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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 t

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.
    - datadrivenangel 1y ago
      Except that the insurance plans charge the employer and so the cheaper plans mean more haggling and potentially out of pocket for you later
- Ancalagon 1y ago
  why dont other countries have similar amounts of healthcare fraud in their single-payer systems?
  - polski-g 1y ago
    They do. Billions are lost in Germany every year due to fraud.
arealaccount 1y ago
I never understood why insurers get all the flack while the providers get a pass.
- cogman10 1y ago
  Because the common interaction people have with their insurers is "We are denying this because of <REASON>" which they have to fight to get healthcare. When a provider rips off an insurer it's invisible to the general public. Also, incidentally, when people talk about fraud in Medicare/Medicaid, the providers are almost always where that happens (yet that's often not pointed out).
  - deathanatos 1y ago
    > Because the common interaction people have with their insurers is "We are denying this because of <REASON>" Of the multiple times my insurance has declined to cover one thing or another, not once have I ever gotten a reason. The claim is just billed to the patient, directly. I'm then left wondering things like "Hey, your plan documentation says 'preventative care is 100% covered'. This was preventative care. Why is it being declined?" If I want to know, it's an hour of my time, at least, going back & forth with insurance to learn "Oh, '100% covered' … except in these cases."
- walkabout 1y ago
  FWIW I hate most medical billing departments (and hospitals are the worst) about as much as I hate insurance. They're at least as likely to fuck something up (curiously, always in their favor, not yours) as insurers, from what I've seen. And they're almost as unpleasant to deal with—at least they don't generally keep you on hold for literal hours, but it's still not great. And one of the ugliest public-facing roles in all of American medicine has to be the insurance-vultures whose job is to hover about emergency rooms pestering very-sick people for their billing information. Fucking gross.
- potato3732842 1y ago
  Every party at every point in the system is various shades of complicit in fleecing us. That's the magic of the system. It's all divided up in so many ways and so many of the feedback loops touch through the people getting screwed that it's impossible to build a "these guys might not be wholly responsible, but they're responsible enough things will get better if we push them off a cliff or legislate them into poverty or whatever" consensus you need to build to change things 17% of the US GDP is healthcare, now obviously there's a lot of nurses and random courier drivers and all sorts of other stuff in there, but they would all need to take some amount of haircut for us to get fleeced less. The GDP contribution of slavery was ~13% just preceding the civil war and credible moves (i.e. electing Lincoln) to make them take a haircut caused, you know, the civil war. There is likely no "clean" way to fix this problem other than a century long frog boiling exercise

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.
  - datadrivenangel 1y ago
    Except that the insurance plans charge the employer and so the cheaper plans mean more haggling and potentially out of pocket for you later
Ancalagon 1y ago
why dont other countries have similar amounts of healthcare fraud in their single-payer systems?
- polski-g 1y ago
  They do. Billions are lost in Germany every year due to fraud.

arealaccount 1y ago

I never understood why insurers get all the flack while the providers get a pass.

cogman10 1y ago
Because the common interaction people have with their insurers is "We are denying this because of <REASON>" which they have to fight to get healthcare. When a provider rips off an insurer it's invisible to the general public. Also, incidentally, when people talk about fraud in Medicare/Medicaid, the providers are almost always where that happens (yet that's often not pointed out).
- deathanatos 1y ago
  > Because the common interaction people have with their insurers is "We are denying this because of <REASON>" Of the multiple times my insurance has declined to cover one thing or another, not once have I ever gotten a reason. The claim is just billed to the patient, directly. I'm then left wondering things like "Hey, your plan documentation says 'preventative care is 100% covered'. This was preventative care. Why is it being declined?" If I want to know, it's an hour of my time, at least, going back & forth with insurance to learn "Oh, '100% covered' … except in these cases."
walkabout 1y ago
FWIW I hate most medical billing departments (and hospitals are the worst) about as much as I hate insurance. They're at least as likely to fuck something up (curiously, always in their favor, not yours) as insurers, from what I've seen. And they're almost as unpleasant to deal with—at least they don't generally keep you on hold for literal hours, but it's still not great. And one of the ugliest public-facing roles in all of American medicine has to be the insurance-vultures whose job is to hover about emergency rooms pestering very-sick people for their billing information. Fucking gross.
potato3732842 1y ago
Every party at every point in the system is various shades of complicit in fleecing us. That's the magic of the system. It's all divided up in so many ways and so many of the feedback loops touch through the people getting screwed that it's impossible to build a "these guys might not be wholly responsible, but they're responsible enough things will get better if we push them off a cliff or legislate them into poverty or whatever" consensus you need to build to change things 17% of the US GDP is healthcare, now obviously there's a lot of nurses and random courier drivers and all sorts of other stuff in there, but they would all need to take some amount of haircut for us to get fleeced less. The GDP contribution of slavery was ~13% just preceding the civil war and credible moves (i.e. electing Lincoln) to make them take a haircut caused, you know, the civil war. There is likely no "clean" way to fix this problem other than a century long frog boiling exercise