[HN Gopher] The fight between doctors and insurance companies ov...
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The fight between doctors and insurance companies over 'downcoding'
Author : ceejayoz
Score : 124 points
Date : 2025-10-09 12:36 UTC (10 hours ago)
(HTM) web link (www.nbcnews.com)
(TXT) w3m dump (www.nbcnews.com)
| coleca wrote:
| Good startup idea would be to work with medical practices to use
| AI to automate the disputing of the "downcoding" by insurers.
| ActionHank wrote:
| The business will be very quickly bought up to kill the
| product.
| daveguy wrote:
| If they can afford it. What's Mark Cuban been up to lately?
|
| 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.
| ceejayoz wrote:
| > the government has been so villified that we have to
| depend on billionaires
|
| https://knowyourmeme.com/memes/were-all-trying-to-find-
| the-g...
| cogman10 wrote:
| Man this is a hellscape.
|
| I can quickly see something like this turning in an AI arms
| race between insurance and the provider with each auto-
| approving/denying/disputing the other. All the while locking
| out smaller players because they can't afford the 3rd party
| disputotron.
| tantalor wrote:
| Hate it, thanks
| Spivak wrote:
| You would have to leverage the law (if you have one) that
| involves the state resolving the dispute because otherwise the
| automated disputes would probably be dropped on the floor. The
| insurance company has the leverage because they're actually in
| possession of the money and the contract that gives them
| stupidly high discretion on how much to pay out.
|
| Doing nothing but flipping the burden, doctors get paid
| whatever they invoice and insurance have to claw it back would
| make a lot of this stonewalling bullshit go away. But with an
| openly corrupt government paid by insurance it'll never happen.
| pragmatic wrote:
| Its a terrible business.
|
| The data is a disaster. Turnover is high, errs everywhere.
| Disputing is the easy part. Hard part is finding the contracts
| lol.
| vjvjvjvjghv wrote:
| The result will be that doctor AIs will be fighting insurer AIs
| and the loser will be the patient. As always.
| elwebmaster wrote:
| Already working on this, let's connect if you are interested:
| https://forms.gle/cxQZg5Q27PsT65d97
| Apreche wrote:
| 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.
| hn_go_brrrrr wrote:
| 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.
| postflopclarity wrote:
| good luck suing when lawyers cost the doctor 2k/hour and the
| insurance companies have armies of in house counsel.
| gwbas1c wrote:
| 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.
| some_random wrote:
| 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.
| Pet_Ant wrote:
| Man, it's almost like healthcare and human lives shouldn't be
| for profit...
| pastor_williams wrote:
| "It is not from the benevolence of the butcher, the brewer,
| or the baker, that we expect our dinner, but from their
| regard to their own interest."
| jasonlotito wrote:
| Exactly. Glad you agree it shouldn't be for profit,
| either.
| pastor_williams wrote:
| 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.
| kbelder wrote:
| I wish health care worked like veterinary care. Except,
| now, veterinary care is becoming more like human health
| care, and it sucks.
| nocoiner wrote:
| Vets are really the most amazing doctors and I hate to
| see what is happening to their industry. Hopefully in
| exchange for dealing with the bullshit of human health
| care, at least maybe the money is getting a little better
| for them (a lot of them are just criminally underpaid).
| philipallstar wrote:
| Find some doctors, nurses, researchers, manufacturers etc
| etc who will work for no money and we can remove money from
| the problem.
| jasonlotito wrote:
| > Find some doctors, nurses, researchers, manufacturers
| etc etc who will work for no money and we can remove
| money from the problem.
|
| Not being for profit doesn't mean you don't pay people.
|
| Further, I wonder how the Sixth Amendment works then? So
| many non-profit people working for... no money?
|
| This "work for no money argument" is so incredibly weak,
| I had to make sure I quoted the argument so the person
| wouldn't change it.
| philipallstar wrote:
| Eventually everyone works for profit if they get paid.
| Spending time only is pure profit in money.
| iamnothere wrote:
| A reasonable wage or salary isn't usually considered
| "profit" in a legal sense. This is why nonprofits can
| still pay employees. Any money that is left over after
| costs (including wages/salaries) needs to be reinvested,
| spent on the organizational mission, or held for future
| use, not distributed through dividends or other
| distributions as in a for-profit enterprise.
| JumpCrisscross wrote:
| > _reasonable wage or salary isn't usually considered
| "profit" in a legal sense_
|
| This is a semantic punt to the word "reasonable."
| iamnothere wrote:
| The IRS has some guidelines that they use to decide what
| is "reasonable" but they don't give out whatever actual
| formula or process they use to determine this. It's
| supposed to be based on industry averages (more or less)
| but in reality it's hard to determine what exactly that
| means. Generally you are "safe" paying in an industry
| average range, but if outside that range you need legal
| and accounting support to back up your own assessment.
| JumpCrisscross wrote:
| > _you are "safe" paying in an industry average range,
| but if outside that range you need legal and accounting
| support to back up your own assessment_
|
| What? The IRS doesn't regulate wages. They just care
| about getting their money. If I pay you $10bn a year to
| yell at my cat, the IRS is fine so long as I pay payroll
| and you income taxes.
| hibikir wrote:
| Have you spent much time looking inside non profits? A
| lot of hospitals in the US are non profits. Some are part
| of non profit universities too. This in no way leads to
| superior cost controls, or those universities being
| cheap. What it does mean is that they get some
| significant tax advantages (for instance, no property
| taxes), and that there's fewer optimization incentives.
| When you limit yourself to the US definition of a non
| profit company, it doesn't make care better or cheaper.
| OkayPhysicist wrote:
| Most people do not profit off their labor. 2/3rds of
| people are living paycheck to paycheck, which means that
| they are being paid approximately the same amount that
| their labor costs to produce. That makes their wages an
| exchange of equal value, and thus not profitable.
| some_random wrote:
| You're welcome to come up with an alternative system of
| aligning interests, so far all of the other ones have
| failed horrifically.
| sensanaty wrote:
| I live in NL. I pay 130 euros a month for my health
| insurance, and a max of 375 yearly on deductibles should
| I accrue some costs. The only reason I pay 130 is because
| I earn above a certain number, otherwise it's discounted
| and even free at a certain level (and I opted into the
| more expensive tier to also have dental coverage). In my
| case, my employer even pays for my insurance so in
| reality I don't even pay anything monthly (that's rare
| here though).
|
| I recently did an in-depth sleep study, got a CPAP
| machine prescribed to me, free replacement filters and
| replacement tubes + mask for it whenever I need them. I
| also got xrays and CT scans because of a foot injury
| around the same time. I also got comprehensive blood
| tests done.
|
| None of it cost me a penny other than the ~100 euros a
| month, the doctors and GPs are paid well, the quality of
| care I received was exceptional, and in the worst case
| scenario possible I would've only paid 375 euros max.
|
| My mother in law has osteoporosis and a number of other
| chronic illnesses, so she has to see specialists quite
| often. The quality of care she receives is similarly
| excellent to the one I received, and due to her
| disability her healthcare is partially covered as well.
|
| It's not perfect of course, but it sure does beat all the
| horror stories you often hear coming from across the pond
| of people ending up in lifelong medical debt should, God
| forbid, something happen to them that they realistically
| have no control over. So I'm sorry, but I don't buy that
| the for-profit fucked up system you guys have going on
| over there is the best of the lot, especially if you're
| an average Joe and not someone from SV earning obscene
| amounts.
| hibikir wrote:
| "Healthcare that isn't for profit" doesn't mean just a
| national health insurance. Just that as a random citizen
| you are shielded from seeing all the same issues
| underneath. The pharma companies, test providers,
| equipment makers and personnel are all making profits. I
| bet the total amount paid is higher that 130 euros a
| month. There's profit all through the system, so claims
| that healthcare should not be for profit are silly.
|
| Now, what happens is that the profits have to be kept in
| check, either via price controls or sufficient
| competition. It's not hard to argue that the choices made
| in the US are quite suboptimal, but it's far more of a
| regulatory problem than purely a matter of people making
| money. If nobody makes money, there's no healthcare.
| lawlessone wrote:
| > so far all of the other ones have failed horrifically.
|
| Have they?
|
| i live in neither country but i know i'd rather have
| cancer in the UK than the US.
|
| That Breaking Bad meme about Walter getting lung cancer
| in the UK comes to mind.
| hylaride wrote:
| > so far all of the other ones have failed horrifically.
|
| Uh, what? Other systems have their problems, but they're
| varying levels of functional, and the health and life
| expectancy of the populations in most other developed
| countries is higher than the US, all the while spending a
| fraction.
|
| Most other developed countries have a mix of public and
| private insurance and/or delivery, with the better run
| systems being better rationalized in dealing with costs
| and having an actual market where it makes sense to form
| one (eg you can't practically shop around for ER care,
| but you can for elective or planable services). The
| French system is held in high regards in particular
| (though it isn't really replicatable due to their unique
| civil service setup).
| lesuorac wrote:
| Sure but imagine you hire a landscaper and they send you a $40
| invoice for $20 of law cutting and $20 of leaf cleanup. You go
| look outside and see a ton of leafs so you just send them $20.
|
| That's the insurance companies' stance. The work you performed
| is this and so our agreed upon rate is this.
| bshep wrote:
| but the landscaper has a photo of the clean yard after they
| finished. They send it to you but you ( as the insurance
| company) say they need to call a specific time and speak to
| your 12y/o who is the yard representative of the house.
|
| 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 )
| kstrauser wrote:
| But in reality, the landscaper bills you for $100, you say
| you're only going to pay $90, and then you write them a check
| for $31.50.
|
| (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.
| pragmatic wrote:
| 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 about upcoding on this thread is blissfully
| clueless.
| kamarg wrote:
| > 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.
| datadrivenangel wrote:
| 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.
| brewdad wrote:
| 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?
| toast0 wrote:
| 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.
| lozenge wrote:
| 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.
| spiffytech wrote:
| 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.
| tptacek wrote:
| Care providers make massively, massively more money than
| insurance providers.
| aspenmayer wrote:
| Care providers also likely spend much more time and labor
| on making that money than the insurance providers spend
| making their end, though I only have anecdotal evidence of
| this through my involvement in healthcare providers'
| practices as an MSP.
| tptacek wrote:
| It's $2.5Tn vs $0.3Tn. It's more than 8x more.
| aspenmayer wrote:
| That's one half of the proportion. What is the time/labor
| spent?
| bena wrote:
| It's truly fucked up.
|
| Most insurances won't publish their fee schedules. So doctors
| don't know what they will pay. So what they do is bill insanely
| high knowing the insurance will come back with "Nah, we only
| cover $X". They'll collect $X, then write off the remainder.
| Because the fear is not getting the maximum money possible. If
| the doctor would bill $100 and the insurance pays up to $200,
| then the doctor "lost" $100.
|
| Regardless of how much it actually cost the doctor to provide
| the service.
|
| It's also why the "cash price" is usually much cheaper, because
| it's closer to what it costs the doctor to provide the service.
| hibikir wrote:
| Ah, but this has also lead to many private practices getting
| bought by hospital groups, at which point they have superior
| pricing power. The doctor makes more money, and the insurance
| company pays more, as it's harder to strongarm a company that
| owns 8 hospitals than a 3 doctor practice. Either way, the
| price goes up.
| anigbrowl wrote:
| 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.
| kotaKat wrote:
| 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 attention to so they can get an extra
| several hundred dollars a day for billing higher level cases
| daily.
| polski-g wrote:
| 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.com/story/news/local/arizona-health/20...
| vjvjvjvjghv wrote:
| " 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.
| polski-g wrote:
| 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.
| datadrivenangel wrote:
| Except that the insurance plans charge the employer and
| so the cheaper plans mean more haggling and potentially
| out of pocket for you later
| Ancalagon wrote:
| why dont other countries have similar amounts of healthcare
| fraud in their single-payer systems?
| arealaccount wrote:
| I never understood why insurers get all the flack while the
| providers get a pass.
| cogman10 wrote:
| Because the common interaction people have with their
| insurers is "We are denying this because of <REASON>" which
| they have to fight to get healthcare.
|
| 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).
| walkabout wrote:
| FWIW I hate most medical billing departments (and hospitals
| are the worst) about as much as I hate insurance.
|
| 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.
| potato3732842 wrote:
| Every party at every point in the system is various shades of
| complicit in fleecing us. That's the magic of the system.
| It's all divided up in so many ways and so many of the
| feedback loops touch through the people getting screwed that
| it's impossible to build a "these guys might not be wholly
| responsible, but they're responsible enough things will get
| better if we push them off a cliff or legislate them into
| poverty or whatever" consensus you need to build to change
| things
|
| 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
| nocoiner wrote:
| You think nurses and couriers are the ones who need to take
| pay cuts to get healthcare expenses under control??? Lm,
| and I cannot stress this enough, fao.
| unyttigfjelltol wrote:
| Because it's only human nature to complain about the people
| who _aren't_ in the room. Insurers are not only absent, they
| are economically adverse to the two parties making decisions
| in the room.
| myko wrote:
| In years of working in the medical industry it is rare for
| health systems to purposefully upcode a patient's visit (this
| is taken extremely seriously) while insurers attempting not
| to pay the bill and sticking it to the patient and health
| system is standard practice
| daoboy wrote:
| For what it's worth, this sort of gaming works both ways.
|
| Many medical administrations do everything they can to upcode in
| order to bill for more money.
|
| The whole system is a mess.
| nadermx wrote:
| It's beyond our control, says only country where this happens
| daily.
| antonymoose wrote:
| Pretty sure fraudulent billing practices exist in a variety
| of nations and industries.
| vjvjvjvjghv wrote:
| Other countries are making efforts to keep things in check
| though
| https://www.npr.org/2025/01/04/nx-s1-5246231/potential-
| fraud.... The US for some reason can't even address blatant
| fraud. One example is the stuff insurers do with Medicare
| Advantage. There is fraud and Congress knows about it but
| besides some hearings nothing is happening.
| jasonlotito wrote:
| 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.
| acheron wrote:
| But shitting on the US gets you lots of Internet upvotes,
| and isn't that the important thing?
| bluGill wrote:
| IT is beyond our control because we have setup a system where
| the people who are paying don't want to control things.
|
| 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).
| potato3732842 wrote:
| There's an old mechanics saying "if X was covered by
| insurance it'd cost what Y does" where X is some routine
| thing (tires/brakes/etc) and Y is autobody or glass
| services typically covered by insurance.
|
| This proverb seems to also apply to health insurance and
| the things they do/don't cover.
|
| Putting routine stuff under the purview of insurance is
| stupid regardless of context. There are other cheaper,
| faster, simpler and more transparent ways of doing that.
| pastor_williams wrote:
| Doctors have also spent a lot of time lobbying to make
| becoming a doctor harder so that the fewer doctors will be
| able to command better salaries. It sounds like they are
| attempting to reverse that and open up more spots for
| residencies but I imagine that there is a lot of momentum
| to overcome.
| pnathan wrote:
| I wonder how this plays out with Kaiser and other integrated
| practices.
| breadwinner wrote:
| They try to convince you that you're fine and don't need any
| treatment.
| gwbas1c wrote:
| 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.
| mbb70 wrote:
| "Figure out which codes they can use to get the most revenue"
| is a billion dollar industry with many players, subspecialties
| and surprisingly few lawsuits.
| mschuster91 wrote:
| A lack of lawsuits can just be an off the record agreement
| that _no one_ benefits from the entire mess being dragged in
| front of the courts with public record laws, because _that_
| is how you give future Luigis ideas.
|
| The more shady the industry, the more everyone involved is
| shying awaa from sunlight.
| silexia wrote:
| 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.
| eigencoder wrote:
| 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...
| throwawayqqq11 wrote:
| 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.
| darth_avocado wrote:
| 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).
| 3D30497420 wrote:
| 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>
| hypeatei wrote:
| > 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?
| danaris wrote:
| 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 _only_ goal nowadays is to make as
| much money as possible for as little effort as possible.
| hypeatei wrote:
| > 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.
| lozenge wrote:
| 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.
| lotsofpulp wrote:
| The linked article is about insurers trying to reduce
| spending by downcoding.
|
| So which is it? Insurers unfairly denying reimbursement
| for what should be valid claims, or insurers unfairly
| increasing spending on claims so they can increase their
| profits.
|
| Also, go look at 5, 10, and 15 year returns for the big
| insurers (UNH/Elevance/CVS/Cigna/Humana/Molina/Centene)
| if you think health insurance is a good business for
| earning money. Spoiler alert: they're less than
| desirable, stick with SP500.
| wat10000 wrote:
| A 25% margin is pretty good, and companies aren't hitting
| the limit currently.
| lotsofpulp wrote:
| 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.
| testing22321 wrote:
| > _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._
|
| Malicious compliance engaged.
|
| Start with code "1" and go to "99999999999999999" until
| they tell you it's covered.
| supportengineer wrote:
| 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.
| i80and wrote:
| 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.
| lotsofpulp wrote:
| 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.
| supportengineer wrote:
| 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)."
| xhrpost wrote:
| Yup, I agree HSA is superior but depending on your
| situation (and plans offered), the HDHP can be much more
| expensive out of pocket[1], even if you're paying with
| after tax dollars. Sweet spot I think is using a good low
| deductible plan when it makes sense but having a spouse
| with an HSA which both spouses can use for expenses.
|
| [1]: or so it seems, I tried to figure this out earlier
| in the year and the data is just lacking in order to make
| a perfect decision.
| delecti wrote:
| 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.
| fnicfnac wrote:
| What is the point of having a low deductible when you
| could put the premium difference in a HSA and use it on
| either the deductible or something uncovered?
| hibikir wrote:
| The math on whether you are ahead with the HSA or not is
| non trivial, especially if you are married and neither
| employer offers any subsidy when you put your spouse in
| your plan. HSAs are often better, but it's a very
| unfortunate math problem, where you carry quite a bit of
| risk. The HSA contributions from your employer are often
| nowhere near enough to make it win all the time. If your
| employer's does, consider yourself lucky. On any given
| open enrollment, my household has at least 30
| combinations of healthcare plans to consider, and that's
| ignoring dentals, visions and the like
| lotsofpulp wrote:
| Surely, that is offset by having to forfeit or waste any
| FSA money not needed by the end of the year. It really
| only makes sense if you have a minimum amount of
| guaranteed healthcare expenses every year.
| tpmoney wrote:
| All the FSA money in your account is available
| immediately at the beginning of the year. Ironically that
| would make it a better choice for anyone with a lot of
| medical expenses on an HDHP if it wasn't for the fact
| that FSAs are capped by law.
|
| As someone who does deal with enough medical stuff to
| clear the deductible (and sometimes the OOP max) on their
| normal health plan annually, it's still much more
| convenient, again because the money is all there at the
| beginning of the year when the expenses are highest
| lotsofpulp wrote:
| My HSA money is also available in the first pay period of
| the calendar year. It's up to the employer to decide when
| they want to contribute it.
| tpmoney wrote:
| That assumes your employer does any contributions to your
| HSA. And if your employer is sticking you with an HDHP,
| that's not always a given. Your own payroll deductions
| are pay-as-you-go
| toast0 wrote:
| 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.
| pkaye wrote:
| 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.
| darth_avocado wrote:
| It is a relatively easy fix tbh. You spend on medical bills
| through the account like you do right now, but the way you
| fund it is your post tax contributions. At the end of the
| year the account sends you a statement of what you used and
| you can use it to get the tax paid on the money back when
| you file the taxes.
| themafia wrote:
| And if you're wrong on your medical expense paperwork it
| could be a felony!
|
| Why shouldn't the institutions that do this all day and
| claim it as their special expertise handle all of this?
| Why should I even be /capable/ of losing money due to my
| lack of experience with the system?
|
| The money is forfeited back to the employer. There should
| be a law that money is now taxed and forwarded to the
| employee in their regular payroll.
|
| This system is designed to screw over regular consumers.
| darth_avocado wrote:
| Like I said, you don't have to do anything. It's would be
| like your W2 as long as you use your account.
| anonymars wrote:
| Cue that tuba/horn motif from "The Price is Right" (famous
| for "guess as close as you can without going over")
| cblum wrote:
| > FSAs are insane, conceptually.
|
| Indeed. I don't understand why they cant just make medical
| expenses tax-deductible up to a certain amount. The effect
| would be the same. Why do I need a separate account for it,
| and why do I have to guess how much I'll need every year
| (as you pointed out)?
|
| I guess at least part of the answer is that the companies
| administering FSAs make money out of this system. Sigh.
| ratelimitsteve wrote:
| Pharmtech: "With your current insurance we can't sell you
| this medicine at any price. We're under an agreement."
|
| Me: "Okay, what if we don't go through insurance?"
|
| Pharmtech: "$45 for the prescription."
|
| Me: "That's a bit higher than last time."
|
| Pharmtech: _performs some sort of incantation_ "Okay, $12."
|
| Me: "How did we go from not at any price to $12?"
|
| for those of you keeping score at home, the medicine was
| generic colchicine which costs $.30/dose
| (https://pmc.ncbi.nlm.nih.gov/articles/PMC7851728/), and I
| was getting 12
| salawat wrote:
| Medicine not in formulary. Their clinical department
| decided it was not worth covering for $reasons. The
| Pharmacy, likely to be considered a preferred pharmacy,
| signed a contract to be bound by that company's clinical
| formulary for policyholders.
|
| $45 was probably cash price, the they can let it go for if
| they do their ordering through a pharmacy supply group.
|
| $12 may be a price with a discount program like GoodRx
| applied. Data changes hands behind the scenes to make the
| lower price at the till possible. Don't know how GoodRx
| works, but been around long enough to know you're probably
| the product.
|
| You'll be amazed the complexity of the pharmacy benefits
| management complex.
|
| t. Been there, seen it, tried to fix it best I could, left
| in abject horror.
| unyttigfjelltol wrote:
| Turns out there are rational commercial players in these
| markets if you just go all-cash. The price is abandoning
| the incantations and local pharmacies, hospitals,
| ignoring your insurance. Harder to do that with services,
| but it's coming as well.
| ceejayoz wrote:
| It's deeply frustrating that the $12 doesn't go towards
| the deductible. I just saved the insurer a bunch of
| money!
| salawat wrote:
| You did nothing from their point of view except waive
| having them cover the claim, thusly leaving more money on
| their hands to be managed longer. Your "price discovery"
| isn't something they aren't aware of. On the contrary,
| their surveillance/clinical team have been crunching the
| numbers and making unilateral decisions on how the
| population is best guided to drugs based on their bottom
| line benefit to the insurer.
|
| You don't really factor into it except as an actuarial
| data point. But you might have kicked off an overpayment
| check back to the consumer in 12 months because golly
| gee, those pesky regulations! Don't worry though, you can
| hand it back because the premiums went up again!
| rufus_foreman wrote:
| There's an XKCD where the person who did the file download
| dialog for Windows visits some friends,
| https://xkcd.com/612/.
|
| "I'm just outside town, so I should be there in fifteen
| minutes...actually, it's looking more like six days...No,
| wait, thirty seconds"
|
| Sounds like that guy got a job setting prices for
| prescription medicine.
| andrewmcwatters wrote:
| This is absolutely unacceptable when per employee healthcare
| employer costs are basically now something like, I don't
| know, 20,000-25,000 USD?
| jimbokun wrote:
| "What is the cash price?" magically puts you back in the land
| of Classical Capitalism, where the service provider wants to
| keep you as a customer and knows their internal costs and you
| as a consumer of the service can evaluate their reputation
| for quality and cost vs other providers.
|
| It's adding 3rd parties like "insurance" (which only works as
| insurance in very limited catastrophic circumstances) and
| government plans that create the nightmare of the Mystery
| Price Only Knowable After Service Has Been Rendered.
| prasadjoglekar wrote:
| Sorta. The reason to go thru insurance is to count the money
| paid against your deductible. If you pay cash outside
| insurance, it doesn't.
|
| And if you have an HSA, you have a high deductible plan.
| testing22321 wrote:
| .... So you pay many thousands a year for insurance, but it's
| easier not to use it?
|
| Ummm
| aduffy wrote:
| 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.
| alphazard wrote:
| 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.
| wisty wrote:
| I disagree with the language you use.
|
| 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...)
| potatoicecoffee wrote:
| 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.
| djoldman wrote:
| 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.
| _boffin_ wrote:
| Are you talking overnight? If so, that's an easy predictable
| outcome.
| hypeatei wrote:
| 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.
| djoldman wrote:
| 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.
| hypeatei wrote:
| 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...
| djoldman wrote:
| I'm not proposing that all guardrail responsibilities be
| shifted to the insurer. Just the "medically necessary"
| provision.
|
| Doctors would still have a Duty to Code Services
| Accurately and a Duty to Maintain the Medical Record
| (which would clearly enable an insurer to prove a non-
| medically necessary therapies). There would be plenty
| plenty of evidence for an insurer to immediately respond.
|
| So claims could be rejected on the basis of failing to
| code accurately or lack of record.
| renewiltord wrote:
| 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 unlikely
| someone else will if they have to pay on your behalf.
|
| Essentially, place yourself in the role of each participant:
|
| - patient: wants to maximize care, money no object since it isn't
| theirs
|
| - medical practice: wants to maximize money spent on care
|
| - insurer: wants to minimize money spent on care
|
| Normally, the first two would be happy to collude to charge the
| third any amount of money since they'd both get what they want.
| And that is indeed what happens. So you get the natural result
| that the insurer doesn't want to support certain payments even if
| they were kind and pure-hearted. That they don't want to when
| they're neither should then not be a surprise.
|
| You can remove that pressure by turning the interaction into:
|
| - patient: wants to maximize care with minimized cost
|
| - practice: wants to minimize care with maximized cost
|
| The pressures between the two parties are now opposite and you
| can find the market equilibrium. With this opposition you'll
| suddenly find that patients start complaining about doctors
| ordering unnecessary procedures and so on, just like insurers
| claim in the other model.
|
| You can also work through with the other versions to model where
| equilibrium will set in and see if it's where it does. Most of
| the time you don't need to assume any moral valence for the
| participants. They might as well be machines. It is their roles
| that determine how they act, not their personalities.
| elwebmaster wrote:
| How about this one:
|
| - patient: wants to maximize care, money no object since it
| isn't theirs
|
| - medical practice: wants minimize care since money is based on
| number of patients not care
|
| - insurer (government): wants to minimize money spent on care
| while maximizing care because money comes from healthy citizens
| who pay taxes
| renewiltord wrote:
| There are two differently behaving conforming things in
| reality of these I think. Both Medicare and the UK/CA NHS in
| my knowledge conform to your description.
|
| In Medicare, this incentivizes maximizing patients on
| 'recurring revenue procedures' like dialysis.
|
| In the UK NHS (which I know better), it leads to the
| government denying certain kinds of care depending on the
| Adjusted QALYs / pound spent that the intervention will
| provide.
|
| TANSTAAFL after all, but yes, perhaps the interesting thing
| about the government being in that model is that patients can
| control government in a way that they cannot control
| insurance companies (i.e. they're not strictly oppositional)
| and consequently when the insurer is the government you get
| spend-bias in the direction of who has government power. In
| the US, that turns out to be old people. Additionally,
| governments have non-health-related sources of revenue so a
| government health plan can be used as a redistribution
| mechanism.
|
| But I think it leads to these outcomes predictably with a
| splitter placed on how much control the government exerts
| over the practice and how much control the patients exert on
| the government.
| atomicnumber3 wrote:
| >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.
| lingrush4 wrote:
| 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.
| xeromal wrote:
| 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
| fph wrote:
| Aren't these basically mutual healthcare providers? We have
| them in Europe.
| renewiltord wrote:
| Yes, you can do that. HealthPartners[0] is such a consumer-
| governed non-profit. It is entirely opt-in. It is not illegal
| in America to do that and, as you can see, others have done
| that.
|
| In HealthPartners' case, they do deny claims despite having
| the structure you mentioned. I think if you wanted to run
| such a pooled insurance company that advertised that it would
| pay any and all claims made to it and would deny precisely
| zero claims, you could and you would find it very easy to
| onboard both patients and providers to it, at least so long
| as its fund was solvent.
|
| 0: https://en.wikipedia.org/wiki/HealthPartners
| ChadNauseam wrote:
| > Sure wish there was a system that just did that, without
| trying to also generate insane profits off it.
|
| Health insurance companies in the US must pay 80% of premiums
| to providers. All their overhead (e.g. their accountants and
| actuaries and so on) comes out of the remaining 20%. What's
| left is their profit. People have this fantasy that all the
| money we spend on healthcare is secretly going to greedy
| insurance companies while doctors struggle to get by. But
| insurance company profits are a drop in the bucket.
|
| The real villains are the doctors who recommend expensive
| MRIs and act like it's a complete surprise that the bill they
| give you is so high. And then go lobby the government to
| limit their competition. I would love to have a doctor in
| france look over my radiology and tell me if I have cancer.
| But that's illegal, I need to hire an American.
| Coincidentally, the average radiologist in San Francisco
| makes $660,000/year (about $400/hour).
| breadwinner wrote:
| The problem is that patients are usually not in a position to
| determine if the care the doctor says is needed is really
| needed or not. This is the same as taking your out-of-warranty
| car to the mechanic. How do you know if the mechanic is telling
| the truth?
|
| Still, this would be better than the current system. Even when
| you don't know if the doctor is telling the truth you can go by
| their reputation for telling the truth. Reputations will matter
| more, and doctors will care about maintaining their reputations
| in their community.
| themafia wrote:
| > but you'll never be denied care if you pay for it yourself.
|
| If you can pay. You're still required to have insurance
| anyways. Which is a regressive tax and harms the people most in
| need of these services. It's a cruel joke.
|
| Those living paycheck to paycheck are screaming at you right
| now.
| mylifeandtimes wrote:
| yup. So if you decide you want to have a child, you just get
| ready to fork out 40-80K for the birth.
|
| Because anyone can afford that, right?
|
| Oh, and by the way, if you are in Texas abortion is illegal. In
| case you didn't actually __decide__ to get (yourself, your
| partner) pregnant.
|
| So it's either 40-80K or 40 years. Easy choice.
| standardUser wrote:
| 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.
| themafia wrote:
| Congress has considered that the employees of this industry are
| wealthy enough to contribute generously and often to their "re-
| election campaigns." They couldn't care less if your medical
| bills bankrupt you or not.
| hibikir wrote:
| This would all be well and good if the doctors weren't also
| profiteering. When you visit one, you still don't know if their
| recommendations are good for me or for them. I have seen
| allergists which are no less slimy than used car salesmen. See
| also studies on dentists and their varied recommendations for
| the same patient.
|
| The US insurance system doesn't seem to be giving us low
| prices, but let's not pretend it's all their fault. It's just a
| complex market where it's hard to compare providers, and
| therefore is prone to a lot of inefficiency.
| dboreham wrote:
| People who have always lived in the USA have no idea how many
| things about life in the USA are batshit crazy. This is probably
| the top of the list. At least before we turned to fascism...
| ratelimitsteve wrote:
| 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.
| doormatt wrote:
| >Wagner's office estimates he lost over $3,000 to downcoding in
| the first half of the year, but other doctors across the country
| have fared far worse.
|
| That's...not a lot of money.
| stackskipton wrote:
| Doctors are probably raising alarms over growing practice. It's
| 3000 this year, but becomes 10000 next year and 50000 the year
| after.
| MattGrommes wrote:
| Yep. Frog, boiling water, etc.
|
| If they get away with it for a few offices and a little
| money, it just becomes how they do business and grows.
| costcopizza wrote:
| What, if any, alternative framework other than single payer could
| be put into place instead of our current hellscape?
|
| 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.
| Taikonerd wrote:
| The real problem is the billing model we have, where every
| individual act a clinician performs is separately billable...
| and separately haggle-able.
|
| One model that has shown promise is "bundled payments." For
| example, imagine that a certain insurance company switches to a
| bundled model for childbirth. They say, "we will pay a hospital
| $X to cover everything related to this patient's childbirth.
| Maybe it will be a very simple birth and the hospital will make
| a lot of money on it. Maybe it will be more complex/expensive,
| and the hospital will make less money. In some rare cases, the
| hospital will actually _lose_ money. "
|
| Why is this a better model? Well, 2 reasons:
|
| 1. the hospital has an incentive to provide care _efficiently_
| , rather than trying to churn out as many procedures as
| possible so they can bill more
|
| 2. there's just fewer numbers for providers and payers to
| haggle over
| 827a wrote:
| Where I live, we have three major hospital chains. Imagine one
| of them is Kaiser Permanente. My primary care is through
| Kaiser. When I needed to see a podiatrist to get a toenail
| removed, they were through Kaiser. When I went to an ER a few
| years ago for some abdominal pain, it was a Kaiser ER.
|
| It is _beyond_ me why my employer is paying an insurance
| company anything at this point. Kaiser should be selling me an
| annual plan where everything at Kaiser is covered, maybe up to
| a point, and then they have insurance-like network
| relationships with e.g. other ERs in the area, if you need
| them, plus out-of-area addons for when I 'm traveling.
|
| This is, fundamentally, in Kaiser's interest to sell (again, I
| don't live near Kaiser Permanente, I'm just using them as an
| example; every population center has networks of healthcare
| providers like this). They hate dealing with insurance as much
| as their patients do. But only recently have these healthcare
| mega-conglomerates achieved so much monopolistic integration
| that they could actually do this and people would be
| interested.
|
| Also, interestingly: My dentist does not accept insurance;
| direct pay. My eye doctor also does not accept insurance. This
| is also a new thing; it wasn't long ago that I recall them
| actually asking for it, but nowadays they just bill directly.
| It hasn't gotten more expensive (beyond the fact that my
| employer is paying for useless dental and vision insurance, but
| at least those are only like $1-$4/paycheck).
|
| Idk, my point is, I think things are changing and will continue
| to change faster than you might think. I'd love to see
| government-ran single-payer, but even admitting that is very
| unlikely to happen on the near term, there's just so much
| excess, waste, and bureaucracy in the medical system that some
| kind of short-circuiting direct-to-consumer play, by someone,
| will happen. Once a major healthcare provider chain can prove
| that this D2C model works (and it _would_ work), the dominoes
| will fall.
| cmdli wrote:
| > I'm surprised there isn't a Costco like medical group that's
| nationwide, has a membership, and works solely to provide care
| efficiently.
|
| What you are describing is an HMO, which hasn't had that much
| lower costs historically. Theoretically, you pay once and then
| they take care of you, but in practice costs haven't been that
| much lower.
| viktorcode wrote:
| The author lost me in the first sentence calling Deutsche Bahn a
| well-liked company. I don't know which planet they are from.
| immibis wrote:
| > 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
|
| > Duct tapers, ...
|
| > Box tickers, ...
|
| > Taskmasters ...
| greenchair wrote:
| 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.
| remus wrote:
| 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.
| m101 wrote:
| 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
|
| 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).
| senderista wrote:
| As long as providers have an incentive to overtreat and
| overcharge, I don't see how we can control costs without an
| adversarial system, as infuriating and dysfunctional as it is. I
| never had to deal with any of this while enrolled in a nonprofit
| HMO (there must be some internal adversarial dynamics there,
| though).
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