14 ms·

The fight between doctors and insurance companies over 'downcoding'

242 points by ceejayoz 1y ago

coleca 1y ago
Good startup idea would be to work with medical practices to use AI to automate the disputing of the "downcoding" by insurers.
- ActionHank 1y ago
  The business will be very quickly bought up to kill the product.
  - daveguy 1y 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 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.
    - ceejayoz 1y ago
      > the government has been so villified that we have to depend on billionaires https://knowyourmeme.com/memes/were-all-trying-to-find-the-guy-who-did-this https://knowyourmeme.com/memes/were-all-trying-to-find-the-g...
- cogman10 1y 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 1y 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 1y ago
  Hate it, thanks
- Spivak 1y 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.
- pragmatic 1y 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.
- vjvjvjvjghv 1y ago
  The result will be that doctor AIs will be fighting insurer AIs and the loser will be the patient. As always.
- elwebmaster 1y ago
  Already working on this, let's connect if you are interested: https://forms.gle/cxQZg5Q27PsT65d97 https://forms.gle/cxQZg5Q27PsT65d97
- deleted 1y ago
  [deleted]
- abrichvi85 1y 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)00291-0/fulltext 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/ http://em-billing-assistant.onrender.com/ Leave your name and email here if you would like to receive updates: https://forms.gle/MoVhdna81pq9F45NA https://forms.gle/MoVhdna81pq9F45NA
Apreche 1y 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 1y 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.
  - nradov 1y ago
    When providers join payer networks they generally waive their right to sue over issues like this.
- postflopclarity 1y ago
  good luck suing when lawyers cost the doctor 2k/hour and the insurance companies have armies of in house counsel.
- gwbas1c 1y 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_random 1y 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.
kotaKat 1y 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-g 1y 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/2025/10/08/alexandra-gehrke-apex-medicare-fraud/85615052007/ https://www.azcentral.com/story/news/local/arizona-health/20...
  - deleted 1y ago
    [deleted]
  - vjvjvjvjghv 1y 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.
    - polski-g 1y ago
      My employer switches insurance carriers every 4 years or so because another carrier has a more competitive rate. "What's best for the employer" is also what's best for me -- I can walk across the street and get a new job if I become unhappy. They want to keep their healthcare costs down so they can keep my salary high as dollars lost to my healthcare compensation are invisible to me.
daoboy 1y 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 1y ago
  It's beyond our control, says only country where this happens daily.
  - antonymoose 1y ago
    Pretty sure fraudulent billing practices exist in a variety of nations and industries.
    - vjvjvjvjghv 1y ago
      Other countries are making efforts to keep things in check though https://www.npr.org/2025/01/04/nx-s1-5246231/potential-fraud-could-have-earned-insurance-companies-billions-off-of-medicare-advantage https://www.npr.org/2025/01/04/nx-s1-5246231/potential-fraud.... The US for some reason can’t even address blatant fraud. One example is the stuff insurers do with Medicare Advantage. There is fraud and Congress knows about it but besides some hearings nothing is happening.
    - jasonlotito 1y ago
      It does. And having lived 10 years in Canada and 10 years in the US and used both their healthcare systems quite a bit, I have seen both sides. Let me just say I moved to the US for healthcare 10 years ago and we do not regret it one bit. The US is easy to point and laugh at, but that just comes from ignorance.
      - acheron 1y ago
        But shitting on the US gets you lots of Internet upvotes, and isn’t that the important thing?
      - 1y ago
pnathan 1y ago
I wonder how this plays out with Kaiser and other integrated practices.
- breadwinner 1y ago
  They try to convince you that you're fine and don't need any treatment.
gwbas1c 1y 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 1y 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 1y 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 1y 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 1y 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.
- philipallstar 1y 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 1y 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 1y 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.
  - Taikonerd 1y 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_avocado 1y 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).
3D30497420 1y 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>
- hypeatei 1y 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 1y 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.
    - hypeatei 1y ago
      > An insurance company's only goal nowadays is to make as much money as possible How can that be true when their profits are capped on collected premiums? Look up the Medical Loss Ratio (MLR) rule to see what I'm referring to. If you wanted to squeeze money out of people, health insurance would be the least appealing industry to do that in since you're required to spend 80-85% of premiums on medical care.
djoldman 1y 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_ 1y ago
  Are you talking overnight? If so, that’s an easy predictable outcome.
- hypeatei 1y 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.
  - djoldman 1y 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.
    - hypeatei 1y ago
      Doctors/patients are human too and your proposed system would be ripe for abuse. If you're well versed in submitting claims, and you know they have to pay out, then you could inundate them with fraudulent ones. > That to me would imply that doctors/patients are submitting a huge amount of incorrect claims UnitedHealthcare says that 10% of claims go through additional review for various reasons[0]. I don't know if there are stats for the industry as a whole, but my guess is that they deal with a lot of errors. 0: https://www.uhc.com/news-articles/newsroom/how-many-claims-are-denied https://www.uhc.com/news-articles/newsroom/how-many-claims-a...
renewiltord 1y 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.
- elwebmaster 1y 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
  - renewiltord 1y 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.
standardUser 1y 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.
- themafia 1y 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.
- hibikir 1y 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.
  - standardUser 1y 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 1y 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...
ratelimitsteve 1y 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.
- cindyllm 1y ago
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- philipallstar 1y ago
  If you keep the same regulatory environment then the same industry will arise.
s5300 1y ago
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doormatt 1y 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 1y 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 1y 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 1y 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.
- Taikonerd 1y 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
- 827a 1y 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.
viktorcode 1y 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.
immibis 1y 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 1y 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 1y 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 1y 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/ 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 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).
- testing22321 1y 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 1y 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.
- Braxton1980 1y 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 1y 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).
crazygringo 1y 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.
- leoh 1y ago
  >Everything about American healthcare is bad. Except the part where you are cared for by a competent clinician?
  - danpalmer 1y 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.
    - harvey9 1y ago
      I read the post you replied to as simply meaning it's a non bad thing, not that it is better care than elsewhere.
      - danpalmer 1y ago
        Perhaps that was all that was intended by it, if that's the case I guess I don't have a problem with it, the US does have competent clinicians. But my interpretation was a rebuttal to the cost, linking it and suggesting that paying so much gets you better healthcare, something I have heard from defenders of the US healthcare system in the past. As far as I understand it this link is not causal.
cameldrv 1y 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.
- sarchertech 1y ago
  Doctors lose their license and go to jail for Medicare fraud all the time.
- Our_Benefactors 1y 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 1y 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.
tonymet 1y 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.
- sarchertech 1y 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.
  - tonymet 1y 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
    - sarchertech 1y ago
      >indirectly through medical boards reducing capacity My wife has served on government medical advisory boards, and handles resident education. I've heard plenty of virtual meetings in the background. I've never once heard anyone discussing adding requirements for any unnecessary reason whatsoever. Not even a hint anything that would reduce capacity. If anything it's "how can we add capacity without reducing quality?" >absurd hour restrictions What do you mean by hour restrictions? The only hour restrictions that are enforced are on Residents and that is 80 hours per week. If you're talking about doctors choosing to work less than 40 hours per week, that's general because they'll completely burn out. My wife is a pediatric ER doctor, she works less than 40 hours per week, but she has no set schedule and could be working 7a-4p one day, 1p-11p the next, and 10p-7a the next. For many of those shifts she's the only doctor there, and is responsible for the life and death of every single patient that walks through the door. She's the one who gets to tell a young mom that her 3 year old has a brain tumor, she's the one who has to code an already dead 5 year old found face down in a pool victim for an extra 15 minutes so her parents can get there because studies have shown it helps them process grief if they can see people doing everything they can to save their kid. And to top it off any mistake she makes could literally cost us our house because it's relatively common in our state for people to awarded judgements that are larger than malpractice insurance limits. If she worked 40 hours a week she'd be completely burned out in 6 months. >excessive testing & procedures You can 100% blame fear of litigation for that. My wife is constantly balancing her desire to save patient's parent's money with her desire to get answers and her fear of legal liability. >petty / pointless consults You can blame fear of litigation for that one too. Calling in a specialist for a consult works the same as testing. It's a balancing act. I know a lot of doctors, some of them are assholes, but I don't know a single one who even consider changing their treatment recommendations based on how much money it nets them.
randcraw 1y ago
The obvious solution: doctors need to start upcoding their cases by default.
- nradov 1y 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 1y 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 1y 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 https://yuzu.health/blog that gets into the dynamics of this stuff. Legacy insurance is cooked.
- mayneack 1y ago
  Don't you mean "we" have a cool blog? Looks like you work there.
- keoneflick 1y 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.
oakmad 1y 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 1y 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.
  - throwaway173738 1y 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.
    - herbst 1y ago
      Being in Switzerland. I don't mind talking to mine. So far they paid for everything I needed, they are a big company easy to deal with fast in communication which I barely need as doctors usually deal with them their self. Imagine: I just pick a doctor, make an appointment whenever I need help for anything. They then do everything else and I just pay my monthly fee, that is basically the same for anyone. Zero hassle.
  - crazygringo 1y 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.
teleforce 1y 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/ 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/ https://pubmed.ncbi.nlm.nih.gov/32447353/
- valleyer 1y 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 1y 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.
- nradov 1y 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 1y 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.
firesteelrain 1y 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
xtajv 1y ago
Translation: Insurance companies intentionally injecting bugs into their own software to make requests that don't respect user input. Despicable.
notmyjob 1y ago
What would the Austrians say?
mielioort 1y ago
[dead]
sharts 1y 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.

242 points by ceejayoz 1y ago

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

ActionHank 1y ago
The business will be very quickly bought up to kill the product.
- daveguy 1y 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 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.
  - ceejayoz 1y ago
    > the government has been so villified that we have to depend on billionaires https://knowyourmeme.com/memes/were-all-trying-to-find-the-guy-who-did-this https://knowyourmeme.com/memes/were-all-trying-to-find-the-g...
cogman10 1y 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 1y 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 1y ago
Hate it, thanks
Spivak 1y 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.
pragmatic 1y 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.
vjvjvjvjghv 1y ago
The result will be that doctor AIs will be fighting insurer AIs and the loser will be the patient. As always.
elwebmaster 1y ago
Already working on this, let's connect if you are interested: https://forms.gle/cxQZg5Q27PsT65d97 https://forms.gle/cxQZg5Q27PsT65d97
deleted 1y ago
[deleted]
abrichvi85 1y 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)00291-0/fulltext 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/ http://em-billing-assistant.onrender.com/ Leave your name and email here if you would like to receive updates: https://forms.gle/MoVhdna81pq9F45NA https://forms.gle/MoVhdna81pq9F45NA

Apreche 1y 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 1y 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.
- nradov 1y ago
  When providers join payer networks they generally waive their right to sue over issues like this.
postflopclarity 1y ago
good luck suing when lawyers cost the doctor 2k/hour and the insurance companies have armies of in house counsel.
gwbas1c 1y 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_random 1y 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.

kotaKat 1y 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-g 1y 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/2025/10/08/alexandra-gehrke-apex-medicare-fraud/85615052007/ https://www.azcentral.com/story/news/local/arizona-health/20...
- deleted 1y ago
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- vjvjvjvjghv 1y 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.
  - polski-g 1y ago
    My employer switches insurance carriers every 4 years or so because another carrier has a more competitive rate. "What's best for the employer" is also what's best for me -- I can walk across the street and get a new job if I become unhappy. They want to keep their healthcare costs down so they can keep my salary high as dollars lost to my healthcare compensation are invisible to me.

daoboy 1y 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 1y ago
It's beyond our control, says only country where this happens daily.
- antonymoose 1y ago
  Pretty sure fraudulent billing practices exist in a variety of nations and industries.
  - vjvjvjvjghv 1y ago
    Other countries are making efforts to keep things in check though https://www.npr.org/2025/01/04/nx-s1-5246231/potential-fraud-could-have-earned-insurance-companies-billions-off-of-medicare-advantage https://www.npr.org/2025/01/04/nx-s1-5246231/potential-fraud.... The US for some reason can’t even address blatant fraud. One example is the stuff insurers do with Medicare Advantage. There is fraud and Congress knows about it but besides some hearings nothing is happening.
  - jasonlotito 1y ago
    It does. And having lived 10 years in Canada and 10 years in the US and used both their healthcare systems quite a bit, I have seen both sides. Let me just say I moved to the US for healthcare 10 years ago and we do not regret it one bit. The US is easy to point and laugh at, but that just comes from ignorance.
    - acheron 1y ago
      But shitting on the US gets you lots of Internet upvotes, and isn’t that the important thing?
    - 1y ago

pnathan 1y ago

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

breadwinner 1y ago
They try to convince you that you're fine and don't need any treatment.

gwbas1c 1y 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 1y 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 1y 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 1y 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 1y 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.

philipallstar 1y 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 1y 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 1y 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.
- Taikonerd 1y 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_avocado 1y 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).

3D30497420 1y 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>

hypeatei 1y 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 1y 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.
  - hypeatei 1y ago
    > An insurance company's only goal nowadays is to make as much money as possible How can that be true when their profits are capped on collected premiums? Look up the Medical Loss Ratio (MLR) rule to see what I'm referring to. If you wanted to squeeze money out of people, health insurance would be the least appealing industry to do that in since you're required to spend 80-85% of premiums on medical care.

djoldman 1y 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_ 1y ago
Are you talking overnight? If so, that’s an easy predictable outcome.
hypeatei 1y 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.
- djoldman 1y 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.
  - hypeatei 1y ago
    Doctors/patients are human too and your proposed system would be ripe for abuse. If you're well versed in submitting claims, and you know they have to pay out, then you could inundate them with fraudulent ones. > That to me would imply that doctors/patients are submitting a huge amount of incorrect claims UnitedHealthcare says that 10% of claims go through additional review for various reasons[0]. I don't know if there are stats for the industry as a whole, but my guess is that they deal with a lot of errors. 0: https://www.uhc.com/news-articles/newsroom/how-many-claims-are-denied https://www.uhc.com/news-articles/newsroom/how-many-claims-a...

renewiltord 1y 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.

elwebmaster 1y 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
- renewiltord 1y 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.

standardUser 1y 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.

themafia 1y 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.
hibikir 1y 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.
- standardUser 1y 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 1y 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...

ratelimitsteve 1y 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.

cindyllm 1y ago
[dead]
philipallstar 1y ago
If you keep the same regulatory environment then the same industry will arise.

s5300 1y ago

[dead]

doormatt 1y 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 1y 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 1y 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 1y 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.

Taikonerd 1y 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
827a 1y 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.

viktorcode 1y 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.

immibis 1y 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 1y 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 1y 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 1y 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/ 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 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).

testing22321 1y 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 1y 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.
Braxton1980 1y 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 1y 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).

crazygringo 1y 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.

leoh 1y ago
>Everything about American healthcare is bad. Except the part where you are cared for by a competent clinician?
- danpalmer 1y 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.
  - harvey9 1y ago
    I read the post you replied to as simply meaning it's a non bad thing, not that it is better care than elsewhere.
    - danpalmer 1y ago
      Perhaps that was all that was intended by it, if that's the case I guess I don't have a problem with it, the US does have competent clinicians. But my interpretation was a rebuttal to the cost, linking it and suggesting that paying so much gets you better healthcare, something I have heard from defenders of the US healthcare system in the past. As far as I understand it this link is not causal.

cameldrv 1y 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.

sarchertech 1y ago
Doctors lose their license and go to jail for Medicare fraud all the time.
Our_Benefactors 1y 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 1y 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.

tonymet 1y 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.

sarchertech 1y 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.
- tonymet 1y 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
  - sarchertech 1y ago
    >indirectly through medical boards reducing capacity My wife has served on government medical advisory boards, and handles resident education. I've heard plenty of virtual meetings in the background. I've never once heard anyone discussing adding requirements for any unnecessary reason whatsoever. Not even a hint anything that would reduce capacity. If anything it's "how can we add capacity without reducing quality?" >absurd hour restrictions What do you mean by hour restrictions? The only hour restrictions that are enforced are on Residents and that is 80 hours per week. If you're talking about doctors choosing to work less than 40 hours per week, that's general because they'll completely burn out. My wife is a pediatric ER doctor, she works less than 40 hours per week, but she has no set schedule and could be working 7a-4p one day, 1p-11p the next, and 10p-7a the next. For many of those shifts she's the only doctor there, and is responsible for the life and death of every single patient that walks through the door. She's the one who gets to tell a young mom that her 3 year old has a brain tumor, she's the one who has to code an already dead 5 year old found face down in a pool victim for an extra 15 minutes so her parents can get there because studies have shown it helps them process grief if they can see people doing everything they can to save their kid. And to top it off any mistake she makes could literally cost us our house because it's relatively common in our state for people to awarded judgements that are larger than malpractice insurance limits. If she worked 40 hours a week she'd be completely burned out in 6 months. >excessive testing & procedures You can 100% blame fear of litigation for that. My wife is constantly balancing her desire to save patient's parent's money with her desire to get answers and her fear of legal liability. >petty / pointless consults You can blame fear of litigation for that one too. Calling in a specialist for a consult works the same as testing. It's a balancing act. I know a lot of doctors, some of them are assholes, but I don't know a single one who even consider changing their treatment recommendations based on how much money it nets them.

randcraw 1y ago

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

nradov 1y 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 1y 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 1y 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 https://yuzu.health/blog that gets into the dynamics of this stuff. Legacy insurance is cooked.

mayneack 1y ago
Don't you mean "we" have a cool blog? Looks like you work there.
keoneflick 1y 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.

oakmad 1y 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 1y 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.
- throwaway173738 1y 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.
  - herbst 1y ago
    Being in Switzerland. I don't mind talking to mine. So far they paid for everything I needed, they are a big company easy to deal with fast in communication which I barely need as doctors usually deal with them their self. Imagine: I just pick a doctor, make an appointment whenever I need help for anything. They then do everything else and I just pay my monthly fee, that is basically the same for anyone. Zero hassle.
- crazygringo 1y 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.

teleforce 1y 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/ 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/ https://pubmed.ncbi.nlm.nih.gov/32447353/

valleyer 1y 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 1y 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.
nradov 1y 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 1y 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.

firesteelrain 1y 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

xtajv 1y ago

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

notmyjob 1y ago

What would the Austrians say?

mielioort 1y ago

[dead]

sharts 1y 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.