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The problem is there is a bunch of hidden complexity in medical coding and billing. There's 5 Evaluation & Maintenance (E&M) codes that may apply to an office v

The problem is there is a bunch of hidden complexity in medical coding and billing. There's 5 Evaluation & Maintenance (E&M) codes that may apply to an office visit, another 5 for ER visits, 4 for tele-medicine consults - which one is used depends on multiple factors that you can only know after the fact, and which one is applicable to the visit determines the expense. This doesn't factor in other procedures such as labs, and whether such charges are required to be bundled into the E&M fee by a specific payer or not - plus differing allowables from each payer. Add in the fact that nearly nobody bothers doing pre-authorizations except surgery centers and other outpatient services that payers require prior authorization for anyway and the whole situation turns into a giant clusterfuck. Is it POSSIBLE to do all of this and give you a proper quote before a visit? Sure, but it requires some fairly complex software to do so and manual input of tons of different data specific to your insurance contract that almost nobody wants to do it (ironically, the billing company I work for DOES this - but since we aren't involved in patient care it's only utilized to ensure we get paid properly by insurance companies).

tyingq 9y ago
Even with a line item precoded estimate, it would require some negotiation between what the doctor/lab thinks it costs versus what the insurance thinks. Doctors/Labs are often surprised after the fact by what the insurance company allows, thinks is miscoded, will pay, etc.
amerkhalid 9y ago
However, most hospitals don't enforce any requirements of "codes" or there are bunch of inter-changeable codes. If you get a bill from hospital, you can call billing department, ask them if they can try a different code to bill insurance company. And it is possible new code will lower your out of pocket cost. On few occasions I did this, I end up owing nothing out of pocket.
flubert 9y ago
>Sure, but it requires some fairly complex software to do so and manual input of tons of different data specific to your insurance contract that almost nobody wants to do it Can someone quantify the value added by having this complexity baked into the system? Is there any advantage besides the "confusopoly" aspect? https://en.wikipedia.org/wiki/Confusopoly https://en.wikipedia.org/wiki/Confusopoly Who is the main benefactor (in $$$) behind the drive for complication of medical billing? Doctors? Medical Office Receptionists? Insurance companies? Other third parties that doctors hire to handle paperwork? What are the benefits supposed to be over whatever we were using in 1975? If you were founding a clinic on Mars for the first colony, would anyone duplicate our current system of medical billing?
- arcbyte 9y ago
  Theres no main benefactor. It was Medicare/Medicaid that initiated code based payment and because they are the largest payor, everyone else was forced to go along. What they get out of it now are public health statistics. Doctors dont get anything out of this. Ultimately treating medical coding as the price determination mechanism is the cancer behind all our problems.
  - chimeracoder 9y ago
    > What they get out of it now are public health statistics. We actually don't really get those out of the medical billing situation either. ICD codes are what's used for public health statistics, whereas CPT codes are used for billing. I mean, we could use that data for public health statistics, but we don't really. And we could still have gotten it without the rest of the sacrifices that have come along with the code-based payment systems that have turned practices into offices for billing, with a marginal medical practice on the side. Unfortunately, as you said, because Medicare is 40% of the payer market, once they switched to this model, it created the vicious cycle we're now in.
    - dragonwriter 9y ago
      > ICD codes are what's used for public health statistics, whereas CPT codes are used for billing. Very roughly (it's more complex, but not worth more detail here) ICD-10-CM diagnosis codes are used for billing, and ICD-10-PCS procedure codes are used for institutional billing, as well. HCPCS (which include CPT) procedure codes are used for professional services billing.
      - chimeracoder 9y ago
        > Very roughly (it's more complex, but not worth more detail here) ICD-10-CM diagnosis codes are used for billing, and ICD-10-PCS procedure codes are used for institutional billing, as well. HCPCS (which include CPT) procedure codes are used for professional services billing. Yeah, this is the rabbit hole I was hoping not to have to go down. :) All I wanted to illustrate was that the desire for public health statistics could be satisfied without requiring a move to the flaws of the current billing model - they're different systems. (And historically, the move to the current billing model came about primarily for reasons other than a desire for public health statistics).

tyingq 9y ago

Even with a line item precoded estimate, it would require some negotiation between what the doctor/lab thinks it costs versus what the insurance thinks. Doctors/Labs are often surprised after the fact by what the insurance company allows, thinks is miscoded, will pay, etc.

amerkhalid 9y ago

However, most hospitals don't enforce any requirements of "codes" or there are bunch of inter-changeable codes. If you get a bill from hospital, you can call billing department, ask them if they can try a different code to bill insurance company. And it is possible new code will lower your out of pocket cost. On few occasions I did this, I end up owing nothing out of pocket.

flubert 9y ago

>Sure, but it requires some fairly complex software to do so and manual input of tons of different data specific to your insurance contract that almost nobody wants to do it Can someone quantify the value added by having this complexity baked into the system? Is there any advantage besides the "confusopoly" aspect? https://en.wikipedia.org/wiki/Confusopoly https://en.wikipedia.org/wiki/Confusopoly Who is the main benefactor (in $$$) behind the drive for complication of medical billing? Doctors? Medical Office Receptionists? Insurance companies? Other third parties that doctors hire to handle paperwork? What are the benefits supposed to be over whatever we were using in 1975? If you were founding a clinic on Mars for the first colony, would anyone duplicate our current system of medical billing?

arcbyte 9y ago
Theres no main benefactor. It was Medicare/Medicaid that initiated code based payment and because they are the largest payor, everyone else was forced to go along. What they get out of it now are public health statistics. Doctors dont get anything out of this. Ultimately treating medical coding as the price determination mechanism is the cancer behind all our problems.
- chimeracoder 9y ago
  > What they get out of it now are public health statistics. We actually don't really get those out of the medical billing situation either. ICD codes are what's used for public health statistics, whereas CPT codes are used for billing. I mean, we could use that data for public health statistics, but we don't really. And we could still have gotten it without the rest of the sacrifices that have come along with the code-based payment systems that have turned practices into offices for billing, with a marginal medical practice on the side. Unfortunately, as you said, because Medicare is 40% of the payer market, once they switched to this model, it created the vicious cycle we're now in.
  - dragonwriter 9y ago
    > ICD codes are what's used for public health statistics, whereas CPT codes are used for billing. Very roughly (it's more complex, but not worth more detail here) ICD-10-CM diagnosis codes are used for billing, and ICD-10-PCS procedure codes are used for institutional billing, as well. HCPCS (which include CPT) procedure codes are used for professional services billing.
    - chimeracoder 9y ago
      > Very roughly (it's more complex, but not worth more detail here) ICD-10-CM diagnosis codes are used for billing, and ICD-10-PCS procedure codes are used for institutional billing, as well. HCPCS (which include CPT) procedure codes are used for professional services billing. Yeah, this is the rabbit hole I was hoping not to have to go down. :) All I wanted to illustrate was that the desire for public health statistics could be satisfied without requiring a move to the flaws of the current billing model - they're different systems. (And historically, the move to the current billing model came about primarily for reasons other than a desire for public health statistics).