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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'

#81

Post by toast0 »

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 lost some money, or at least had a hard time using it, because I was quoted a price for something, set the FSA for the next year based on that, and then the billing ended up where only some of the price was eligible for FSA.

Combined with the PITA level, there's no way I'm doing it again. I can't see how it's worth my time. One of these three options is very likely:

a) my income level is low, so every dollar counts, but my marginal tax rate is also low, so spending a ton of extra time on this is not worth saving ~ 15% on taxes for health care

b) my income level is high, so my marginal tax rate is high, but saving 40% of taxes for health care is not worth the time, because health care is not a meaningful amount of income

c) my health care spending is high relative to income, and I can deduct health care costs on my tax return. Then I can deduct a lot more than the FSA will reimburse for, and the records don't need to satisfy a third party, unless I'm audited by the IRS.

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

#82

Post by pkaye »

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.

FSA does have the concept of rollover of up to $600 but its up to the employer to decide. I imagine that full rollover is not allowed because otherwise people would use the FSA to defer some tax payments to end of year. But there are ways they could have handled it better.

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

#83

Post by lingrush4 »

atomicnumber3 wrote: post #73
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 mo…

There's nothing stopping you from starting your own non-profit health insurance company. If greedy health insurance companies are really the root of the problem, you should be able to out-compete them fairly easily.

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

#84

Post by toast0 »

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.

Yeah, there's an industry of companies that insert themselves between the medical record and the insurance company to upcode claims and get better payments. This article is about the reverse process, where the insurance company looks at the claims and downcodes them to send worse payments.

IMHO, in office care should be more of a time and materials billing than billing based on procedures done. Of course, then the doctors' billing office would aggressively measure time the doctor spent, and the insurance company would suggest the doctor took too long for whatever.

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

#86

Post by lozenge »

hypeatei wrote: post #74
danaris wrote: post #59

Earlier quoted context omitted.

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.

So increase the health care spending, then you can raise premiums. An issue the ACA drafters already knew about, and tried (and failed) to deal with.

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

#87

Post by [deleted] »

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…

[deleted]

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

#88

Post by lozenge »

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.

You'll notice the doctor's office in the article already has a team of billing experts. But instead of working on new claims, they are being forced to relitigate claims they already submitted that weren't accepted.

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

#89

Post by xeromal »

atomicnumber3 wrote: post #73
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 mo…

That assumes the humans will do their best to take care of themselves but given the ability they will be bailed out, they let their health go knowing they don't need to actively take care of themselves.

The outliers drain the coffers

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

#90

Post by aduffy »

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…

I've had numerous encounters where doctors (and dentists) attempt to charge me for services they've already been reimbursed for from the insurance company.

It's only after hours of scouring my EOBs and being on the phone with my insurance that I then come back to the practice's office with evidence in hand, and they dismiss the charges.

I'm pretty sure this is just a racket because they expect most people not to put up a fight and just pay, or get sent to collections hell.

The amount of work you need to do as a patient in our health system is so dumb.

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