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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'

#271

Post by sarchertech »

darth_avocado wrote: post #238
sarchertech wrote: post #193

Earlier quoted context omitted.

>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…

> Go to PCP with cold symptoms that haven’t cleared in 10 days 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 viruses that can last 2 weeks and mimic bacterial infections.

Most cases of bacterial infection will also clear on their own after 2 weeks.

There are no good noninvasive diagnostic tests to distinguish bacterial sinusitis from viral because is the presence of normal nasal flora.

The standard of care is to consider antibiotic treatment after 2 weeks of symptoms for adults and 3 weeks for children.

There’s a reason for these standards:

As of a few years ago physicians were prescribing antibiotics for 80% of cases of sinusitis. Despite the fact that only about 1%-2% of cases actually needed it.

20% of antibiotic prescriptions in the US are for sinus infections.

This is a massive contributor to antibiotic overprescription, which is why the current criteria is 2 weeks of symptoms.

I don’t know what happened in your online visit, but scheduling an online visit and then if your symptoms persisted past 2 weeks prescribing antibiotics during the the online visit would have been entirely appropriate.

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

#272

Post by lotsofpulp »

wat10000 wrote: post #107
hypeatei wrote: post #74

Earlier quoted context omitted.

> An insurance company's only goal nowadays is to make as much money as possible How can that be true when their profits are capped on collected premiums? Look up the Medical Loss Ratio (MLR) rule to see what I'm referring to. If you wanted to squeeze money out of people, health insurance would be the least appealing industry to do that in since you're required to spend 80-85% of premiums on medical care.

A 25% margin is pretty good, and companies aren't hitting the limit currently.

The 7 publicly listed health insurers have ~2% profit margins, with the exception of UNH at 6%, but that is due to its healthcare provider business earning higher margins.

The other insurers are almost all non profit (various BCBS affiliated insurers, Kaiser, Providence, etc).

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

#273

Post by danpalmer »

harvey9 wrote: post #254
danpalmer wrote: post #245

Earlier quoted context omitted.

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.

Perhaps that was all that was intended by it, if that's the case I guess I don't have a problem with it, the US does have competent clinicians.

But my interpretation was a rebuttal to the cost, linking it and suggesting that paying so much gets you better healthcare, something I have heard from defenders of the US healthcare system in the past. As far as I understand it this link is not causal.

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

#274

Post by bena »

nradov wrote: post #229
bena wrote: post #98

Earlier quoted context omitted.

It's truly fucked up. Most insurances won't publish their fee schedules. So doctors don't know what they will pay. So what they do is bill insanely high knowing the insurance will come back with "Nah, we only cover $X". They'll collect $X, then write off the remainder. Because the fear is not getting the maximum money possible. If the doctor would bill $100 and the insurance pays up to $200, then the doctor "lost" $1…

Health plans are legally required to publish their rates and they all comply with this now. You can literally just go to any payer web site and download the MRF. There are occasional data errors but overall the numbers are generally accurate. https://www.cms.gov/priorities/healthplan-price-transparency... https://github.com/CMSgov/price-transparency-guide

As of 2022, that explains it. It’s been a bit since I’ve worked in the field.

It’s good that it’s changed

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

#275

Post by M95D »

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…

1) Report fraud to insurer? 2) Get a lawyer?

Would any of that work?

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

#276

Post by iamnothere »

JumpCrisscross wrote: post #165
iamnothere wrote: post #160

Earlier quoted context omitted.

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.

Actually as a nonprofit you are required to pay at or below a reasonable wage/salary or you may face sanctions: https://www.nolo.com/legal-encyclopedia/how-determine-reason...

Similarly as an S Corp (maybe other corp types too) then officers must take at or above a reasonable wage/salary to limit the tax advantage: https://www.irs.gov/pub/irs-news/fs-08-25.pdf

This is intended to prevent people from, for instance, setting up a “nonprofit” where they just funnel all gains into their pocket while gaining all the other tax benefits of being a nonprofit. You can’t overpay people, you can’t engage in transactions where you intentionally overpay a supplier for materials/services and then they compensate you for the extra amount, etc.

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

#277

Post by throwaway173738 »

empressplay wrote: post #189
aduffy wrote: post #90

Earlier quoted context omitted.

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.

I’m pretty sure this is the US.

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

#278

Post by throwaway173738 »

doctorpangloss wrote: post #261
oakmad wrote: post #243

I’ve lived under several different healthcare systems around the world as an adult. Coming from my time America, nothing felt more like freedom to me than walking out of a hospital in London, with a new child, and having had no interaction with a billing desk.

On the other hand, aren’t comments like yours about the aesthetic experience of billing exactly the problem? It’s not like you didn’t pay for healthcare in Europe, you just had good vibes about the particular way that you paid. Employer sponsored health insurance plans are popular and also give good vibes.

Who have you talked to that enjoyed dealing with their insurance provider? Every single provider I’ve had had nightmarishly complicated customer support who couldn’t be trusted to give you accurate information.

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

#279

Post by crazygringo »

doctorpangloss wrote: post #261
oakmad wrote: post #243

I’ve lived under several different healthcare systems around the world as an adult. Coming from my time America, nothing felt more like freedom to me than walking out of a hospital in London, with a new child, and having had no interaction with a billing desk.

On the other hand, aren’t comments like yours about the aesthetic experience of billing exactly the problem? It’s not like you didn’t pay for healthcare in Europe, you just had good vibes about the particular way that you paid. Employer sponsored health insurance plans are popular and also give good vibes.

> Employer sponsored health insurance plans are popular and also give good vibes.

This sounds so crazy to me that I feel like something got miscommunicated.

Who has good vibes about their health insurance? In America?

It's not the "aesthetic experience". It's about paying fairly and progressively in a predictable way via taxation, vs. completely unpredictable billing in the US. Is it in network? Is it pre-authorized? Did your doctor code it correctly? Is it below your deductible? Is there a copayment? What mystery charges will there be? What will insurance refuse to cover, wrongly? How many rounds of appeals will you have to go, over how many months? Not so good vibes.

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

#280

Post by iamnothere »

philipallstar wrote: post #263
iamnothere wrote: post #57

Earlier quoted context omitted.

A reasonable wage or salary isn’t usually considered “profit” in a legal sense. This is why nonprofits can still pay employees. Any money that is left over after costs (including wages/salaries) needs to be reinvested, spent on the organizational mission, or held for future use, not distributed through dividends or other distributions as in a for-profit enterprise.

I'm not saying profit in that sense. I'm just saying that it's monetary profit all the way down when it comes to paid work. People work for profit. People invest for profit. People bet for profit.

The person you were replying to seemed to be discussing profit in the sense of tax law, not whether or not people should be paid at all. I don’t think anyone here is saying that doctors should not be paid.
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