The Fight Between Doctors and Insurance Companies Over 'downcoding'

Edit: in case the reference isn't clear -- https://en.wikipedia.org/wiki/Cost_Plus_Drugs

And I think it is a sad state of affairs when the government has been so villified that we have to depend on billionaires for basic public good works.

(That’s because you’re a major, well-known insurer and pay an industry high 35%. The guy who mows the Medicare yard might pay 40 cents on the dollar. The person mowing the Medicaid yard has to file 87 forms to get paid his $6.)

Source: I’ve co-owned doctors offices.

The 12 y/o say ‘no you stink’ and hangs up. Then you send the landscaper a letter saying ‘sorry your peer to peer was denied’

( I know this is exaggerating a bit and made to sound funny but it mostly works like that in healthcare )

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.

https://www.cms.gov/priorities/healthplan-price-transparency...

https://github.com/CMSgov/price-transparency-guide

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.

When a provider rips off an insurer it's invisible to the general public.

Also, incidentally, when people talk about fraud in Medicare/Medicaid, the providers are almost always where that happens (yet that's often not pointed out).

17% of the US GDP is healthcare, now obviously there's a lot of nurses and random courier drivers and all sorts of other stuff in there, but they would all need to take some amount of haircut for us to get fleeced less.

The GDP contribution of slavery was ~13% just preceding the civil war and credible moves (i.e. electing Lincoln) to make them take a haircut caused, you know, the civil war.

There is likely no "clean" way to fix this problem other than a century long frog boiling exercise

They're at least as likely to fuck something up (curiously, always in their favor, not yours) as insurers, from what I've seen. And they're almost as unpleasant to deal with—at least they don't generally keep you on hold for literal hours, but it's still not great.

And one of the ugliest public-facing roles in all of American medicine has to be the insurance-vultures whose job is to hover about emergency rooms pestering very-sick people for their billing information. Fucking gross.

My boss wants insurance to be expensive - if I could afford it I would be more willing to quit (retire early).

Finding cheaper services isn't in my interest - I'm not paying any bills anyway.

Insurance companies like the complexity because it means I can't understand the system and so I have to use them.

Doctors don't really care as they just have administrators play the game for them. Once in a while they look at the game and say something, but really this is just they don't understand how the game is played (they shouldn't - they are doctors, they should be looking at medical issues not administrative ones).

The more shady the industry, the more everyone involved is shying awaa from sunlight.

Well, we sort of do: we have Medicare's reimbursement rates, which are indeed a price catalog for every service... but only if you're covered by Medicare, of course.

I've heard that price negotiations between private payers and providers are often done with reference to the Medicare rate: "I'll pay you 20% over Medicare for this."

Or it was viral after all and you cleared it on your own.

Doctors who specialize in this have a hard time accurately distinguishing bacterial infections from viral. There’s no reason to trust your own opinion on the matter. It’s too easy to fool yourself.

If doctors prescribed antibiotics to every person who came in insisting they have a bacterial infection, we’d all be in for a bad time.

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 only goal nowadays is to make as much money as possible for as little effort as possible.

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.

"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.