Good startup idea would be to work with medical practices to use AI to automate the disputing of the "downcoding" by insurers.
The result will be that doctor AIs will be fighting insurer AIs and the loser will be the patient. As always.
The fight between doctors and insurance companies over 'downcoding'
31–40 of 354 posts
Re: The fight between doctors and insurance companies over 'downcoding'
#32If someone invoices me, and I don’t pay the full amount in a timely manner, what do you think will happen? Late fees, reports to credit bureaus, collections agencies hounding me, maybe even lawsuits? If insurance companies underpay, doctors should treat that no differently. Don’t appeal through the insurance company itself. Imagine I go to a store and pay less than the full amount at the register, and then the grocer…
Sure but imagine you hire a landscaper and they send you a $40 invoice for $20 of law cutting and $20 of leaf cleanup. You go look outside and see a ton of leafs so you just send them $20. That's the insurance companies' stance. The work you performed is this and so our agreed upon rate is this.
but the landscaper has a photo of the clean yard after they finished. They send it to you but you ( as the insurance company) say they need to call a specific time and speak to your 12y/o who is the yard representative of the house.
The 12 y/o say ‘no you stink’ and hangs up. Then you send the landscaper a letter saying ‘sorry your peer to peer was denied’
( I know this is exaggerating a bit and made to sound funny but it mostly works like that in healthcare )
Re: The fight between doctors and insurance companies over 'downcoding'
#33For what it's worth, this sort of gaming works both ways. Many medical administrations do everything they can to upcode in order to bill for more money. The whole system is a mess.
It's beyond our control, says only country where this happens daily.
IT is beyond our control because we have setup a system where the people who are paying don't want to control things.
My boss wants insurance to be expensive - if I could afford it I would be more willing to quit (retire early).
Finding cheaper services isn't in my interest - I'm not paying any bills anyway.
Insurance companies like the complexity because it means I can't understand the system and so I have to use them.
Doctors don't really care as they just have administrators play the game for them. Once in a while they look at the game and say something, but really this is just they don't understand how the game is played (they shouldn't - they are doctors, they should be looking at medical issues not administrative ones).
Re: The fight between doctors and insurance companies over 'downcoding'
#34If someone invoices me, and I don’t pay the full amount in a timely manner, what do you think will happen? Late fees, reports to credit bureaus, collections agencies hounding me, maybe even lawsuits? If insurance companies underpay, doctors should treat that no differently. Don’t appeal through the insurance company itself. Imagine I go to a store and pay less than the full amount at the register, and then the grocer…
Insurance companies hold tremendous leverage over care providers, up to and including the power to effectively put them out of business on a whim. Care providers don't like picking fights with insurance companies.
Re: The fight between doctors and insurance companies over 'downcoding'
#35Earlier quoted context omitted.
So what should happen when Docs lie about what procedures they did? Because it happens quite frequently and for some reason is always left out of these discussions.
Man, it's almost like healthcare and human lives shouldn't be for profit...
"It is not from the benevolence of the butcher, the brewer, or the baker, that we expect our dinner, but from their regard to their own interest."
Re: The fight between doctors and insurance companies over 'downcoding'
#36Ah yes, this is a fight between the practices (sometimes not the doctors!) upcoding their visits and the insurance companies wanting to push back and downcode the visits to what they actually entailed. Healthcare practices want to maximize revenue and push up the “level” of a doctors visit and they can do it with just adding one or two extra little questionnaires or an extra test or two that you might not pay attenti…
I never understood why insurers get all the flack while the providers get a pass.
Every party at every point in the system is various shades of complicit in fleecing us. That's the magic of the system. It's all divided up in so many ways and so many of the feedback loops touch through the people getting screwed that it's impossible to build a "these guys might not be wholly responsible, but they're responsible enough things will get better if we push them off a cliff or legislate them into poverty or whatever" consensus you need to build to change things
17% of the US GDP is healthcare, now obviously there's a lot of nurses and random courier drivers and all sorts of other stuff in there, but they would all need to take some amount of haircut for us to get fleeced less.
The GDP contribution of slavery was ~13% just preceding the civil war and credible moves (i.e. electing Lincoln) to make them take a haircut caused, you know, the civil war.
There is likely no "clean" way to fix this problem other than a century long frog boiling exercise
Re: The fight between doctors and insurance companies over 'downcoding'
#37Ah yes, this is a fight between the practices (sometimes not the doctors!) upcoding their visits and the insurance companies wanting to push back and downcode the visits to what they actually entailed. Healthcare practices want to maximize revenue and push up the “level” of a doctors visit and they can do it with just adding one or two extra little questionnaires or an extra test or two that you might not pay attenti…
There is immense pressure on insurance companies to lower costs, as they get blamed for the "American health care system". The only one on the side of the payer is the insurance company, they're the only one who wants to keep costs down for the consumer. Given the massive amounts of fraud in government health insurance (medicare) it would of course be prevalent in the private insurance market. https://www.azcentral.c…
“ they're the only one who wants to keep costs down for the consumer.”
They don’t. They want to increase profits by pushing more and more cost to the patient while squeezing providers. The patient is always the loser in this system. One reason is that most patients don’t even have a choice of insurance because their employer picks the insurance that’s best for the employer.
Re: The fight between doctors and insurance companies over 'downcoding'
#38Ah yes, this is a fight between the practices (sometimes not the doctors!) upcoding their visits and the insurance companies wanting to push back and downcode the visits to what they actually entailed. Healthcare practices want to maximize revenue and push up the “level” of a doctors visit and they can do it with just adding one or two extra little questionnaires or an extra test or two that you might not pay attenti…
There is immense pressure on insurance companies to lower costs, as they get blamed for the "American health care system". The only one on the side of the payer is the insurance company, they're the only one who wants to keep costs down for the consumer. Given the massive amounts of fraud in government health insurance (medicare) it would of course be prevalent in the private insurance market. https://www.azcentral.c…
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Re: The fight between doctors and insurance companies over 'downcoding'
#39If someone invoices me, and I don’t pay the full amount in a timely manner, what do you think will happen? Late fees, reports to credit bureaus, collections agencies hounding me, maybe even lawsuits? If insurance companies underpay, doctors should treat that no differently. Don’t appeal through the insurance company itself. Imagine I go to a store and pay less than the full amount at the register, and then the grocer…
Insurers (payers in the industry lingo) simply don’t pay or underpay. Proving this sucks bc smaller practices have horrible staff turnover, the EMRs are dog shit and the contracts are who knows where and in what format. Recovery is beyond the scope of most small practices. Its a nightmare where providers are often shorted millions of dollars and that ends up coming out of the patient’s pocket. Everyone yammering abou…
> Recovery is beyond the scope of most small practices.
Seems like a business opportunity. Could probably work very similar to other collections agencies where they either buy the debt for pennies on the dollar or take a percentage of the collected amount.
Re: The fight between doctors and insurance companies over 'downcoding'
#40Earlier quoted context omitted.
It's beyond our control, says only country where this happens daily.
IT is beyond our control because we have setup a system where the people who are paying don't want to control things. My boss wants insurance to be expensive - if I could afford it I would be more willing to quit (retire early). Finding cheaper services isn't in my interest - I'm not paying any bills anyway. Insurance companies like the complexity because it means I can't understand the system and so I have to use th…
There's an old mechanics saying "if X was covered by insurance it'd cost what Y does" where X is some routine thing (tires/brakes/etc) and Y is autobody or glass services typically covered by insurance.
This proverb seems to also apply to health insurance and the things they do/don't cover.
Putting routine stuff under the purview of insurance is stupid regardless of context. There are other cheaper, faster, simpler and more transparent ways of doing that.