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In a past life, I worked in health insurance fraud detection. Everybody should know, the health insurance system in the US is fundamentally broken and has been

In a past life, I worked in health insurance fraud detection. Everybody should know, the health insurance system in the US is fundamentally broken and has been almost since its inception in the early 20th century. The lack of adequate consumer protection, transparency, health systems and appropriate government regulation, in addition to organizational oversight, has lead to a situation where we have poor systems that can easily be exploited. And they are exploited. What the third party care outsourcing/billing company mentioned in the article (Emcare) was doing sounds like upcoding. They bill the highest cost service they legitimately can to maximize profit. In this case, as a third party billing organization, they both want to maximize the profit for their customer (the hospital system), but also for themselves, as they surely take a cut as a middle man. Likely, they were operating within the gray area where illegal upcoding has to be proven in a court of law. It is an expensive process, that requires review and comparison of huge amounts of medical records with claims to determine whether the more expensive procedure billed was medically necessary/appropriate, or if it was egregious. That legal process does pan out sometimes in the end, but it can take years and just adds even more overhead. Coding correctly, fairly and getting reimbursed correctly and fairly is incredibly complex. There are an enormous number of combinations of services (usually represented by codes called HCPCs and CPT codes) and diagnoses (ICD-10... which has 100,000s of codes), as well as all different regulations and scenarios for settings of care (inpatient, outpatient, doctor's office, etc.). Props go to the hospital system for taking back their coding after they realized what the third party was doing, but the reality is, it was probably financially benefiting the hospital system too. Every technology that I know of has been tried to address these issues, such as data mining, machine learning, rule-based expert systems, etc. and none of them has addressed the root cause, which is the basic system is fundamentally flawed. All the politics you see about US healthcare in the news are, in a way, representative of the root problem - how big and complex the systems are now, how much money they represent, and how many interests are involved. We have a tangled web. I don't know the solution (and many have been proposed).

snuxoll 9y ago
> Props go to the hospital system for taking back their coding after they realized what the third party was doing, but the reality is, it was probably financially benefiting the hospital system too. I doubt the hospital system got anything from it, physician groups usually keep all their revenue from professional services claims - the hospital gets paid whatever they do for their facility claim regardless of what the professional claim pays.
- sixdimensional 9y ago
  It's possible you're right. Without knowing the details of the relationship, you never know. The reason I say that is the article points out another glaring issue - the shortage of ER docs that we are currently facing. I know this first-hand, as I have a family member who is one and is working harder than ever. Some of these arrangements are to make up for the shortage, and the hospital systems and physician groups are often working in partnership... so it could be there was benefit for both since the hospital system needed coverage for their ER (due to physician shortages), and Emcare is providing the physicians. Without the physicians doing the services in the hospital, there would be no facility claim either...
  - snuxoll 9y ago
    > It's possible you're right. Without knowing the details of the relationship, you never know. This is true, and being a mere software developer I'm in the dark on the contents of any of the contracts my parent company has with facilities either. > The reason I say that is the article points out another glaring issue - the shortage of ER docs that we are currently facing. I know this first-hand, as I have a family member who is one and is working harder than ever. Insert my standard rant about restricted med-school/residency admissions and cost of tuition here.
    - sixdimensional 9y ago
      It's sad but true that we are getting to a point where all we have are standard rants about these topics, but can't find the solution. I'm guilty of the same too. Stalemate. We need to go through Kurt Lewin's change model process - "unfreezing, change, and refreezing" and find something better. It's like, we need agile healthcare or something - fail fast and iterate faster... without costing people their lives or their savings. https://en.wikipedia.org/wiki/Kurt_Lewin#Change_process https://en.wikipedia.org/wiki/Kurt_Lewin#Change_process
AngeloAnolin 9y ago
> Every technology that I know of has been tried to address these issues, such as data mining, machine learning, rule-based expert systems, etc. and none of them has addressed the root cause, which is the basic system is fundamentally flawed. There's no technology cure for the insatiable greed of a few. Sad reality.
AndrewKemendo 9y ago
how big and complex the systems are now, how much money they represent, and how many interests are involved I don't follow what you're saying. Are you proposing that the root of the problem is that it's a huge, expensive, complex industry, where a lot of people work?
- sixdimensional 9y ago
  Yes, I'm proposing that the high level of complexity and ambiguity involved (which originates from the intersection of the technology, organizations, politics, finances and people) in the US healthcare and health insurance system is the root cause of the problem. It is another giant machine, like the military industrial complex, for example. I don't want to go so far as to say all huge institutions have problems like this, but I am thinking along those lines. Some have proposed simplifying health insurance greatly by running a "single payor" system, where the emphasis is on a single health insurance entity that covers claims for every person in the US. While that might seem like a simplification in terms of process, procedure and organizations, it is very unlikely to happen in the US, and I'm not sure we could even administer that well either. If you look at other countries that are closer to single payor, maybe say, the British NHS system - even in those countries, private insurance still exists and competes. The NHS does provide care for everyone and eliminates some issues by having a stricter control system, but the quality, availability and timeliness of that care is often called into question. In the end, being able to dictate quality, access, and affordability (and preventing fraud) comes down to control vs. morals/ethics. Many are vying for control, for many different reasons and this often tears apart the basic industry, while morals/ethics are difficult to maintain.
  - AndrewKemendo 9y ago
    Thanks for clarifying. I think however it's the wrong measure. There are industries that are as large or larger with as much if not more complexity that aren't failing to such a degree that their size is a systemic risk. For example the US Real estate market is 7.4 Trillion, about 2X the size of the health care market with many more players and much more predicable outcomes. Finance and insurance are about the same size as well and are not terribly broken. [1]https://en.wikipedia.org/wiki/Economy_of_the_United_States#GDP_by_industry https://en.wikipedia.org/wiki/Economy_of_the_United_States#G...
xenihn 9y ago
This really sucks. I don't even see how an overhaul could be done.
rmmw 9y ago
Hi sixdimensional, thank you for the insightful comment here. I've been researching this area, and I'd love to chat more with you, would you be open to that? My email is on my profile page, feel free to email me on that address and I'll follow up.

snuxoll 9y ago

> Props go to the hospital system for taking back their coding after they realized what the third party was doing, but the reality is, it was probably financially benefiting the hospital system too. I doubt the hospital system got anything from it, physician groups usually keep all their revenue from professional services claims - the hospital gets paid whatever they do for their facility claim regardless of what the professional claim pays.

sixdimensional 9y ago
It's possible you're right. Without knowing the details of the relationship, you never know. The reason I say that is the article points out another glaring issue - the shortage of ER docs that we are currently facing. I know this first-hand, as I have a family member who is one and is working harder than ever. Some of these arrangements are to make up for the shortage, and the hospital systems and physician groups are often working in partnership... so it could be there was benefit for both since the hospital system needed coverage for their ER (due to physician shortages), and Emcare is providing the physicians. Without the physicians doing the services in the hospital, there would be no facility claim either...
- snuxoll 9y ago
  > It's possible you're right. Without knowing the details of the relationship, you never know. This is true, and being a mere software developer I'm in the dark on the contents of any of the contracts my parent company has with facilities either. > The reason I say that is the article points out another glaring issue - the shortage of ER docs that we are currently facing. I know this first-hand, as I have a family member who is one and is working harder than ever. Insert my standard rant about restricted med-school/residency admissions and cost of tuition here.
  - sixdimensional 9y ago
    It's sad but true that we are getting to a point where all we have are standard rants about these topics, but can't find the solution. I'm guilty of the same too. Stalemate. We need to go through Kurt Lewin's change model process - "unfreezing, change, and refreezing" and find something better. It's like, we need agile healthcare or something - fail fast and iterate faster... without costing people their lives or their savings. https://en.wikipedia.org/wiki/Kurt_Lewin#Change_process https://en.wikipedia.org/wiki/Kurt_Lewin#Change_process

AngeloAnolin 9y ago

> Every technology that I know of has been tried to address these issues, such as data mining, machine learning, rule-based expert systems, etc. and none of them has addressed the root cause, which is the basic system is fundamentally flawed. There's no technology cure for the insatiable greed of a few. Sad reality.

AndrewKemendo 9y ago

how big and complex the systems are now, how much money they represent, and how many interests are involved I don't follow what you're saying. Are you proposing that the root of the problem is that it's a huge, expensive, complex industry, where a lot of people work?

sixdimensional 9y ago
Yes, I'm proposing that the high level of complexity and ambiguity involved (which originates from the intersection of the technology, organizations, politics, finances and people) in the US healthcare and health insurance system is the root cause of the problem. It is another giant machine, like the military industrial complex, for example. I don't want to go so far as to say all huge institutions have problems like this, but I am thinking along those lines. Some have proposed simplifying health insurance greatly by running a "single payor" system, where the emphasis is on a single health insurance entity that covers claims for every person in the US. While that might seem like a simplification in terms of process, procedure and organizations, it is very unlikely to happen in the US, and I'm not sure we could even administer that well either. If you look at other countries that are closer to single payor, maybe say, the British NHS system - even in those countries, private insurance still exists and competes. The NHS does provide care for everyone and eliminates some issues by having a stricter control system, but the quality, availability and timeliness of that care is often called into question. In the end, being able to dictate quality, access, and affordability (and preventing fraud) comes down to control vs. morals/ethics. Many are vying for control, for many different reasons and this often tears apart the basic industry, while morals/ethics are difficult to maintain.
- AndrewKemendo 9y ago
  Thanks for clarifying. I think however it's the wrong measure. There are industries that are as large or larger with as much if not more complexity that aren't failing to such a degree that their size is a systemic risk. For example the US Real estate market is 7.4 Trillion, about 2X the size of the health care market with many more players and much more predicable outcomes. Finance and insurance are about the same size as well and are not terribly broken. [1]https://en.wikipedia.org/wiki/Economy_of_the_United_States#GDP_by_industry https://en.wikipedia.org/wiki/Economy_of_the_United_States#G...

xenihn 9y ago

This really sucks. I don't even see how an overhaul could be done.

rmmw 9y ago

Hi sixdimensional, thank you for the insightful comment here. I've been researching this area, and I'd love to chat more with you, would you be open to that? My email is on my profile page, feel free to email me on that address and I'll follow up.