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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'

#311

Post by harvey9 »

arethuza wrote: post #295
harvey9 wrote: post #253

Earlier quoted context omitted.

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.

In my experience, its not so much what the NHS won't fund but getting access to what it does fund in a timely fashion. Of course there is dentistry, which is a complete nightmare... people trying to do their own extractions with a pair of pliers is the sort of thing you used to associated with the US but I've actually met some people who have tried that due to how poor NHS dental services are and how expensive privat…

Long queues are what most people will notice but some things are not approved by NICE or are limited to control cost, for example IVF.

You're right about dentistry.

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

#312

Post by FireBeyond »

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…

> It is beyond me why my employer is paying an insurance company anything at this point. 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.

Well, then you are beholden to Kaiser. Kaiser will not pay for any treatment or medication for weight loss other than gastric bypass surgery. Kaiser will not pay for many medications for mental health, especially for adolescents. Will not pay for medications that could be used for ED, even if not being prescribed for that.

And the most annoying, recently: My partner got a couple of root canals, and was in significant pain and discomfort as you'd expect. Dentist sent her prescriptions for antibiotics and pain management to Kaiser, and we go after her surgery to pick them up at the Kaiser UC/ER hybrid.

No pain meds for you. "We will only fill that through mail order - you'll get it in 5-7 business days". Very helpful for that post-surgical pain now. The irony being that they absolutely had those drugs in stock and available, they were just only for their UC/ER inpatients.

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

#313

Post by FireBeyond »

ChadNauseam wrote: post #159
atomicnumber3 wrote: post #73

Earlier quoted context omitted.

>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 unlikely someone else will if they have to pay on your behalf. Ok, hear me out for a minute. What if I wanted to pool with several people, so that if any of us had unexpected medical needs, it wouldn't bankrupt any of us. Knowing that mo…

> 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…

It's almost as if, then, providers know they can push their rates up, and reimbursement rates go up, since all that means is that premiums go up. And by a stunning coincidence, how much that 20% is goes up.

And then they buy/create PBMs which aren't covered by those limitations, and then force their customers into using them. "Oh, you want a convenient 90 day refill? Sure. If you go through our wholly-owned mail order pharmacy. From your pharmacy? No. You can keep going there every 30 days for your meds."

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

#314

Post by tonymet »

sarchertech wrote: post #192
tonymet wrote: post #187

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 "…

Most doctors don’t do their own billing. It’s too complex. They have specialists who take their notes and turn them into bills.

while you're right most of the billing pressure is likely coming from administrators and boards, doctors do participate with petty / pointless consults , excessive testing & procedures, absurd hour restrictions, and indirectly through medical boards reducing capacity, among other factors

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

#315

Post by recursive »

darth_avocado wrote: post #242
recursive wrote: post #197

Earlier quoted context omitted.

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.

Please read the entire thread for the full context which you are missing.

If by "the entire thread", you mean all the ancestors of this comment, I already have.

I'm not sure which of these is supposed to be the context I'm missing. It may be the "It is a relatively easy fix tbh..." comment. I couldn't understand the wording of accounting procedure there.

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

#316

Post by nobody9999 »

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.

>Here are the magic words in US Health Care: "What is the cash price?"

I'm not so sure about that. Especially in a hospital setting.

Many years ago, I was admitted to the hospital for several days as it was suspected (wrongly, but that's another issue with the perverse incentives in US "healthcare") that I had MRSA and the doctor wanted me on IV antibiotics while testing proceeded.

I spent three days in the hospital, getting discharged when the tests came back negative for MRSA.

Shortly thereafter, I received a detailed "explanation of benefits" (EOB) from my insurer, which put the cost of my hospital stay at ~USD$12,000 which included stays in two hospital rooms simultaneously as well as a pap smear (despite the fact that I do not have a cervix). When I complained about this, the insurer tried to make it seem unimportant, but I pressed the issue as both the hospital and the insurer seemed to be involved in some sort of fraud WRT billing.

I was told I shouldn't care because I wasn't actually paying, but I persisted as I was concerned that there was something hinky going on. That culminated in a conference call with my insurance company, the hospital's accounts receivable group and me.

The two other parties talked in insurance billing jargon for a while, but when pressed, they stated that the charges on the "explanation of benefits" was a fiction and that the insurance company and hospital group's contract set a USD$1,500/day flat rate for patients admitted to the hospital's facilities -- roughly 1/3 of the "costs" cited in the EOB.

The made up stuff (which they didn't even try to hide that it was made up) was there as "protection" for the hospital group as the "cash price" of such services, even though I couldn't have received such services (two rooms at the same time? A pap smear[0] despite the fact that I don't have a female reproductive system, nor do/did I present as anything other than a cis male?).

I imagine that there may be some cases where a "cash price" actually does reflect costs and might even be less than insurance costs (although that seems unlikely given my experience), but insurers and healthcare providers do and have for decades gamed the "cash price" to justify the insane overcharging of healthcare services. YMMV.

[0] https://www.mayoclinic.org/tests-procedures/pap-smear/about/...

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

#317

Post by darth_avocado »

sarchertech wrote: post #271
darth_avocado wrote: post #238

Earlier quoted context omitted.

> 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…

Standard of care for persistent symptoms compatible with acute bacterial rhinosinusitis for more than 10 days IS prescribing antibiotics.

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

#318

Post by wat10000 »

lotsofpulp wrote: post #303
wat10000 wrote: post #301

Earlier quoted context omitted.

Not sure what the relevance of that is. If anything, small profit margins just further incentivize trying to pay out less.

You wrote they had 25% margins. And obviously a business with 2% profit margins is incentivized to spend less, if they didn’t, they would be out of business!

Gross versus net margin. The other commenter was saying they don't have incentives to cut costs because of the MLR limit, but that limit is a 25% margin over the cost of their "product." For a product that boils down to just moving money around, 25% is pretty good.

This is illustrated by the fact that they aren't actually bumping into the legal MLR limit currently. It would make sense if they don't care about cutting costs because the law doesn't allow them to spend less, but that's not where they are at the moment. If they could cut their medical spending by 1% they could increase their profit by 40%.

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

#319

Post by breadwinner »

nradov wrote: post #298
breadwinner wrote: post #92

Earlier quoted context omitted.

The problem is that patients are usually not in a position to determine if the care the doctor says is needed is really needed or not. This is the same as taking your out-of-warranty car to the mechanic. How do you know if the mechanic is telling the truth? Still, this would be better than the current system. Even when you don't know if the doctor is telling the truth you can go by their reputation for telling the tr…

Reputation is pretty much worthless. Patient reviews are largely based on how nice the doctor seems (bedside manner) and have no correlation with actual clinical outcomes.

That's with today's system not the proposed system.

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

#320

Post by hintklb »

arethuza wrote: post #295
harvey9 wrote: post #253

Earlier quoted context omitted.

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.

In my experience, its not so much what the NHS won't fund but getting access to what it does fund in a timely fashion. Of course there is dentistry, which is a complete nightmare... people trying to do their own extractions with a pair of pliers is the sort of thing you used to associated with the US but I've actually met some people who have tried that due to how poor NHS dental services are and how expensive privat…

Weirdly enough the US is actually amazing for dentistry.

With any insurance you get 2 cleanings every year fully included and most routine fillings are almost completely covered. Easy to find appointments everywhere

My experience in Europe has been that it is super difficult to schedule anything. Waiting time of multiple months for new patients.

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