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A petabyte of health insurance prices per month

blog.turquoise.health

51–60 of 275 posts

Re: A petabyte of health insurance prices per month

#51

Earlier quoted context omitted.

Here's the full list of codes for "Bitten by ____, _____ encounter" https://www.icd10data.com/ICD10CM/Codes/V00-Y99/W50-W64/W61- The hierarchy looks like this: W61.6 Contact with duck = W61.61 Bitten by duck == W61.61XA …… initial encounter == W61.61XD …… subsequent encounter == W61.61XS …… sequela = W61.62 Struck by duck == W61.62XA …… initial encounter == W61.62XD …… subsequent encounter == W61.62XS …… sequela = W6…

I wonder if bitten by duck is more expensive that bitten by chicken.

> I wonder if bitten by duck is more expensive that bitten by chicken.

They're diagnosis codes, so they're mostly irrelevant for determining cost. You don't get charged for "having the flu" - you get charged for the various services or treatments you received in the course of your illness.

Diagnosis codes do factor into claims reimbursement indirectly. For example, some services can be done either as treatment or for preventive purposes, and insurance is legally required[0] to cover the latter at no cost to the patient, whereas insurers can require that the patient pay for the former. But that's pretty indirect - by and large, the payment agreements between insurers and in-network providers apply to services rendered, which doesn't really factor in diagnoses codes (assuming that the service was appropriate for the diagnosis in the first place). That's assuming fee-for-service: capitation is a whole other model, although in that case it's still typically determined independent of the diagnosis, because the whole point of capitation is to minimize care delivered.

But getting bitten by a duck vs. a chicken is unlikely to cause any difference in the price you pay, unless:

(a) the injuries from the duck bite were significantly different from the injuries from a chicken bite, or

(b) one was considered an occupational exposure and the other wasn't (in which case worker's compensation would be billed for it).

[0] well, until March of this year, when a judge in Texas overturned that clause of the ACA

Re: A petabyte of health insurance prices per month

#52

Earlier quoted context omitted.

Here's the full list of codes for "Bitten by ____, _____ encounter" https://www.icd10data.com/ICD10CM/Codes/V00-Y99/W50-W64/W61- The hierarchy looks like this: W61.6 Contact with duck = W61.61 Bitten by duck == W61.61XA …… initial encounter == W61.61XD …… subsequent encounter == W61.61XS …… sequela = W61.62 Struck by duck == W61.62XA …… initial encounter == W61.62XD …… subsequent encounter == W61.62XS …… sequela = W6…

But why? I could understand from a treatment perspective the type of animal mattering (but even then initial vs subsequent encounters?). From a billing perspective, wouldn't it make sense to have animal bite exam fee, with possible additional charges for bandaging, stitches, rabies shot, etc based on doctor's discretion?

Because, like it or not, a doctor's discretion can sometimes be self-serving. The more treatments a doctor gives, the more they get paid, and there is an enormous information imbalance between doctor and patient. (As in, they went to medical school, and you didn't.)

Unfortunately, some doctors are willing to take advantage of this.

Re: A petabyte of health insurance prices per month

#53

There are separate charge codes for everything , and all of those codes need to be reflected in the pricing data. There's a price to slap on a bandaid. There's a price to give someone a Tylenol. Hell, W61.61XA is the medical code for "Bitten by duck, initial encounter." Presumably, this means there's also a code for "Bitten by duck, again." Medical billing is broken , and it's no surprise that the amount of data is o…

Here's the full list of codes for "Bitten by ____, _____ encounter" https://www.icd10data.com/ICD10CM/Codes/V00-Y99/W50-W64/W61- The hierarchy looks like this: W61.6 Contact with duck = W61.61 Bitten by duck == W61.61XA …… initial encounter == W61.61XD …… subsequent encounter == W61.61XS …… sequela = W61.62 Struck by duck == W61.62XA …… initial encounter == W61.62XD …… subsequent encounter == W61.62XS …… sequela = W6…

"I'd like to file a complaint. This is my fourth time being bitten by a duck not my second time. You have overcharged me!"

This is possible in America today. Great job post ww2 employer coverage side effects!

Re: A petabyte of health insurance prices per month

#54

Earlier quoted context omitted.

But why? I could understand from a treatment perspective the type of animal mattering (but even then initial vs subsequent encounters?). From a billing perspective, wouldn't it make sense to have animal bite exam fee, with possible additional charges for bandaging, stitches, rabies shot, etc based on doctor's discretion?

[flagged]

Bitten by a communist just yesterday. I wonder how it is coded.

Re: A petabyte of health insurance prices per month

#55
post #11

Earlier quoted context omitted.

I think there's plenty of malice in the system, for example https://www.propublica.org/article/cigna-pxdx-medical-health...

I agree, but is the design of the system malicious? I don't think so. It's just stupid, and exploited by malicious people.

There rarely are systems designed in a malicious way. Most malicious systems slowly get shaped actors to their advantage. In some cases (insider trading or corruption) the government steps in and stops the abuse by laws and regulation. In the healthcare system they aren’t doing this and are letting profit oriented players shape the system.

Re: A petabyte of health insurance prices per month

#56
post #8

They are making it impossible to handle the data so everyone gives up trying so they can go on screwing people over.

While the pitchfork argument may be appealing, the actual article makes a convincing case that it's just combinatorial expansion: > As a result, the Transparency in Coverage rule requires insurance companies to do the math for patients and, in most cases, publish prices as dollar amounts. That’s helpful for patients, but it requires that a price be pre-calculated for every possible service. ... So, they could publish…

I work with petabytes of data. A petabyte of text is an insane amount of text. You need a billion X multiplication of basic data. That’s not just combinatrionics, it’s deliberate obfuscation.

Re: A petabyte of health insurance prices per month

#57

Gotta wonder how other countries with functional healthcare store and calculate pricing. There has to be a better way. This looks like denormalizing a huge number of small tables such that the resulting list of prices is like n^n growth for any possible addition.

Oddly enough, despite all the problems in Communist Cuba, they have been able to keep much of a modern health care system going with absolute minimum resources. It appears that empowering doctors to make decisions is a big part of that. Controversial to be sure, but also interesting if only for the extreme scale of contrast.

Re: A petabyte of health insurance prices per month

#58
post #25

There are separate charge codes for everything , and all of those codes need to be reflected in the pricing data. There's a price to slap on a bandaid. There's a price to give someone a Tylenol. Hell, W61.61XA is the medical code for "Bitten by duck, initial encounter." Presumably, this means there's also a code for "Bitten by duck, again." Medical billing is broken , and it's no surprise that the amount of data is o…

My personal favorite is V97.33XD "Sucked into jet engine, subsequent encounter."

[flagged]

Re: A petabyte of health insurance prices per month

#59
post #28

Gotta wonder how other countries with functional healthcare store and calculate pricing. There has to be a better way. This looks like denormalizing a huge number of small tables such that the resulting list of prices is like n^n growth for any possible addition.

That's exactly what it is, because as another comment pointed out the legislation currently doesn't allow them to just publish a [human,machine]-readable rules engine for calculating price, so they must publish this asinine amount of data every month in perpetuity until someone who's taken a math class in the last 70 years ends up in Congress.

This does seem to be machine readable, but inefficient. Given the fight the insurers have put up about publishing this, I would expect any allowance of "rules engine" to allow them not to publish anything, or to just play the same game again.

For instance, my "rules engine" is to look up the price contained in my db table (proprietary, of course) and multiply by another record in a different table. Or if a court forces us to provide both tables, we find that the structure is similarly unusable as this one. So best case is to get the same garbage.

Basically, I'd rather force them to be as explicit as possible, even if it's difficult to sort through, than to allow a loophole that might allow them to not publish prices.

Re: A petabyte of health insurance prices per month

#60
I used to work for a company that writes claims benefit management software. This:

> Notice how every item has a price that requires external information to understand:

> Per diem rates are paid for each day a patient is in the hospital. We need to know how long the patient will be in the hospital to know the total amount. > Rates for Cardiac Studies require knowing the price the hospital will bill in the future. The rate is essentially “44.8% of another unknown price,” which isn’t terribly helpful to a patient. > Radiology rates are based on an external price list that has to be looked up in an entirely different database. External rate lists are very common in health insurance but are not helpful unless you have access to the latest price list and can do the math yourself.

is where they stood out from their competitors, who typically had huge, and very wide database tables to capture this, but my ex-employer had written a DSL that allowed billing rules to be described with lookups and logic.

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