4 ms·

2 FTEs vs a department. Most hospitals have entire departments to handle insurer coding and some even have departments just to handle insurer disputes.

CWuestefeld 7mo ago
to handle insurer coding Coding is a different layer. Everything needs coding, whether for gov't or commercial payers. So the folks doing this coding can't be separated out for commercial. In fact, it's kind of the opposite: CPT codes (for procedures) - these are defined by AMA, but mandated by CMS (i.e., Medicare/caid). Because the gov't mandated them, the commercial payers adopted them too. HCPCS codes (equipment and supplies) - defined by CMS. ICD-10-PCS codes (hospital inpatient stuff) - defined by CMS.
- gamblor956 7mo ago
  And yet my point still stands. Hospitals employ more people to handle private insurer coding than they do to handle Medicaid.
CWuestefeld 7mo ago
I think maybe I did a bad job of explaining. Of course providers have teams to deal with getting approvals from, submitting to, and disputing with, all the various Payers. At this level, we can consider all the Payers roughly equivalent. But for Medicare/caid, there's an ADDITIONAL layer of work that CMS requires Providers to perform. The Providers need to ensure they're compliant with all kinds of standards, and jump through hoops to document and prove to CMS that they're compliant. These standards aren't limited to the specific care - procedures, meds, etc. - being expended on a particular patient. They encompass the entirety of the Provider's operations. For example CMS makes Providers provide documentation about their average pay rates, stuff that's not related to the care of any given patient. The existence of that additional layer of reporting and compliance is the work that they're offloading onto the Providers, and thus increasing costs of providing care without it being legible if you were to audit CMS's own expenses.
- Retric 7mo ago
  > At this level, we can consider all the Payers roughly equivalent. No we really can’t, economies of scale means when Medicare changes something you’re spreading costs across a lodge number of visits. When an insurance company changes something that same cost is spread among a vastly smaller pool.

CWuestefeld 7mo ago

to handle insurer coding Coding is a different layer. Everything needs coding, whether for gov't or commercial payers. So the folks doing this coding can't be separated out for commercial. In fact, it's kind of the opposite: CPT codes (for procedures) - these are defined by AMA, but mandated by CMS (i.e., Medicare/caid). Because the gov't mandated them, the commercial payers adopted them too. HCPCS codes (equipment and supplies) - defined by CMS. ICD-10-PCS codes (hospital inpatient stuff) - defined by CMS.

gamblor956 7mo ago
And yet my point still stands. Hospitals employ more people to handle private insurer coding than they do to handle Medicaid.

CWuestefeld 7mo ago

I think maybe I did a bad job of explaining. Of course providers have teams to deal with getting approvals from, submitting to, and disputing with, all the various Payers. At this level, we can consider all the Payers roughly equivalent. But for Medicare/caid, there's an ADDITIONAL layer of work that CMS requires Providers to perform. The Providers need to ensure they're compliant with all kinds of standards, and jump through hoops to document and prove to CMS that they're compliant. These standards aren't limited to the specific care - procedures, meds, etc. - being expended on a particular patient. They encompass the entirety of the Provider's operations. For example CMS makes Providers provide documentation about their average pay rates, stuff that's not related to the care of any given patient. The existence of that additional layer of reporting and compliance is the work that they're offloading onto the Providers, and thus increasing costs of providing care without it being legible if you were to audit CMS's own expenses.

Retric 7mo ago
> At this level, we can consider all the Payers roughly equivalent. No we really can’t, economies of scale means when Medicare changes something you’re spreading costs across a lodge number of visits. When an insurance company changes something that same cost is spread among a vastly smaller pool.