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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'

#71

Post by hypeatei »

djoldman wrote: post #61
hypeatei wrote: post #58

Earlier quoted context omitted.

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.

Doctors/patients are human too and your proposed system would be ripe for abuse. If you're well versed in submitting claims, and you know they have to pay out, then you could inundate them with fraudulent ones.

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

UnitedHealthcare says that 10% of claims go through additional review for various reasons[0].

I don't know if there are stats for the industry as a whole, but my guess is that they deal with a lot of errors.

0: https://www.uhc.com/news-articles/newsroom/how-many-claims-a...

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

#72

Post by kbelder »

pastor_williams wrote: post #49
jasonlotito wrote: post #45

Earlier quoted context omitted.

Exactly. Glad you agree it shouldn't be for profit, either.

I have no problem with it being for profit. The issue is the alignment of interests and the thumb on the scales by government and vested interests. If health insurance worked like car insurance I think we'd be in a better state.

I wish health care worked like veterinary care. Except, now, veterinary care is becoming more like human health care, and it sucks.

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

#73

Post by atomicnumber3 »

renewiltord wrote: post #55

People get annoyed at insurers who will deny treatment but most of the time you can just pay it yourself. The government has decided that everyone should pay for health insurance but you'll never be denied care if you pay for it yourself. 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…

>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 most of us would not need it.

And then, since we're all on the hook for each other's general health, we also agreed to share the cost of preventative care, because it was literally cheaper for us to all pay for preventative care than to try to just solo it and then hit the group with the cost of terminal cancer care instead of catching it early and doing a small excision. (and other such examples.)

And then what if we made the pool HUGE, to even further spread out the costs?

Sure wish there was a system that just did that, without trying to also generate insane profits off it.

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

#74

Post by hypeatei »

danaris wrote: post #59
hypeatei wrote: post #54

Earlier quoted context omitted.

> 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…

No, I assure you, it is very common for doctors' offices not to know whether a particular procedure will be covered. This is not just because of the capriciousness of insurance adjusters, but because they have to deal with all the 273 different variations of insurance plans that people who come through their offices might have. In general , a doctor's primary goal will be to get you good care. An insurance company's…

> An insurance company's only goal nowadays is to make as much money as possible

How can that be true when their profits are capped on collected premiums? Look up the Medical Loss Ratio (MLR) rule to see what I'm referring to. If you wanted to squeeze money out of people, health insurance would be the least appealing industry to do that in since you're required to spend 80-85% of premiums on medical care.

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

#75

Post by acheron »

jasonlotito wrote: post #42
antonymoose wrote: post #23

Earlier quoted context omitted.

Pretty sure fraudulent billing practices exist in a variety of nations and industries.

It does. And having lived 10 years in Canada and 10 years in the US and used both their healthcare systems quite a bit, I have seen both sides. Let me just say I moved to the US for healthcare 10 years ago and we do not regret it one bit. The US is easy to point and laugh at, but that just comes from ignorance.

But shitting on the US gets you lots of Internet upvotes, and isn’t that the important thing?

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

#76

Post by lotsofpulp »

i80and wrote: post #70
supportengineer wrote: post #68

Earlier quoted context omitted.

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.

I don’t understand why any decision maker in any business in the USA chooses to offer their employees (and hence themselves) health FSAs at all, especially when the much superior in every way Fidelity HSA is available.

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

#77

Post by supportengineer »

lotsofpulp wrote: post #76
i80and wrote: post #70

Earlier quoted context omitted.

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.

I don’t understand why any decision maker in any business in the USA chooses to offer their employees (and hence themselves) health FSAs at all, especially when the much superior in every way Fidelity HSA is available.

HSA requires a high deductible health plan, not everyone could afford that deductible.

"To contribute to an HSA, you'll need to be enrolled in an HSA-eligible health plan, also called a high-deductible health plan (HDHP)."

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

#78

Post by Ancalagon »

polski-g wrote: post #14
kotaKat wrote: post #8

Ah 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…

why dont other countries have similar amounts of healthcare fraud in their single-payer systems?

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

#79

Post by throwawayqqq11 »

eigencoder wrote: post #28

My pediatrician always charges us for an office visit + preventative care when we go in for a preventative care visit. It's obviously to get more $$ from insurance. I feel like this goes both ways...

An obligation to pay is always good for the billing side. Think about the sociopathic prices of US pharmaceuticals.

Afaik any other country with mandatory health care also puts a ceiling on prices. In germany, there is a price catalog for any service, with only few exceptions, and doctors/hospitals cannot legally charge anything else for these covered services. Now guess what the US does not have, even thought obama had foreign consultants explicitly advising for it.

Health ensureance companies are certainly not the most altruistic but any profit oriented company trying to cut cost where ever possible is hardly a supprise.

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

#80

Post by delecti »

lotsofpulp wrote: post #76
i80and wrote: post #70

Earlier quoted context omitted.

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.

I don’t understand why any decision maker in any business in the USA chooses to offer their employees (and hence themselves) health FSAs at all, especially when the much superior in every way Fidelity HSA is available.

HSAs are only available alongside high deductible plans (HDHP), which aren't necessarily ideal in all situations. FSAs are the only option like that if you don't have an HDHP.
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