Translation: Insurance companies intentionally injecting bugs into their own software to make requests that don't respect user input.
Despicable.
The fight between doctors and insurance companies over 'downcoding'
341–350 of 354 posts
Re: The fight between doctors and insurance companies over 'downcoding'
#342There'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…
There's plenty of hasty generalizations going on in this comment.
If you see this sort of thing happening in the U.S., the place to complain is your state's insurance board.
Medicine is hard enough without people TRYING to do harm.
And actuarial science is brutal enough WITHOUT glossy justifications for assuming that healthcare providers are bad actors.
Re: The fight between doctors and insurance companies over 'downcoding'
#343What would the Austrians say?
Re: The fight between doctors and insurance companies over 'downcoding'
#344Earlier quoted context omitted.
Just asked my wife (ER doctor). She says it's 2 weeks for adults, 3 weeks for kids.
I also confirmed with a MD friend of mine, 10 days or more of worsening symptoms could be indicative of bacterial sinusitis. For adults you can begin the treatment on that diagnosis. You can also start antibiotic treatments before 10 days in certain conditions but it is generally not recommended. Just because a patient shows up on 11th day with worsening symptoms doesn’t mean you have to wait 2 weeks.
Sure. It’s a guideline not a hard rule. Doctors have wide latitude. A doctor could give you antibiotics whenever they want.
The doctor didn’t do anything wrong by asking you to wait a few days.
In addition to residency, my wife is fellowship trained, she’s who PCPs end up sending patients to. She’s basically level 2 tech support (an ENT would be level 3 for this particular problem). She sees the results of this stuff all the time.
And the majority of PCPs vastly overprescribe antibiotics for sinus infections. The vast majority of patients who come in saying they have a sinus infection and asking for antibiotics are wrong.
Doctors are tasked with antibiotic stewardship, but people complain on review sites when they don’t get what they want, so many of them just do it.
Re: The fight between doctors and insurance companies over 'downcoding'
#345[dead]
Re: The fight between doctors and insurance companies over 'downcoding'
#346All of this happens because so many drink the free market koolaid. Insurance, in general, is glorified paper pushing and legalized gambling.
Yes lobbyists exist but I don’t understand why so many regular people support this broken middle-man system.
Re: The fight between doctors and insurance companies over 'downcoding'
#347Earlier quoted context omitted.
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
>indirectly through medical boards reducing capacity My wife has served on government medical advisory boards, and handles resident education. I've heard plenty of virtual meetings in the background. I've never once heard anyone discussing adding requirements for any unnecessary reason whatsoever. Not even a hint anything that would reduce capacity. If anything it's "how can we add capacity without reducing quality?"…
I'm sure there is a noble excuse for every one of these problems. But the providers have the most leverage in reducing costs, so they must also accept the blame.
My complaint is two parts really. Providers are wasteful, and policy makers are not able to pressure them to optimize, because of the incredible PR.
In other words, there's no hope to reverse healthcare insolvency because cost growth will continue to explode with this combination.
Re: The fight between doctors and insurance companies over 'downcoding'
#348Earlier quoted context omitted.
I'm sorry, but this is bullshit. The American system is nothing like the Soviet one. I've seen both first hand. Both are kinda crappy but in very different ways. If I had to choose one though it'd be Soviet for sure because it's still guaranteed healthcare no matter what your financial situation is.
So you deny that both the US healthcare system and USSR economy are / were bogged down in red tape and regulation, which is clearly my main point? Or you're just mad that I'm using Communism as a punchline when criticising neoliberalism?
Yes. The Soviet system did not require me to jump multiple hoops to get healthcare. Either it was covered or it wasn't, and if it was then there was surprisingly little bureaucracy for the end user.
I'm not a fan of Soviet communism in general, and that's putting it mildly. I'm not a huge fan of its healthcare system either because while it was truly universal, it deprioritized patient comfort - so e.g. many things would be done without anesthesia or with only the very basic stuff that wasn't particularly effective. Dental, in particular, was a nightmare.
Nevertheless, your points are so wildly off that they deserve pushback.
Re: The fight between doctors and insurance companies over 'downcoding'
#349This doesn't surprise me: The "fee for service" system encourages doctors to perform as many services as they can so they can bill for more. I've certainly had my fair share of tests and procedures where I wonder if the provider was just trying to find something to bill for. I'm also not surprised that some providers will try to figure out which codes they can use to get the most revenue. ("Hey, if I do procedure A i…
The counter to this is that now when you go to urgent care, they're only allowed to do one thing and send you to the ER for any other concurrent problems where you pay 10x more because it's an "emergency"
Re: The fight between doctors and insurance companies over 'downcoding'
#350Earlier quoted context omitted.
The legal minimum MLR is 80%. So if you spend X, the maximum revenue you're legally allowed to have is X * 1.25.
Sorry, I am not following. Medical loss ratio = medical expenses divided by revenue. Margin = money left over after various expenses divided by revenue So if revenue is $100, and medical expenses are $80, then the remaining funds are $20, or 20% margin.
You’re right, I had the idea that you divide by cost, not revenue. So a 20% legal maximum margin. Which is still a fair bit above what they actually achieve, so there’s plenty of motivation to reduce their medical spending.