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 had a single blood test done awhile back and no one knew if insurance would cover it, or which of the dozen or so billing codes it involved (taking the sample, delivering the sample, testing the sample, etc.) might be covered. It was an expensive test so I spent days bouncing between the doctor's billing team and the insurance company until the settled answer was: No one knows, do the test and insurance will decide. So I did it and insurance denied covering the doctor-recommended test. The salaries involved for all the billing people (and my time) would have covered the cost of the test. </rant>
In Australia I just take my blood test form to any pathology place and they do it for free (for me) and bill the government a set price from the medicare benefits schedule.
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.
> 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 forward anyway?
It was not designed to make money. It was designed to cost less, in the same way the USSR was designed to make workers rich - it simply failed spectacularly.
Neoliberals dislike both regulation and public ownership, but made a Faustian bargain where they replaced public ownership with more regulation, thinking that regulation was the lessor of the two evils. In reality, it's not - like in the USSR where they had corporatised but heavily regulated "companies". A heavily regulated company doesn't make money by offering better value to customers, it makes money by finding loopholes in regulations, and regulators will always lose the cat and mouse game of closing these loopholes.
Neoliberals end up creating a system that's actually a lot like the USSR (if the famous "Well intentioned Commissaire" essay is representative of the USSR) - heavy regulations, with corporate entities outsmarting the regulators to enrich their owners (or managers) while minimising the value they create. Neoliberals deny the need for pubic management, but are forced to badly reinvent it (via heavy regulation). Communists deny the need for incentives, and are forced to badly reinvent it (once again via regulation), ending up not a million miles away from where neoliberals end up - with endless regulation and lost efficiency.
It's worth noting that the US spends far more tax dollars (per capita) than Australia on health (Australia has a hybrid public / private model). Medicare, Medicaid and the VA costs about as much as Canada's expensive public system (per capita) since the US is so insanely inefficient.
The biggest problem with the American system is that it's just illegal for me to sell you good, simple insurance.
Let's say I draft an insurance contract that says for any treatment if >5 of 10 randomly selected doctors agree that the procedure was warranted, then I have to pay out the cost of the procedure, no questions asked. This contract is less hassle, clear, and doesn't require arguing with an insurance company since it specifies how disputes are resolved.
But I'm not going to give it to you for free. I need to know the expected payout in order to come up with a price and sell it to you. You know, like how all other insurance works. There is a price that is positive EV for me, but better aligns with your risk tolerance, and is therefore positive utility for you as well. In America, pricing it is illegal. I cannot, by my own methods, determine a fair price and sell it to you.
That's why we can't have nice things, because it's illegal for two people to agree on a price and terms and create a good deal for themselves.
There's plenty of upcoding going on with doctors as well though.
I go to a particular doctor and I'll see a bunch of random things on the bill that don't seem to have anything to do with my visit. Like a thousand dollars worth.
But then insurance rejects them, but I still don't have to pay a cent -- the doctor never actually charges me.
It seems quite clear they're just trying to throw things at the wall and see what sticks.
This doesn't surprise me: The "fee for service" system encourages doctors to perform as many services as they can so they can bill for more. I've certainly had my fair share of tests and procedures where I wonder if the provider was just trying to find something to bill for.
I'm also not surprised that some providers will try to figure out which codes they can use to get the most revenue. ("Hey, if I do procedure A instead of B, I get paid more, so why would I do B?")
That being said, I also wouldn't be surprised if many of these turn into lawsuits, or ultimately push to revise the whole "fee for service" system.
I've seen a lot of upcoding on my bills and it really aggravates me. It's fraud and the doctors should be happy that the insurance company is just reducing their payments instead of dropping them or trying to get them prosecuted. When someone loads their grocery bag full of cosmetics and razor blades, they get on the news and YouTube, but when a doctor systematically bills for services he didn't perform to the tune of millions of dollars, almost nothing happens.
I’ve lived under several different healthcare systems around the world as an adult. Coming from my time America, nothing felt more like freedom to me than walking out of a hospital in London, with a new child, and having had no interaction with a billing desk.
On the other hand, aren’t comments like yours about the aesthetic experience of billing exactly the problem? It’s not like you didn’t pay for healthcare in Europe, you just had good vibes about the particular way that you paid. Employer sponsored health insurance plans are popular and also give good vibes.
If anyone wondering why it is call 'downcoding', it's because there's WHO ICD coding standard or international classification of diseases now at version 11 or ICD-11 [1]. It's mainly used for classification of disease mortality not morbidity, not until the latest version iteration of ICD-11 in which it now caters for both [2].
Due the usefulness of the diseases classification coding based on ICD, it's also being used in many part of the world especially in US for healthcare insurance claim purposes.
[1] International Classification of Diseases 11th Revision:
The global standard for diagnostic health information:
No, that's completely wrong. Downcoding has nothing to do with ICD versions. This article is talking about changes to the billed HCPCS (including CPT) codes to ones with lower rates. Most US healthcare claims do include at least one ICD-10-CM code to indicate the diagnosis but this is just supporting information. Payers don't change diagnosis codes. ICD-11 isn't used on US claims at all, although it might be adopted in a few years.
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...
Yeah enough gets talked about insurers acting in bad faith, but let’s not forget hospitals also acting in bad faith for their end. Some personal examples:
1. Sitting in a Urgent care. They get you in the exam room. You sit there for 15 mins, doctor comes and sees you for 5 mins (mostly rushes the exam), do a blood draw, ask me to sit around while they run the test, doctor leaves, as soon as 45 mins are over the nurse comes over to let me know it’s taking longer to run the test so I can go home and they’ll call when the results are out. A month later charge thousands of dollars to insurance for a 45 min Urgent Care visit that doesn’t cover the lab work.
2. Go to PCP with cold symptoms that haven’t cleared in 10 days. I insist it’s a sinus infection, they send me back with no antibiotics and ask to schedule and online appointment in 2 days. I insist I come in in person, but they schedule an online appointment anyway. Nothing gets better and I see the doctor online after 2 days, they say I’ll have to come in so that they can evaluate me in person and prescribe antibiotics. I go in person, get antibiotics and get cured. Insurance gets charged for 3 separate hour long visits ($750 each and none of them lasted more than 10 mins).
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.
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.
What would happen is that costs to self-funded employers would increase so much that many of them would simply stop offering health insurance benefits and choose to pay the tax penalty instead. The only way the current system sort of works is with health plans maintaining strict utilization management.
(In general society would be better off if access to healthcare wasn't tied to employment but that's a separate issue.)
If someone invoices me, and I don’t pay the full amount in a timely manner, what do you think will happen? Late fees, reports to credit bureaus, collections agencies hounding me, maybe even lawsuits?
If insurance companies underpay, doctors should treat that no differently. Don’t appeal through the insurance company itself. Imagine I go to a store and pay less than the full amount at the register, and then the grocery store appeals to ME to decide whether I actually should have paid the correct amount. It’s absurd.
Doctors should treat the insurance companies like anyone else who owes them money and isn’t paying in full on time.
Insurance companies hold tremendous leverage over care providers, up to and including the power to effectively put them out of business on a whim. Care providers don't like picking fights with insurance companies.
Doctors have extensive contracts with insurance companies, and often have employees dedicated to billing. I wouldn't make assumptions here, other than "downcoding" is probably just subtle enough to not be worth it to fight.
I'm 90% certain that submitting claims to an insurer subjects doctors to resolving any disputes via an appeal followed by an arbitration process, and that the right to sue or handle the debt in the regular way is severely attenuated.
So what should happen when Docs lie about what procedures they did? Because it happens quite frequently and for some reason is always left out of these discussions.
I was thinking the same thing. Would it be permissible to bring each underpayment to small claims court as a separate case? If enough doctors did this, it would very quickly be a legal DDoS attack, like we've seen happen with mandatory arbitration.
It's pretty obvious to everyone that doctors have been abusing these levels. See doc for 20 minutes for a low complexity item but get charged for a 30 minute medium complexity. The insurance companies aren't blind. They've got the stats in hand for each doctor. I mean some of the ranking data is already built into the portal tools they give consumers for finding a doc.
It's a huge system with a lot of people involved so no doubt there is abuse, but there is also natural and expected levels of variation in the complexity of patients that doctors doing notionally the same job will actually encounter. If you're doing an honest job and happened to have seen more complex patients than average I think you'd rightly be pretty angry if you were then forced to do more paperwork to justify yourself to an insurance company who starts downcoding your patients.
the health insurance industry needs to be razed to the ground and rebuilt from scratch. there's no saving something that is ostensibly designed to help people get healthcare but realistically denies them what they're entitled to for years (in some cases, they just try to keep the ball in the air until the patient dies, then there's no one to appeal) and then once the care is approved steals from the service provider by automatically altering the bills without any evidence of fraud or theft.
I went to the dentist a couple of weeks ago and had the shortest dental visit I've had. They did the X-rays, then the dental assistant spent five minutes cleaning my teeth and pronounced them good. The dentist came in and looked for about one minute and said they were fine. I was sent on my way.
They billed my insurance for over a thousand dollars.
I'm on the side of the insurance companies. they are likely the only "responsible adults" keeping providers in check. Providers are extremely wasteful and "creative" with their billing. Staff are generally idle, and staff-to-patient ratios are 10-20:1 if not more. There is little urgency around the clinic, staff take off at 4pm and are impossible to catch on a Friday. Every procedure bills a redundant and pointless "consult"-- a $1500 meeting that could have been an email.
Providers benefit from possibly the best PR of any industry. Insurance companies are the "Ticketmaster" of the healthcare industry. Their entire objective is to be the punching bag for wasteful healthcare providers.
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.
For those looking for a fix to US healthcare I think it's something like this:
- (user incentive to reduce cost) insurance is structured as co-pay of [20+]% on all expenses, no exceptions
- (price transparency) require healthcare providers to quote upfront for care, via API/website/phone/in-person. Price paid by anyone is the same except for expenses related to billing. E.g
- (create competition) enable creation of small scale clinics, testing facilities, and laboratories
And for God's sake, get the government out of it!!
One (social) system that may work well is the South Korean one: private provision of healthcare services; government run insurance scheme with mandatory payments by those that can afford to pay
I love markets, but health insurance really is a tough one given the govt can't seem to let people make their own mistakes on healthcare, so I think it might make sense to make it govt run.
Edit: the thing to acknowledge here is that it probably won't push the frontier of healthcare as much as the current US system does, but at least it would be high quality and affordable (not people's largest or second largest expense item).
> More than half of societal work is pointless, both large parts of some jobs and five types of entirely pointless jobs:
> Flunkies, ...
> Goons, who act to harm or deceive others on behalf of their employer, or to prevent other goons from doing so, e.g., lobbyists, corporate lawyers, telemarketers, public relations specialists; <-- YOU ARE HERE
[+] [-] 3D30497420|5 months ago|reply
On the opacity, I have one informative anecdote. I had a single blood test done awhile back and no one knew if insurance would cover it, or which of the dozen or so billing codes it involved (taking the sample, delivering the sample, testing the sample, etc.) might be covered. It was an expensive test so I spent days bouncing between the doctor's billing team and the insurance company until the settled answer was: No one knows, do the test and insurance will decide. So I did it and insurance denied covering the doctor-recommended test. The salaries involved for all the billing people (and my time) would have covered the cost of the test. </rant>
[+] [-] supportengineer|5 months ago|reply
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.
[+] [-] potatoicecoffee|5 months ago|reply
[+] [-] aduffy|5 months ago|reply
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.
[+] [-] hypeatei|5 months ago|reply
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 forward anyway?
[+] [-] xtajv|5 months ago|reply
Flood insurance protects against the rare disaster where there's a flood.
Health insurance protects against the rare disaster where somebody's actually able to get healthcare.
[+] [-] wisty|5 months ago|reply
It was not designed to make money. It was designed to cost less, in the same way the USSR was designed to make workers rich - it simply failed spectacularly.
Neoliberals dislike both regulation and public ownership, but made a Faustian bargain where they replaced public ownership with more regulation, thinking that regulation was the lessor of the two evils. In reality, it's not - like in the USSR where they had corporatised but heavily regulated "companies". A heavily regulated company doesn't make money by offering better value to customers, it makes money by finding loopholes in regulations, and regulators will always lose the cat and mouse game of closing these loopholes.
Neoliberals end up creating a system that's actually a lot like the USSR (if the famous "Well intentioned Commissaire" essay is representative of the USSR) - heavy regulations, with corporate entities outsmarting the regulators to enrich their owners (or managers) while minimising the value they create. Neoliberals deny the need for pubic management, but are forced to badly reinvent it (via heavy regulation). Communists deny the need for incentives, and are forced to badly reinvent it (once again via regulation), ending up not a million miles away from where neoliberals end up - with endless regulation and lost efficiency.
It's worth noting that the US spends far more tax dollars (per capita) than Australia on health (Australia has a hybrid public / private model). Medicare, Medicaid and the VA costs about as much as Canada's expensive public system (per capita) since the US is so insanely inefficient.
(edit: The essay I mentioned - https://highered.blogspot.com/2009/01/well-intentioned-commi...)
[+] [-] alphazard|5 months ago|reply
Let's say I draft an insurance contract that says for any treatment if >5 of 10 randomly selected doctors agree that the procedure was warranted, then I have to pay out the cost of the procedure, no questions asked. This contract is less hassle, clear, and doesn't require arguing with an insurance company since it specifies how disputes are resolved.
But I'm not going to give it to you for free. I need to know the expected payout in order to come up with a price and sell it to you. You know, like how all other insurance works. There is a price that is positive EV for me, but better aligns with your risk tolerance, and is therefore positive utility for you as well. In America, pricing it is illegal. I cannot, by my own methods, determine a fair price and sell it to you.
That's why we can't have nice things, because it's illegal for two people to agree on a price and terms and create a good deal for themselves.
[+] [-] crazygringo|5 months ago|reply
I go to a particular doctor and I'll see a bunch of random things on the bill that don't seem to have anything to do with my visit. Like a thousand dollars worth.
But then insurance rejects them, but I still don't have to pay a cent -- the doctor never actually charges me.
It seems quite clear they're just trying to throw things at the wall and see what sticks.
Everything about American healthcare is bad.
[+] [-] xtajv|5 months ago|reply
If you see this sort of thing happening in the U.S., the place to complain is your state's insurance board.
Medicine is hard enough without people TRYING to do harm.
And actuarial science is brutal enough WITHOUT glossy justifications for assuming that healthcare providers are bad actors.
[+] [-] leoh|5 months ago|reply
Except the part where you are cared for by a competent clinician?
[+] [-] gwbas1c|5 months ago|reply
I'm also not surprised that some providers will try to figure out which codes they can use to get the most revenue. ("Hey, if I do procedure A instead of B, I get paid more, so why would I do B?")
That being said, I also wouldn't be surprised if many of these turn into lawsuits, or ultimately push to revise the whole "fee for service" system.
[+] [-] cameldrv|5 months ago|reply
[+] [-] sarchertech|5 months ago|reply
[+] [-] Our_Benefactors|5 months ago|reply
What does this part mean? I don't follow.
[+] [-] oakmad|5 months ago|reply
[+] [-] doctorpangloss|5 months ago|reply
[+] [-] teleforce|5 months ago|reply
Due the usefulness of the diseases classification coding based on ICD, it's also being used in many part of the world especially in US for healthcare insurance claim purposes.
[1] International Classification of Diseases 11th Revision: The global standard for diagnostic health information:
https://icd.who.int/en/
[2] ICD-11 vs. ICD-10 - a review of updates and novelties introduced in the latest version of the WHO International Classification of Diseases:
https://pubmed.ncbi.nlm.nih.gov/32447353/
[+] [-] nradov|5 months ago|reply
[+] [-] valleyer|5 months ago|reply
I doubt the insurance company would downcode the diagnosis, just the procedure.
[+] [-] nhinck3|5 months ago|reply
[+] [-] eigencoder|5 months ago|reply
[+] [-] darth_avocado|5 months ago|reply
1. Sitting in a Urgent care. They get you in the exam room. You sit there for 15 mins, doctor comes and sees you for 5 mins (mostly rushes the exam), do a blood draw, ask me to sit around while they run the test, doctor leaves, as soon as 45 mins are over the nurse comes over to let me know it’s taking longer to run the test so I can go home and they’ll call when the results are out. A month later charge thousands of dollars to insurance for a 45 min Urgent Care visit that doesn’t cover the lab work.
2. Go to PCP with cold symptoms that haven’t cleared in 10 days. I insist it’s a sinus infection, they send me back with no antibiotics and ask to schedule and online appointment in 2 days. I insist I come in in person, but they schedule an online appointment anyway. Nothing gets better and I see the doctor online after 2 days, they say I’ll have to come in so that they can evaluate me in person and prescribe antibiotics. I go in person, get antibiotics and get cured. Insurance gets charged for 3 separate hour long visits ($750 each and none of them lasted more than 10 mins).
[+] [-] throwawayqqq11|5 months ago|reply
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.
[+] [-] djoldman|5 months ago|reply
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.
[+] [-] hypeatei|5 months ago|reply
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.
[+] [-] nradov|5 months ago|reply
(In general society would be better off if access to healthcare wasn't tied to employment but that's a separate issue.)
[+] [-] _boffin_|5 months ago|reply
[+] [-] Apreche|5 months ago|reply
If insurance companies underpay, doctors should treat that no differently. Don’t appeal through the insurance company itself. Imagine I go to a store and pay less than the full amount at the register, and then the grocery store appeals to ME to decide whether I actually should have paid the correct amount. It’s absurd.
Doctors should treat the insurance companies like anyone else who owes them money and isn’t paying in full on time.
[+] [-] pragmatic|5 months ago|reply
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 about upcoding on this thread is blissfully clueless.
[+] [-] spiffytech|5 months ago|reply
[+] [-] gwbas1c|5 months ago|reply
[+] [-] anigbrowl|5 months ago|reply
[+] [-] some_random|5 months ago|reply
[+] [-] hn_go_brrrrr|5 months ago|reply
[+] [-] postflopclarity|5 months ago|reply
[+] [-] greenchair|5 months ago|reply
[+] [-] remus|5 months ago|reply
[+] [-] ratelimitsteve|5 months ago|reply
[+] [-] philipallstar|5 months ago|reply
[+] [-] cindyllm|5 months ago|reply
[deleted]
[+] [-] doormatt|5 months ago|reply
That's...not a lot of money.
[+] [-] silexia|5 months ago|reply
They billed my insurance for over a thousand dollars.
[+] [-] tonymet|5 months ago|reply
Providers benefit from possibly the best PR of any industry. Insurance companies are the "Ticketmaster" of the healthcare industry. Their entire objective is to be the punching bag for wasteful healthcare providers.
[+] [-] daoboy|5 months ago|reply
Many medical administrations do everything they can to upcode in order to bill for more money.
The whole system is a mess.
[+] [-] standardUser|5 months ago|reply
[+] [-] costcopizza|5 months ago|reply
Have health sharing plans been successful? Those require a religious affiliation IIRC.
I exclude single payer solely because it’s impossible with our current leadership.
I’m surprised there isn’t a Costco like medical group that’s nationwide, has a membership, and works solely to provide care efficiently.
[+] [-] m101|5 months ago|reply
- (user incentive to reduce cost) insurance is structured as co-pay of [20+]% on all expenses, no exceptions
- (price transparency) require healthcare providers to quote upfront for care, via API/website/phone/in-person. Price paid by anyone is the same except for expenses related to billing. E.g
https://surgerycenterok.com/
- (create competition) enable creation of small scale clinics, testing facilities, and laboratories
And for God's sake, get the government out of it!!
One (social) system that may work well is the South Korean one: private provision of healthcare services; government run insurance scheme with mandatory payments by those that can afford to pay
https://en.wikipedia.org/wiki/Healthcare_in_South_Korea
I love markets, but health insurance really is a tough one given the govt can't seem to let people make their own mistakes on healthcare, so I think it might make sense to make it govt run.
Edit: the thing to acknowledge here is that it probably won't push the frontier of healthcare as much as the current US system does, but at least it would be high quality and affordable (not people's largest or second largest expense item).
[+] [-] coleca|5 months ago|reply
[+] [-] immibis|5 months ago|reply
> Flunkies, ...
> Goons, who act to harm or deceive others on behalf of their employer, or to prevent other goons from doing so, e.g., lobbyists, corporate lawyers, telemarketers, public relations specialists; <-- YOU ARE HERE
> Duct tapers, ...
> Box tickers, ...
> Taskmasters ...