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This is insurance fraud and abuse. Over-billing is very common in the American medical world. As long as there is no oversite, nor competition, it will contin

This is insurance fraud and abuse. Over-billing is very common in the American medical world. As long as there is no oversite, nor competition, it will continue and grow worse over time.

tcbawo 7y ago
Speaking of competition, it would be interesting if the major political parties competed on improving results instead of sabotaging results or preventing the other side from getting a win. Both parties have symbiotic relationships with profiteers that stifle progress and innovation.
- saas_sam 7y ago
  Trump signed an exec order* (thx for correction folks!) requiring hospitals to dramatically improve price transparency for patients. A huge win. But of course you'll never hear much about it for obvious reasons.
  - Operyl 7y ago
    Because I wouldn't call that bill something Trump "made." It was something both parties in Congress worked on, all Trump did was sign it.
  - everdrive 7y ago
    >But of course you'll never hear much about it for obvious reasons. I heard all about this, and so did lots of people. It was as well covered as anything is these days.
  - tptacek 7y ago
    First, no he didn't. He issued an EO directing CMS to implement the rule, which doesn't go into effect until 2021 and is facing pretty significant legal challenges. The fact that it's an EO and not a bill is likely part of the reason why its vulnerable to lawsuits. Second, health care experts don't seem to think much of the new rules, since there's little evidence anyone price shops for care, especially since, regardless of published prices, they're not the ones paying for them; they pay indirectly, through premiums. I think price transparency is a good thing and the rule is a good thing, but I don't think this is "huge". Third, the "obvious reasons" snark at the end of your comment poisons what would otherwise have been a valuable contribution to the thread.
    - saas_sam 7y ago
      It wasn't snark it was a direct agreement with the comment I was replying to. That last bit ruined your otherwise okay contribution. (Have you had a lot of coffee today? Have less.)
  - sykick 7y ago
    It is neither a big win nor a great improvement. At the time of need of essential goods/services price transparency is not as helpful as you make it seem. The American health system is so complex, has so many competing interests, and so many negative externalities that I doubt any one new regulation can be anything more than superficially beneficial to patients. I suggest the obvious reason this new regulation doesn’t get as much press attention as you’d like has less to do with Trump and more to do with its futility.
shantly 7y ago
Are insurance companies' take of the pie still defined as a percentage of total spending? If so, they have little reason not to look the other way, especially if fighting the problem in a systemic fashion (rather than just every now and then, or when someone notices and says something) would be tough and expensive and wouldn't be likely to capture its benefits for them in particular (rather than spreading out the benefits over "defector" insurers who don't bother to work on enforcement, too).
- OnlineCourage 7y ago
  No, the ACA maxes out total profit payers can take home at 15% for large groups and 20% for small groups respectively throughout a year, so it's not a commission based system like you are imagining. There are severe penalties for improper billing including prison. No one likes insurance, but HMOs are not at fault here, it was due to overcomplexity and lack of regulation within private practice.
  - shantly 7y ago
    So higher medical spending does not let them make greater profits?
    - OnlineCourage 7y ago
      No, because there are extreme penalties and disincentives to overbill. Also, payers are not strictly payers in the US, they are what is known as HMOs, they are incentivized to bring healthcare costs down or at least slow the rise. Healthcare costs will inevitably rise in the US however, as labor is scarce, practioners are scarce, people are increasingly unhealthy and older...we are in for a massive healthcare cost spike due to economic conditions and blaming HMOs is emotional and politician inspired at best. Its like blaming insurance companies for a rise in car crashes.
      - shantly 7y ago
        Ah, pretty sure I've never been under nor been close to anyone under an HMO so I'm not familiar with how those operate. Given how common stuff like in TFA is, plus so much more on smaller and less eye-popping scales, and seeming endless ability for providers to say "oops our bad now it's fixed" when caught and avoid punishment, I'm skeptical that these extreme penalties kick in often enough to counteract incentives to let prices creep higher. [EDIT] from my personal experience, it's mostly up to individuals to burn tons of time investigating irregularities and escalate them to elected officials & regulators when insurers or providers dig in their heels, to which the officials' and regulators' response is usually a strongly worded letter that makes your particular problem go away, with no follow up, presumably because pursuing it will be difficult, expensive, and unlikely to yield results that help anyone with their next election or promotion. That's kinda how it looks like this one's going, in fact, though maybe there'll be some regulatory follow-up with something resembling teeth, since it got press. It's like the Twitter-complaint model of customer support, but way worse.
FireBeyond 7y ago
Similar to Diagnostic Imaging - firms will aggressively market MRI/CT/PET ownership/co-ownership schemes to physicians, which become a license to print money very quickly. Such doctors who participate in schemes, entirely unsurprisingly, order multiple standard deviations above their expected imaging needs.
cabaalis 7y ago
I think you should assume incompetence instead of malice. > Fathollahi, the Manhattan Specialty Care physician, didn't answer our questions about the bill. Neither did Dr. Shawn Khodadadian, listed in state records as the CEO of Manhattan Gastroenterology. Because they CAN'T. Why didn't NPR publish their response, which is likely along the lines of how they are forbidden to discuss patient charges and procedures? It's far more likely this was a mistake that will end up costing the doctor 25k when the insurance company hires someone who checks for things like this, which they will.
- deleted 7y ago
  [deleted]

This is insurance fraud and abuse. Over-billing is very common in the American medical world. As long as there is no oversite, nor competition, it will continue and grow worse over time.

tcbawo 7y ago

Speaking of competition, it would be interesting if the major political parties competed on improving results instead of sabotaging results or preventing the other side from getting a win. Both parties have symbiotic relationships with profiteers that stifle progress and innovation.

saas_sam 7y ago
Trump signed an exec order* (thx for correction folks!) requiring hospitals to dramatically improve price transparency for patients. A huge win. But of course you'll never hear much about it for obvious reasons.
- Operyl 7y ago
  Because I wouldn't call that bill something Trump "made." It was something both parties in Congress worked on, all Trump did was sign it.
- everdrive 7y ago
  >But of course you'll never hear much about it for obvious reasons. I heard all about this, and so did lots of people. It was as well covered as anything is these days.
- tptacek 7y ago
  First, no he didn't. He issued an EO directing CMS to implement the rule, which doesn't go into effect until 2021 and is facing pretty significant legal challenges. The fact that it's an EO and not a bill is likely part of the reason why its vulnerable to lawsuits. Second, health care experts don't seem to think much of the new rules, since there's little evidence anyone price shops for care, especially since, regardless of published prices, they're not the ones paying for them; they pay indirectly, through premiums. I think price transparency is a good thing and the rule is a good thing, but I don't think this is "huge". Third, the "obvious reasons" snark at the end of your comment poisons what would otherwise have been a valuable contribution to the thread.
  - saas_sam 7y ago
    It wasn't snark it was a direct agreement with the comment I was replying to. That last bit ruined your otherwise okay contribution. (Have you had a lot of coffee today? Have less.)
- sykick 7y ago
  It is neither a big win nor a great improvement. At the time of need of essential goods/services price transparency is not as helpful as you make it seem. The American health system is so complex, has so many competing interests, and so many negative externalities that I doubt any one new regulation can be anything more than superficially beneficial to patients. I suggest the obvious reason this new regulation doesn’t get as much press attention as you’d like has less to do with Trump and more to do with its futility.

shantly 7y ago

Are insurance companies' take of the pie still defined as a percentage of total spending? If so, they have little reason not to look the other way, especially if fighting the problem in a systemic fashion (rather than just every now and then, or when someone notices and says something) would be tough and expensive and wouldn't be likely to capture its benefits for them in particular (rather than spreading out the benefits over "defector" insurers who don't bother to work on enforcement, too).

OnlineCourage 7y ago
No, the ACA maxes out total profit payers can take home at 15% for large groups and 20% for small groups respectively throughout a year, so it's not a commission based system like you are imagining. There are severe penalties for improper billing including prison. No one likes insurance, but HMOs are not at fault here, it was due to overcomplexity and lack of regulation within private practice.
- shantly 7y ago
  So higher medical spending does not let them make greater profits?
  - OnlineCourage 7y ago
    No, because there are extreme penalties and disincentives to overbill. Also, payers are not strictly payers in the US, they are what is known as HMOs, they are incentivized to bring healthcare costs down or at least slow the rise. Healthcare costs will inevitably rise in the US however, as labor is scarce, practioners are scarce, people are increasingly unhealthy and older...we are in for a massive healthcare cost spike due to economic conditions and blaming HMOs is emotional and politician inspired at best. Its like blaming insurance companies for a rise in car crashes.
    - shantly 7y ago
      Ah, pretty sure I've never been under nor been close to anyone under an HMO so I'm not familiar with how those operate. Given how common stuff like in TFA is, plus so much more on smaller and less eye-popping scales, and seeming endless ability for providers to say "oops our bad now it's fixed" when caught and avoid punishment, I'm skeptical that these extreme penalties kick in often enough to counteract incentives to let prices creep higher. [EDIT] from my personal experience, it's mostly up to individuals to burn tons of time investigating irregularities and escalate them to elected officials & regulators when insurers or providers dig in their heels, to which the officials' and regulators' response is usually a strongly worded letter that makes your particular problem go away, with no follow up, presumably because pursuing it will be difficult, expensive, and unlikely to yield results that help anyone with their next election or promotion. That's kinda how it looks like this one's going, in fact, though maybe there'll be some regulatory follow-up with something resembling teeth, since it got press. It's like the Twitter-complaint model of customer support, but way worse.

FireBeyond 7y ago

Similar to Diagnostic Imaging - firms will aggressively market MRI/CT/PET ownership/co-ownership schemes to physicians, which become a license to print money very quickly. Such doctors who participate in schemes, entirely unsurprisingly, order multiple standard deviations above their expected imaging needs.

cabaalis 7y ago

I think you should assume incompetence instead of malice. > Fathollahi, the Manhattan Specialty Care physician, didn't answer our questions about the bill. Neither did Dr. Shawn Khodadadian, listed in state records as the CEO of Manhattan Gastroenterology. Because they CAN'T. Why didn't NPR publish their response, which is likely along the lines of how they are forbidden to discuss patient charges and procedures? It's far more likely this was a mistake that will end up costing the doctor 25k when the insurance company hires someone who checks for things like this, which they will.

deleted 7y ago
[deleted]