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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'

#61

Post by djoldman »

hypeatei wrote: post #58
djoldman wrote: post #48

We'll never know, but: I wonder what would happen if we moved the "medically necessary" requirement burden of proof from the doctor/patient to the insurer. So the insurer would be required to pay out a claim regardless of whether the insurer thought it was medically necessary, but their recourse could be to try to claw it back post-payment.

They'd most likely go bankrupt. There is already an incentive for them to spend on medical care due to the Medical Loss Ratio (MLR) which caps their profits on collected premiums. If you're saying they need to be forced to pay whatever invoice comes to them and start legal battles for each suspect case then yeah... that doesn't seem feasible.

Health insurance companies are not immediately insolvent because they

1. pay out claims slowly

and/or

2. deny or downcode claims outright?

Really? That to me would imply that doctors/patients are submitting a huge amount of incorrect claims.

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

#62

Post by polski-g »

vjvjvjvjghv wrote: post #37
polski-g wrote: post #14

Earlier quoted context omitted.

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.

My employer switches insurance carriers every 4 years or so because another carrier has a more competitive rate. "What's best for the employer" is also what's best for me -- I can walk across the street and get a new job if I become unhappy. They want to keep their healthcare costs down so they can keep my salary high as dollars lost to my healthcare compensation are invisible to me.

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

#63

Post by lotsofpulp »

hypeatei wrote: post #54
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…

> No one knows, do the test and insurance will decide Oh, someone knew but the doctors office wanted to do the expensive thing and get paid (either by you or the insurance) Not saying the blood test was unnecessary but we have no idea what communication happened between the doctor and insurance company. Did they possibly recommend a less expensive test and the doctor decided that'd make him less money so he went forw…

Health insurance companies have told me, on the phone, that they will not tell me the codes the doctor needs to charge for preventative visits in order to for my visit to be covered as preventative care (meaning I don’t have to pay anything).

However, I could tell the insurance customer service person a code, then they could tell me if it was classified as a covered preventative service.

So I, the insurance company’s customer, Googled medical procedure codes and found some on random PDFs, and checked which ones were covered, and then I asked the doctor to provide me the services for that code.

That is American healthcare.

On the flip side, I also had a doctor’s office try to bill my insurance $25 for towels used to wipe the ultrasound jelly off my wife’s belly. My insurance didn’t pay, so the doctor’s office sent me the bill for what insurance didn’t cover, so I called the doctor’s office and asked why I am being charged $25 for the few pieces of paper towel (not even linen towel), and the receptionist said they would waive the charge.

So, moral of the story is bring your own paper towel roll when you expect to get messy at the doctor’s office.

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

#64

Post by standardUser »

It's a system that supports two set of clients, doctors and patients, and fails them both. Yet, Congress has considered it sacred and infallible for a hundred years. Democrat's most earnest attempt ended up strengthening and expanding that system, and Republicans for their part have fought tooth and nail to stack the system even further against the people it's supposed to serve.

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

#66

Post by datadrivenangel »

kamarg wrote: post #39
pragmatic wrote: post #26

Earlier quoted context omitted.

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.

Sending your patient's 'debt' to collections promptly is very unpopular with the patients, and the insurance companies will 100% insist that the patient is responsible.

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

#67

Post by brewdad »

kamarg wrote: post #39
pragmatic wrote: post #26

Earlier quoted context omitted.

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.

It's much easier to treat it like identity theft where the business's problem becomes the customer's problem to solve. In this case, insurance didn't pay what was required so the patient does. There's already a potential collections agency involved if the patient doesn't pay.

Who do you think is easier to squeeze the money from? A mega-insurance corporation or your sick grandma?

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

#68

Post by supportengineer »

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.

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

#69

Post by datadrivenangel »

polski-g wrote: post #62
vjvjvjvjghv wrote: post #37

Earlier quoted context omitted.

“ 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.

My employer switches insurance carriers every 4 years or so because another carrier has a more competitive rate. "What's best for the employer" is also what's best for me -- I can walk across the street and get a new job if I become unhappy. They want to keep their healthcare costs down so they can keep my salary high as dollars lost to my healthcare compensation are invisible to me.

Except that the insurance plans charge the employer and so the cheaper plans mean more haggling and potentially out of pocket for you later

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

#70

Post by i80and »

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.

FSAs are insane, conceptually.

"Guess how much money you're spending in a year on healthcare! But beee caaareful: if you guess too high, YOU LOSE IT"

I still used mine while I still had access to one, but it was grumpy-making and was usually almost more trouble than it was worth.

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