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.
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.
That's the insurance companies' stance. The work you performed is this and so our agreed upon rate is this.
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 )
(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.
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.
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.
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.
https://www.azcentral.com/story/news/local/arizona-health/20...
They don’t. They want to increase profits by pushing more and more cost to the patient while squeezing providers. The patient is always the loser in this system. One reason is that most patients don’t even have a choice of insurance because their employer picks the insurance that’s best for the employer.
When a provider rips off an insurer it's invisible to the general public.
Also, incidentally, when people talk about fraud in Medicare/Medicaid, the providers are almost always where that happens (yet that's often not pointed out).
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.
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
Many medical administrations do everything they can to upcode in order to bill for more money.
The whole system is a mess.
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.
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).
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.
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.
They billed my insurance for over a thousand dollars.
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>
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?
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.
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.
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.
coleca•2h ago
ActionHank•2h ago
daveguy•2h ago
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•2h ago
https://knowyourmeme.com/memes/were-all-trying-to-find-the-g...
cogman10•2h ago
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•1h ago
Spivak•1h ago
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•1h ago
The data is a disaster. Turnover is high, errs everywhere. Disputing is the easy part. Hard part is finding the contracts lol.
vjvjvjvjghv•1h ago
elwebmaster•49m ago