being declined?"
If I want to know, it's an hour of my time, at least, going back & forth with insurance to learn "Oh, '100% covered' … except in these cases."
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…
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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…
I had a test recommended once that was not covered, but my Dr explained this in advance and the cash price to me was $110. There are no 'surprise' denials after the fact.
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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…
>I go in person, get antibiotics and get cured. Or it was viral after all and you cleared it on your own. Doctors who specialize in this have a hard time accurately distinguishing bacterial infections from viral. There’s no reason to trust your own opinion on the matter. It’s too easy to fool yourself. If doctors prescribed antibiotics to every person who came in insisting they have a bacterial infection, we’d all be…
It was a bacterial infection. That was the correct diagnosis. Flu (viral) doesn’t get progressively worse after 10 days and then get better immediately after a couple doses of antibiotics. My symptoms were in line with a sinus infection (I’ve had them before just like I’ve had flu before) and even if they are not able to diagnose correctly after 10 days, there are other tests that can be prescribed that weren’t and there was absolutely no reason to schedule an online appointment when they clearly knew that they’d need an in person check anyway.
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Like I said, you don’t have to do anything. It’s would be like your W2 as long as you use your account.
What do you mean by 'use the account'? Spend the money? That's the problem. If you don't have enough expenses you just lose the money. That's why I've never used one of these.
There's plenty of upcoding going on with doctors as well though. I go to a particular doctor and I'll see a bunch of random things on the bill that don't seem to have anything to do with my visit. Like a thousand dollars worth. But then insurance rejects them, but I still don't have to pay a cent -- the doctor never actually charges me . It seems quite clear they're just trying to throw things at the wall and see wha…
Except the part where you are cared for by a competent clinician?