4 ms·

> And one of the reasons for the most complicated billing system in the world is for-profit Insurance companies. Not really. In fact, Medicare is responsible f

> And one of the reasons for the most complicated billing system in the world is for-profit Insurance companies. Not really. In fact, Medicare is responsible for most of the current billing system, not private insurers.

cptskippy 9y ago
Medicare is relatively simple compared to most insurance companies and their rules. Insurance providers write custom lines of business for employers per state and allow those employers to customize the coverage however they like. This happens annually with revisions done to exclude or include coverage as the employer dictates. Insurance companies, and employers, come up with byzantine rules for what's covered, when it's covered, where it's covered, who is allowed to provide care, prerequisites before approving coverage, what brand of products are permitted in treatment, and on and on. The net effect is that the rules are multi-variant to the point that they cannot realistically be validated or tested by humans. There are entire industries dedicated to maintaining rules management engines specifically for validating policies, coverage, and claims.
- chimeracoder 9y ago
  > Medicare is relatively simple compared to most insurance companies and their rules. As someone who's actually had to deal with this complexity and implement software to facilitate it, I can assure you that Medicare is not at all simple, by any stretch of the imagination. It's not even standard or consistent within Medicare within a geographical region, even if you limit the scope to Part A and Part B, excluding coverage provided under Part C and Part D. > Insurance companies, and employers, come up with byzantine rules for what's covered, when it's covered, where it's covered, who is allowed to provide care, prerequisites before approving coverage, what brand of products are permitted in treatment, and on and on. This is exactly what Medicare itself does. The private insurers generally structure their terms in ways that are similar to what Medicare does. They're not identical, but it's not like Medicare is some haven of simplicity by itself that the private insurers complicate. Medicare itself is unbelievably complicated and abstruse by itself. > There are entire industries dedicated to maintaining rules management engines specifically for validating policies, coverage, and claims. Yes, that's true. And that would be true even if you only looked at Medicare patients.
  - cptskippy 9y ago
    It's not that Medicare is simple, it's not. It's that there are thousands of private insurance companies each holding thousands of lines of insurance each with their own set of rules comparably complex to Medicare. Medicare is by volume the larges provider but size is actually a benefit because it means that it's dealt with more frequently and is more familiar to care providers. A care provider isn't multi-regional, thus when they deal with Medicare it's mostly consistent. The interface is at least similar. However they can have 100 patients with United Healthcare and each patient will have a unique and different line of insurance. Medicare isn't simple, it's just a small piece of a very big shit sandwich.
    - chimeracoder 9y ago
      > A care provider isn't multi-regional, thus when they deal with Medicare it's mostly consistent. The interface is at least similar. This is dead wrong. It's easier to deal with a small ha regional insurers than it is to deal with Medicare on the whole. And as I said in the original post, even within a region, Medicare is very heterogeneous. > Medicare is by volume the largest provider.... Medicare isn't simple, it's just a small piece of a very big shit sandwich. As you said yourself, it's the largest single piece of the sandwich. It also happens to be the core of it as well. Most of the complexity in the billing process stems from how Medicare structures and organizes its own billing, not the other way around.
      - rhizome 9y ago
        This thread reads like you two are talking past each other, are you saying that cptskippy's point about individual lines on the provider side is either nonexistent or irrelevant?
        chimeracoder 9y ago
        > are you saying that cptskippy's point about individual lines on the provider side is either nonexistent or irrelevant? I'm saying that the marginal complexity introduced by private plans is actually quite small compared to the complexity that Medicare already creates. Furthermore, the complexity that private insurers introduce is both directly and indirectly linked to the way Medicare structures its billing and reimbursement policies.
dragonwriter 9y ago
> Not really. In fact, Medicare is responsible for most of the current billing system, not private insurers. Medicare, Medicaid, Private Insurers, and the need for all of them to coordinate between each other all contribute significantly. The need for all of them to sometimes coordinate with non-healthcare payers (e.g., property and casualty insurers) for some claims also adds some complications.

cptskippy 9y ago

Medicare is relatively simple compared to most insurance companies and their rules. Insurance providers write custom lines of business for employers per state and allow those employers to customize the coverage however they like. This happens annually with revisions done to exclude or include coverage as the employer dictates. Insurance companies, and employers, come up with byzantine rules for what's covered, when it's covered, where it's covered, who is allowed to provide care, prerequisites before approving coverage, what brand of products are permitted in treatment, and on and on. The net effect is that the rules are multi-variant to the point that they cannot realistically be validated or tested by humans. There are entire industries dedicated to maintaining rules management engines specifically for validating policies, coverage, and claims.

chimeracoder 9y ago
> Medicare is relatively simple compared to most insurance companies and their rules. As someone who's actually had to deal with this complexity and implement software to facilitate it, I can assure you that Medicare is not at all simple, by any stretch of the imagination. It's not even standard or consistent within Medicare within a geographical region, even if you limit the scope to Part A and Part B, excluding coverage provided under Part C and Part D. > Insurance companies, and employers, come up with byzantine rules for what's covered, when it's covered, where it's covered, who is allowed to provide care, prerequisites before approving coverage, what brand of products are permitted in treatment, and on and on. This is exactly what Medicare itself does. The private insurers generally structure their terms in ways that are similar to what Medicare does. They're not identical, but it's not like Medicare is some haven of simplicity by itself that the private insurers complicate. Medicare itself is unbelievably complicated and abstruse by itself. > There are entire industries dedicated to maintaining rules management engines specifically for validating policies, coverage, and claims. Yes, that's true. And that would be true even if you only looked at Medicare patients.
- cptskippy 9y ago
  It's not that Medicare is simple, it's not. It's that there are thousands of private insurance companies each holding thousands of lines of insurance each with their own set of rules comparably complex to Medicare. Medicare is by volume the larges provider but size is actually a benefit because it means that it's dealt with more frequently and is more familiar to care providers. A care provider isn't multi-regional, thus when they deal with Medicare it's mostly consistent. The interface is at least similar. However they can have 100 patients with United Healthcare and each patient will have a unique and different line of insurance. Medicare isn't simple, it's just a small piece of a very big shit sandwich.
  - chimeracoder 9y ago
    > A care provider isn't multi-regional, thus when they deal with Medicare it's mostly consistent. The interface is at least similar. This is dead wrong. It's easier to deal with a small ha regional insurers than it is to deal with Medicare on the whole. And as I said in the original post, even within a region, Medicare is very heterogeneous. > Medicare is by volume the largest provider.... Medicare isn't simple, it's just a small piece of a very big shit sandwich. As you said yourself, it's the largest single piece of the sandwich. It also happens to be the core of it as well. Most of the complexity in the billing process stems from how Medicare structures and organizes its own billing, not the other way around.
    - rhizome 9y ago
      This thread reads like you two are talking past each other, are you saying that cptskippy's point about individual lines on the provider side is either nonexistent or irrelevant?
      - chimeracoder 9y ago
        > are you saying that cptskippy's point about individual lines on the provider side is either nonexistent or irrelevant? I'm saying that the marginal complexity introduced by private plans is actually quite small compared to the complexity that Medicare already creates. Furthermore, the complexity that private insurers introduce is both directly and indirectly linked to the way Medicare structures its billing and reimbursement policies.

dragonwriter 9y ago

> Not really. In fact, Medicare is responsible for most of the current billing system, not private insurers. Medicare, Medicaid, Private Insurers, and the need for all of them to coordinate between each other all contribute significantly. The need for all of them to sometimes coordinate with non-healthcare payers (e.g., property and casualty insurers) for some claims also adds some complications.