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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'

#251

Post by ChadNauseam »

jodrellblank wrote: post #207
ChadNauseam wrote: post #159

Earlier quoted context omitted.

> Sure wish there was a system that just did that, without trying to also generate insane profits off it. Health insurance companies in the US must pay 80% of premiums to providers. All their overhead (e.g. their accountants and actuaries and so on) comes out of the remaining 20%. What's left is their profit. People have this fantasy that all the money we spend on healthcare is secretly going to greedy insurance comp…

Their overhead (e.g. their accountants and actuaries and so on) spend a lot of time inserting paperwork and delays in between hospitals and patients, fighting hospital invoices and fighting patient claims, doing marketing, and any profit the insurance company makes is money customers "spent on healthcare" which didn't end up being spent on anyone's healthcare. > " Health insurance companies in the US must pay 80% of…

The benefits of allowing people to make money by starting businesses are a separate discussion. I only meant to say that insurance companies are already legally prohibited from making "insane profits".

But to answer your question, there are many people looking to invest their time and money into profitable enterprises. Because insurance is a good that is very beneficial for society, we want people to invest in making it a thing. Therefore, we set up a system where the people who invested in its creation get a tiny fraction of the benefit it generates. There are many areas of life where this works great, like providing food and shelter, and I guess it wasn't obvious that insurance would be an exception for some reason.

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

#252

Post by Rileyen »

One time I got a test done because my doctor recommended it, but insurance refused to cover it. I spent hours making calls, but no one could give me a clear answer.

That’s when I started to wonder if I was actually getting medical care, or just stuck in a system no one really understands.

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

#253

Post by harvey9 »

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…

In Britain the national health service is a single payer and there are some things it won't fund, but you are still free to take out health insurance or be a self pay customer and go to a private doctor or private hospital.

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

#254

Post by harvey9 »

danpalmer wrote: post #245
leoh wrote: post #240

Earlier quoted context omitted.

>Everything about American healthcare is bad. Except the part where you are cared for by a competent clinician?

Are clinicians any more competent than in other countries with similar levels of training? In Europe, UK, or here in Australia for example, the quality of public care seems to be competitive with the US, and the quality of private care here seems often even better. I've heard this "US healthcare is expensive but at least it's good" thing a few times, but never with any particular evidence, and from the few numbers I…

I read the post you replied to as simply meaning it's a non bad thing, not that it is better care than elsewhere.

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

#255

Post by philipallstar »

OkayPhysicist wrote: post #151
philipallstar wrote: post #51

Earlier quoted context omitted.

Eventually everyone works for profit if they get paid. Spending time only is pure profit in money.

Most people do not profit off their labor. 2/3rds of people are living paycheck to paycheck, which means that they are being paid approximately the same amount that their labor costs to produce. That makes their wages an exchange of equal value, and thus not profitable.

> which means that they are being paid approximately the same amount that their labor costs to produce

No, "living paycheck to paycheck" means you're spending everything you get each month. There can be all sorts of reasons for that.

> That makes their wages an exchange of equal value, and thus not profitable.

This is true for all profit. If you lend me money and profit off the interest, we've decided between us that the time value of that money is worth that interest, and so it's an exchange of equal value.

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

#256

Post by arethuza »

malfist wrote: post #232
adastra22 wrote: post #216

Earlier quoted context omitted.

The lab does the blood draw. You pick the lab and negotiate with them.

Put yourself in my shoes last year. 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 ris…

I had a tick bite that was irritated (but not a bullseye rash that I could see) - phoned GP practise, doctor phoned me back a couple of hours later and discussed the situation, ruled out blood tests because they said they were inconclusive at best and arranged for a 3 week course of antibiotics. My wife picked them sup from a pharmacy later that afternoon as she was in town anyway. No direct costs, no mention of money, insurance or anything at the doctors or the pharmacy...

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

#257

Post by immibis »

hibikir wrote: post #139
sensanaty wrote: post #112

Earlier quoted context omitted.

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…

"Healthcare that isn't for profit" doesn't mean just a national health insurance. Just that as a random citizen you are shielded from seeing all the same issues underneath. The pharma companies, test providers, equipment makers and personnel are all making profits. I bet the total amount paid is higher that 130 euros a month. There's profit all through the system, so claims that healthcare should not be for profit ar…

Profit is what's left after everyone is paid for their work. No profit doesn't mean nobody gets paid - it means nobody's trying to simultaneously maximize revenue and minimize costs just so they can pay themselves the difference.

Speaking of tax-funded healthcare, did you know that US residents pay more tax towards healthcare than residents of any other country? And in return for that, they don't get any healthcare so they have to pay a second time to buy their healthcare.

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

#258

Post by immibis »

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.

how about copying the exact thing that works in literally almost every other country in the world

What do you mean failed horrifically? Yes, some countries have long queues. That's because there are actually people getting served. That's just the latency/throughput tradeoff being tilted farther towards throughput - which is what you want, and it's not like people who come in with heart attacks don't get to skip the queue. In America, people get heart attacks and just choose to die so their family won't get bankrupted by an ambulance ride.

Are you possibly getting this information (that healthcare is a horrific failure in every other country) from propaganda sources, instead of information sources?

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

#259

Post by valleyer »

teleforce wrote: post #250

If anyone wondering why it is call 'downcoding', it's because there's WHO ICD coding standard or international classification of diseases now at version 11 or ICD-11 [1]. It's mainly used for classification of disease mortality not morbidity, not until the latest version iteration of ICD-11 in which it now caters for both [2]. Due the usefulness of the diseases classification coding based on ICD, it's also being used…

Generally here the more important codes would be the CPT codes.

I doubt the insurance company would downcode the diagnosis, just the procedure.

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

#260

Post by actionfromafar »

cogman10 wrote: post #7
coleca wrote: post #2

Good startup idea would be to work with medical practices to use AI to automate the disputing of the "downcoding" by insurers.

Man this is a hellscape. I can quickly see something like this turning in an AI arms race between insurance and the provider with each auto-approving/denying/disputing the other. All the while locking out smaller players because they can't afford the 3rd party disputotron.

In fact, you could take out an insurance which will help with the Disputotron costs, should they arise. No you can't know the costs in advance.
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