The fight between doctors and insurance companies over 'downcoding'

https://www.nbcnews.com/health/health-care/guilty-proven-innocent-fight-doctors-insurance-companies-downcoding-rcna230714

by ceejayoz • 10 months ago

242 345 10 months ago

nbcnews.com

coleca• 10 months ago

Good startup idea would be to work with medical practices to use AI to automate the disputing of the "downcoding" by insurers.

ActionHank• 10 months ago

The business will be very quickly bought up to kill the product.

daveguy• 10 months ago

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.

cogman103• 10 months ago

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.

actionfromafar• 10 months ago

In fact, you could take out an insurance which will help with the Disputotron costs, should they arise. No you can't know the costs in advance.

tantalor• 10 months ago

Hate it, thanks

Spivak• 10 months ago

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.

pragmatic2• 10 months ago

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.

vjvjvjvjghv5• 10 months ago

The result will be that doctor AIs will be fighting insurer AIs and the loser will be the patient. As always.

elwebmaster2• 10 months ago

Already working on this, let's connect if you are interested: https://forms.gle/cxQZg5Q27PsT65d97

abrichvi85• 10 months ago

I already have a solution to the downcoding practices of these health insurance carriers.

I recently created an application called EMpowerAI that uses AI to analyze clinical notes and assign appropriate billing codes based on medical complexity or documented time. It also can enhance the Assessment/Plan to justify higher billing codes if the note content supports it.

I presented it at the HRX conference in Atlanta on 9/4/2025 in the top 5 abstracts session. Here is the abstract: https://www.heartrhythmopen.com/article/S2666-5018(25)00291-...

As a Cardiac Electrophysiologist, I optimized the application for cardiology and EP, though it is scalable to other specialties. I am looking for beta testers and would appreciate any feedback. Here is a link to the app:

http://em-billing-assistant.onrender.com/

Leave your name and email here if you would like to receive updates:

https://forms.gle/MoVhdna81pq9F45NA

Apreche• 10 months ago

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• 10 months ago

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.

nradov14• 10 months ago

When providers join payer networks they generally waive their right to sue over issues like this.

postflopclarity• 10 months ago

good luck suing when lawyers cost the doctor 2k/hour and the insurance companies have armies of in house counsel.

gwbas1c2• 10 months ago

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_random2• 10 months ago

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• 10 months ago

Man, it's almost like healthcare and human lives shouldn't be for profit...

lesuorac• 10 months ago

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• 10 months ago

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• 10 months ago

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.

pragmatic2• 10 months ago

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• 10 months ago

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.

spiffytech• 10 months ago

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.

tptacek4• 10 months ago

Care providers make massively, massively more money than insurance providers.

nradov14• 10 months ago

It depends on the size of the provider organization. In some areas there has been a lot of provider consolidation driven by the need to gain more negotiating power with commercial payers. So we end up with only a few large integrated delivery systems dominating certain regional markets.

bena2• 10 months ago

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.

hibikir5• 10 months ago

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.

nradov14• 10 months ago

Health plans are legally required to publish their rates and they all comply with this now. You can literally just go to any payer web site and download the MRF. There are occasional data errors but overall the numbers are generally accurate.

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

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

anigbrowl• 10 months ago

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• 10 months ago

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-g3• 10 months ago

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...

vjvjvjvjghv5• 10 months ago

“ 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.

Ancalagon• 10 months ago

why dont other countries have similar amounts of healthcare fraud in their single-payer systems?

arealaccount• 10 months ago

I never understood why insurers get all the flack while the providers get a pass.

cogman103• 10 months ago

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• 10 months ago

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.

potato37328423• 10 months ago

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

unyttigfjelltol2• 10 months ago

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• 10 months ago

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• 10 months ago

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• 10 months ago

It's beyond our control, says only country where this happens daily.

antonymoose• 10 months ago

Pretty sure fraudulent billing practices exist in a variety of nations and industries.

bluGill• 10 months ago

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).

pnathan• 10 months ago

I wonder how this plays out with Kaiser and other integrated practices.

breadwinner3• 10 months ago

They try to convince you that you're fine and don't need any treatment.

gwbas1c2• 10 months ago

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• 10 months ago

"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• 10 months ago

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.

estimator7292• 9 months ago

The counter to this is that now when you go to urgent care, they're only allowed to do one thing and send you to the ER for any other concurrent problems where you pay 10x more because it's an "emergency"

silexia• 10 months ago

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.

philipallstar6• 10 months ago

Indeed. Part of the problem is news vendors will only tell one side of the story. If that dentist only billed, say, $150 ($40 per x-ray including time, wear, consumables), $20 for teeth cleaning time, $50 for rent, property rates, taxes, profit) then you'd pay far less in insurance. They all bill more because they can.

eigencoder• 10 months ago

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• 10 months ago

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.

Taikonerd2• 10 months ago

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

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

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

darth_avocado8• 10 months ago

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).

sarchertech7• 10 months ago

I go in person, get antibiotics and get cured.

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

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

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

3D304974202• 10 months ago

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>

hypeatei4• 10 months ago

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• 10 months ago

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.

lotsofpulp11• 10 months ago

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.

supportengineer2• 10 months ago

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• 10 months ago

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.

ratelimitsteve4• 10 months ago

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

andrewmcwatters• 10 months ago

This is absolutely unacceptable when per employee healthcare employer costs are basically now something like, I don't know, 20,000-25,000 USD?

jimbokun3• 10 months ago

"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• 10 months ago

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.

testing223214• 10 months ago

…. So you pay many thousands a year for insurance, but it’s easier not to use it?

Ummm

trentnix• 10 months ago

I’ve found, as a fairly recent phenomenon, it’s often higher than the insurance price. The pessimist in me thinks that insurance companies have worked to close that loophole. They need to maintain the illusion of their utility, after all.

khuey2• 10 months ago

Good luck a) actually getting a price named and b) having that price be honored.

Outside of certain procedures which are used to cash payers (dentists, lasik, plastic surgeons, imaging) this is nearly impossible in my experience.

vjvjvjvjghv5• 10 months ago

This is the magic endgame for insurers. Make your product so hard to use that people give up and don't even use insurance.

naijaboiler• 10 months ago

not magic words. sometimes cash price is non-insurance price and is 3x the insurance price. since insurance and providers have a negotiated rates. so paying cash means paying 3-5x

nobody9999• 10 months ago

Here are the magic words in US Health Care: "What is the cash price?"

I'm not so sure about that. Especially in a hospital setting.

Many years ago, I was admitted to the hospital for several days as it was suspected (wrongly, but that's another issue with the perverse incentives in US "healthcare") that I had MRSA and the doctor wanted me on IV antibiotics while testing proceeded.

I spent three days in the hospital, getting discharged when the tests came back negative for MRSA.

Shortly thereafter, I received a detailed "explanation of benefits" (EOB) from my insurer, which put the cost of my hospital stay at ~USD$12,000 which included stays in two hospital rooms simultaneously as well as a pap smear (despite the fact that I do not have a cervix). When I complained about this, the insurer tried to make it seem unimportant, but I pressed the issue as both the hospital and the insurer seemed to be involved in some sort of fraud WRT billing.

I was told I shouldn't care because I wasn't actually paying, but I persisted as I was concerned that there was something hinky going on. That culminated in a conference call with my insurance company, the hospital's accounts receivable group and me.

The two other parties talked in insurance billing jargon for a while, but when pressed, they stated that the charges on the "explanation of benefits" was a fiction and that the insurance company and hospital group's contract set a USD$1,500/day flat rate for patients admitted to the hospital's facilities -- roughly 1/3 of the "costs" cited in the EOB.

The made up stuff (which they didn't even try to hide that it was made up) was there as "protection" for the hospital group as the "cash price" of such services, even though I couldn't have received such services (two rooms at the same time? A pap smear[0] despite the fact that I don't have a female reproductive system, nor do/did I present as anything other than a cis male?).

I imagine that there may be some cases where a "cash price" actually does reflect costs and might even be less than insurance costs (although that seems unlikely given my experience), but insurers and healthcare providers do and have for decades gamed the "cash price" to justify the insane overcharging of healthcare services. YMMV.

[0] https://www.mayoclinic.org/tests-procedures/pap-smear/about/...

aduffy• 10 months ago

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.

empressplay2• 10 months ago

Where do you live, so people know not to move there? Jesus.

M95D• 10 months ago

1) Report fraud to insurer? 2) Get a lawyer?

Would any of that work?

alphazard• 10 months ago

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.

wisty2• 10 months ago

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...)

int_19h3• 10 months ago

I'm sorry, but this is bullshit. The American system is nothing like the Soviet one. I've seen both first hand. Both are kinda crappy but in very different ways. If I had to choose one though it'd be Soviet for sure because it's still guaranteed healthcare no matter what your financial situation is.

potatoicecoffee• 10 months ago

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.

hintklb2• 10 months ago

Hmm sure, but there must similarly be things that are denied right?

I lived in both systems. In a single payer system, the state essentially decide what is allowed and what is not. And with the state as a single payer, they also go back and forth on price with the hospitals.

It still is a better system overall but there is no places where you can just spend as much as you want on healthcare without some type of centralized supervision.

xtajv3• 9 months ago

Fire insurance protects against the rare disaster where there's a fire.

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.

djoldman3• 10 months ago

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_• 10 months ago

Are you talking overnight? If so, that’s an easy predictable outcome.

hypeatei4• 10 months ago

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.

djoldman3• 10 months ago

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.

nradov14• 10 months ago

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.)

renewiltord4• 10 months ago

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.

elwebmaster2• 10 months ago

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

renewiltord4• 10 months ago

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• 10 months ago

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• 10 months ago

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• 10 months ago

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• 10 months ago

Aren't these basically mutual healthcare providers? We have them in Europe.

renewiltord4• 10 months ago

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

ChadNauseam2• 10 months ago

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).

breadwinner3• 10 months ago

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.

nradov14• 10 months ago

Reputation is pretty much worthless. Patient reviews are largely based on how nice the doctor seems (bedside manner) and have no correlation with actual clinical outcomes.

themafia3• 10 months ago

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• 10 months ago

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.

renewiltord4• 10 months ago

The ones who can't afford it (<200% federal poverty level) are covered in Texas. Friend who gave birth in Austin, TX talked to other mothers in the ward and one was having her second under that. There's lots of programs that cover this. Abortion should be legal, yes, but you won't be out that amount if you don't make enough.

System seems fine, though I think I'd prefer if we completely subsidized childbirth and 12 months after for all (because those are people who will keep us solvent in the future).

nradov14• 10 months ago

No one with health insurance pays $40K for a birth. Even for high-deductible health plans the current family out of pocket annual maximum is $21K.

https://www.healthcare.gov/glossary/out-of-pocket-maximum-li...

I'm not trying to defend Texas healthcare policies here but at least get your numbers right.

pazimzadeh• 10 months ago

Not true, I've been denied certain tests even though I offered to pay in cash if the doctor thought it wasn't medically necessary.

standardUser2• 10 months ago

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.

themafia3• 10 months ago

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.

hibikir5• 10 months ago

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.

standardUser2• 10 months ago

I'd argue the problem is that doctors and insurance companies are two for-profit entities fighting it out for every penny, whereas the people who ultimately pay for the services aren't part of that conversation. If making me an afterthought makes you (the doctor) more money, I become an afterthought (assuming I don't have other options, which most people don't). I can't imagine it working any other way, aside from magical altruism.

The dental industry gets no defense from me as I've been subject to attempts at swindling and coercion more times than I can remember, as if it's standard practice.

dboreham• 10 months ago

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...

ratelimitsteve4• 10 months ago

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.

philipallstar6• 10 months ago

If you keep the same regulatory environment then the same industry will arise.

doormatt• 10 months ago

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• 10 months ago

Doctors are probably raising alarms over growing practice. It’s 3000 this year, but becomes 10000 next year and 50000 the year after.

MattGrommes• 10 months ago

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• 10 months ago

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.

Taikonerd2• 10 months ago

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

827a2• 10 months ago

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.

testing223214• 10 months ago

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.

If you’re trying to solve them problem, why on earth do you propose such an expensive, convoluted and strange solution?

Two dozen countTies have solved this. It works very, very well. People pay less and get better outcomes. What more do you want?

Interesco• 10 months ago

Does your dental insurance not reimburse you? My dentist is also direct pay but submits for reimbursement on my behalf. They get paid up front and I get a check a few weeks later.

nradov14• 10 months ago

I don't understand your comment. Kaiser Permanente health plans already work that way. If you go to an out-of-network provider then they can still submit a claim to KP, although prior authorization may be required in some circumstances.

FireBeyond2• 10 months ago

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.

Well, then you are beholden to Kaiser. Kaiser will not pay for any treatment or medication for weight loss other than gastric bypass surgery. Kaiser will not pay for many medications for mental health, especially for adolescents. Will not pay for medications that could be used for ED, even if not being prescribed for that.

And the most annoying, recently: My partner got a couple of root canals, and was in significant pain and discomfort as you'd expect. Dentist sent her prescriptions for antibiotics and pain management to Kaiser, and we go after her surgery to pick them up at the Kaiser UC/ER hybrid.

No pain meds for you. "We will only fill that through mail order - you'll get it in 5-7 business days". Very helpful for that post-surgical pain now. The irony being that they absolutely had those drugs in stock and available, they were just only for their UC/ER inpatients.

cmdli• 10 months ago

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• 10 months ago

The author lost me in the first sentence calling Deutsche Bahn a well-liked company. I don't know which planet they are from.

immibis3• 10 months ago

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• 10 months ago

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• 10 months ago

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• 10 months ago

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).

testing223214• 10 months ago

You don’t need to attempt something that has never been done before with no guarantee of the outcome.

This is a solved problem in two dozen countries and it’s been working for many, many decades.

throwaway2037• 10 months ago

    > 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

Do you know if SK govt owns hospitals? Or are they all private? In Japan, it has a similar system, but lots of the larger facilities are owned by govt, or associated with a public university.

Braxton19802• 10 months ago

"And for God's sake, get the government out of it!!"

But then you suggest using the South Korean system where the government runs the insurance.

And you say; "so I think it might make sense to make it govt run."

So which is it?

senderista• 10 months ago

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).

crazygringo2• 10 months ago

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.

Everything about American healthcare is bad.

leoh2• 10 months ago

Everything about American healthcare is bad.

Except the part where you are cared for by a competent clinician?

danpalmer3• 10 months ago

Are clinicians any more competent than in other countries with similar levels of training? In Europe, UK, or here in Australia for example, the quality of public care seems to be competitive with the US, and the quality of private care here seems often even better.

I've heard this "US healthcare is expensive but at least it's good" thing a few times, but never with any particular evidence, and from the few numbers I remember seeing, healthcare outcomes are generally no better.

xtajv3• 9 months ago

There's plenty of hasty generalizations going on in this comment.

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.

cameldrv• 10 months ago

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.

sarchertech7• 10 months ago

Doctors lose their license and go to jail for Medicare fraud all the time.

Our_Benefactors• 10 months ago

When someone loads their grocery bag full of cosmetics and razor blades, they get on the news and YouTube

What does this part mean? I don't follow.

tanjtanjtanj• 9 months ago

They're talking about shoplifting. Specifically hiding high dollar items in with their groceries, a practice akin to just adding a little bit extra to a medical bill for services not performed.

tonymet3• 10 months ago

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.

sarchertech7• 10 months ago

Most doctors don’t do their own billing. It’s too complex. They have specialists who take their notes and turn them into bills.

tonymet3• 10 months ago

while you're right most of the billing pressure is likely coming from administrators and boards, doctors do participate with petty / pointless consults , excessive testing & procedures, absurd hour restrictions, and indirectly through medical boards reducing capacity, among other factors

danny_codes• 10 months ago

I mean aside from the fact that insurance in healthcare don’t provide any value at all, and healthcare providers provide, you know, actual healthcare, then sure.

Healthcare insurance companies are completely pointless because healthcare is a human right. All other developed countries have figured this out and provide healthcare universally. We could fully socialize “healthcare insurance companies” and have exactly zero negative repercussions. The only outcome would be eliminating a useless industry and saving ~$500 billion a year.

randcraw• 10 months ago

The obvious solution: doctors need to start upcoding their cases by default.

nradov14• 10 months ago

Upcoding for services not actually performed is fraud. Providers who do this may be dropped from the health plan's network, and in extreme cases referred for criminal prosecution.

nvader• 10 months ago

I wonder how this sentence ended up with so many commas.

The problem, doctors say, is that lower and lower reimbursements mean reliable community doctors, like Wagner, could have to make choices that are inherently bad for patients, like cramming more patient visits into a single day to make up for lost revenue, dropping patients on certain insurance plans, or selling their practices altogether.

alakep• 10 months ago

There need to be more companies solving this from first principles like Yuzu Health.

They have a cool blog at https://yuzu.health/blog that gets into the dynamics of this stuff. Legacy insurance is cooked.

mayneack• 10 months ago

Don't you mean "we" have a cool blog? Looks like you work there.

keoneflick• 10 months ago

These sorts of projects always seem to end up with the worst doctors. At the end of the day, seeing a good doctor is all the patient wants.

oakmad2• 10 months ago

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.

doctorpangloss• 10 months ago

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.

throwaway1737383• 10 months ago

Who have you talked to that enjoyed dealing with their insurance provider? Every single provider I’ve had had nightmarishly complicated customer support who couldn’t be trusted to give you accurate information.

crazygringo2• 10 months ago

Employer sponsored health insurance plans are popular and also give good vibes.

This sounds so crazy to me that I feel like something got miscommunicated.

Who has good vibes about their health insurance? In America?

It's not the "aesthetic experience". It's about paying fairly and progressively in a predictable way via taxation, vs. completely unpredictable billing in the US. Is it in network? Is it pre-authorized? Did your doctor code it correctly? Is it below your deductible? Is there a copayment? What mystery charges will there be? What will insurance refuse to cover, wrongly? How many rounds of appeals will you have to go, over how many months? Not so good vibes.

viraptor• 10 months ago

also give good vibes.

I've heard enough "can't afford the risk of changing jobs" and "current work sucks, but I have to have insurance for my current issues". Honestly it doesn't feel like good vibes, especially with the recent issues on the job market.

oakmad2• 9 months ago

I never had good vibes with an employer sponsored plan. I had the same employer for eleven years in TX. Every year the insurer changed. Every year there was the paper work and trying to decipher what was included and what the copay might be. There also weren’t good vibes from the providers and the way they’re forced to operate.

Yes I agree, I pay for healthcare as part of my taxes, essentially the same amount as the guy sitting next to me. To be honest it doesn’t feel any different to paying taxes in the US.

teleforce• 10 months ago

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:

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/

valleyer• 10 months ago

Generally here the more important codes would be the CPT codes.

I doubt the insurance company would downcode the diagnosis, just the procedure.

nhinck3• 10 months ago

Just to add on, it's called coding because it was, at one point, the act of taking chart notes and turning them into ICD codes.

nradov14• 10 months ago

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.

Rileyen• 10 months ago

One time I got a test done because my doctor recommended it, but insurance refused to cover it. I spent hours making calls, but no one could give me a clear answer.

That’s when I started to wonder if I was actually getting medical care, or just stuck in a system no one really understands.

firesteelrain4• 10 months ago

Downcoding is listed as a problem.

But who is to say that it should cost $175? What if it really should be $125?

It’s the people and patients caught in the middle

xtajv3• 9 months ago

Translation: Insurance companies intentionally injecting bugs into their own software to make requests that don't respect user input.

Despicable.

notmyjob• 9 months ago

What would the Austrians say?

sharts• 9 months ago

All of this happens because so many drink the free market koolaid. Insurance, in general, is glorified paper pushing and legalized gambling.

Yes lobbyists exist but I don’t understand why so many regular people support this broken middle-man system.

The fight between doctors and insurance companies over 'downcoding'

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