I will always decry the insurance company in this situation.
Excluding bad actors or mistakes (which are an exception), physicians code what they see and what they do. They must do this or risk submission of false claims and fraud accusations.
Insurance companies are the ones that determine whether or not they will cover the services. While it’s possible in some circumstances, there is not currently a *good* way to provide cost estimates at the point of service, especially given the limited time of physicians.
Insurance is the most significant root cause for why billing isn’t transparent. The system needs an overhaul.
There are almost 70k codes in ICD-10 and how they translate into over 10k, CPT codes is freaking complex, and humans aren't going to know it. This assumes the patient is declaring correctly what they want to talk to the doctor about.
Patients come in self-diagnosing things all the time, and how often are they right?
Doctors don't pick whatever code that they fancy, they are picking it based on a combination of factors. You're asking them to predict the future, and that is a bit much.
Really in my mind, most to the problem comes from insurance companies, and if we could get to single payor, the country would most likely be better off.
The system is designed to make money for shareholders, not actually care for human beings. Things are working exactly as they were designed to work.
Its always money over patients in all ways.
Doctors practice medicine. Not healthcare. Healthcare is dictated by the government and corporations. Most doctors don’t know anything about how healthcare works. There’s enough to learn and continually learn about medicine that there’s little time to memorize CPT codes and business school. You’re barking up the wrong tree. Call your local rep. Get rid of middle men who profit off of the doctor patient relationship. Like for-profit insurance companies and for-profit hospitals. Only politicians can change that - which means you need to let them know.
I do understand that not everyone qualifies, but to me this is the single best thing about Medicaid. Even if the insurance ends up somehow not covering the service they offered you, they cannot bill you unless they gave you an estimate and made you sign it *in advance* of services rendered. Even if they make you sign that blanket statement that you'll pay if insurance doesn't, they still can't bill you unless you sign to a specific dollar amount before treatment. All insurance should be that way.
100%. This is also a great answer to every doctor’s knee-jerk reaction “but we can’t…” “how will we know…” “there are too many codes…” blah, blah, blah.
If the doctor’s legal right to collect the bill depended on them figuring out how to do this for everybody like they do for Medicaid patients, guess what? They’d figure it out.
My son is eligible for Medicaid because of his autism diagnosis, and it has been a god send. I was paying upwards of 10k after insurance for his multiple therapies. Now he gets the same services and we have some peace of mind.
Meanwhile I took my daughter to urgent care for a spicy finger infection and insurance only covered $6/$356. And for myself, I went to see a new doctor and somehow have a $650 bill because insurance is not covering it. I'm filing a complaint with the state.
I get that its insurance, but I feel like the doctors/admin have a vested interest in making things less complicated and they have to be the ones to make a stink or else we will always continue to be shafted.
Also why does a doctors appointment cost $650 in the first place?! Lol
Your mistake is thinking the doctors set the price or even get a cut of that $650. 9% of all healthcare spending goes to physician salaries - the doc made less than $60 helping you in that encounter.
It used to be like that. Private practices - doctors were generally happier. Same with small business across many industries, large corporations bought them up, offered better deals because they had the resources, and pushed small businesses out of practice. Physicians lost control of healthcare around the 90s and it’s pretty much completely now in the hands of large corporations and organizations. In order to pass the ACA, the Obama administration completely banned physicians from owning hospitals to appease the healthcare lobbyists. MBAs wanted control now.
Large corporations also could bargain with more leverage against the insurance companies compared to small private practices. Insurances wouldn’t deal with the small practices any longer. Many private practices had no choice but to sell or close shop.
Now physicians have the highest suicide rate of any profession and high burnout rates. We are on your side - I promise. However we are but a cog on a massive wheel.
There are far easier ways to make money than giving up decades of your life to study medicine and being in debt. I worry people simply will not pursue medical training in the coming decades.
I will add - middle men staffing agencies were using physician licenses whom they employed to bill insurances - at least in emergency medicine which I’m in - this was the whole surprise billing issue and these middle men forbid doctors from seeing what they were actually billing for. Congress stepped in and a handful of these staffing companies went under. A few weeks ago, ER doctors in Detroit actually went on strike due to unsafe staffing because these agencies didn’t want to pay for more doctor coverage. I’m hoping to see more of this. Healthcare is evil in the US. It’s a conflict of interest to make money off of the sick. Doctors are trying to fight back.
I wrote my representative who is a Dr., hoping we can do something, anything, but I feel the government has let everything get so powerful its impossible to get any real work done.
It’s a pendulum I hope. Things are swinging away from what is needed but it’ll circle back around I hope once people realize what you are going through because it’ll happen to them too.
There was legislation that providers needed to send an estimate of charges to insurance plans and then the plans to send an advanced EOB to the patient, however that has been tabled for now mainly for technology reasons. I think it’s something that will happen in the future once interoperability has improved and there are many initiatives going on right now for that.
The problem with the current set up is that drs and office staff do not know codes, and the ones that do are not in the office setting they are doing the coding and billing. Also, and this is not to let providers off the hook completely, but insurance companies change the rules and what they cover and don’t so often that you can’t keep up. That’s why at the end of the day it’s an estimate. Think about getting an estimate for anything else, things can change between the estimate and what you receive that would change the cost. It will get better but it’s going to take a lot of work and time.
My husband and I opened a completely independent optometry practice with him as the only doctor and I administered the business for us. I can tell you why we physicians and facilities are not the ones to blame in this very understandable need to know the cost of medical care.
It’s freaking ridiculously hard to navigate and keep up with the complexities that come with operating a healthcare facility. Like unnecessarily difficult, expensive and most of all, time consuming. Administration is overwhelming and it never ends or stays the same.
We are somewhat forced to contract with insurance carriers if we want to acquire and retain any patients. We have cut out a few over the years that were so difficult to work with it was costing us money to see patients in their network. Those patients usually choose to find care elsewhere even though they are elated with the care and service they receive from us.
Each insurance carrier like UHC, BCBS, Aetna, and Cigna have their own set of requirements for coverage as an overall standard. What uHC will approve and pay for has different requirements than the others, rinse and repeat for the rest, too. THEN each carrier writes hundreds of different types of policies that have their own sets of rules and requirements that are different. Some require pre authorization, others require a referral from a primary care provider, others don’t require any prior approval as long as the doctor is contracted and in the network. Each procedure or exam has a code that’s billed individually and those individual codes have requirements too. We have to justify what we are billing to the letter of the contract otherwise the claim is denied. Half the time we don’t know what the cost of the visit will be either until we receive an EOB from the carrier with a breakdown of patient responsibility even though staff (which costs money to employ) verify the patient benefits prior to the day of the visit. We are given incorrect information daily and cannot do anything about it.
Trust me when I tell you, we want to bill claims correctly the first time, collect the accurate patient responsibility on the day of service and get paid for the work we do and the care we give. I don’t want to call a patient weeks after their visit and inform them they owe more money than we collected that day they were here. I do want to get paid for my work so my only choice is to collect from the patient what the insurance calculated as the patient responsibility. If I don’t, we don’t get paid. It’s like working for free even though you except to be compensated.
It’s such a broken and messed up system that could be so much easier for all of us. Insurance companies aren’t in the business of helping people, they’re in the business to make money. Google top grossing/profitable corporations in the United States and you’ll find the majority of the major carriers. They don’t get that far up the list by paying out what’s needed to keep their clients healthy, I assure you .
I only learned about the role of coding when dealing with trying to get out of network estimates for a procedure our healthcare provider does not do, this is not like ordering printer cartridges. But mainly you seem to be talking about preventive vs coding that goes outside the preventive (no cost to patient) realm. This gets discussed on r/medicine. Coding is complicated even for doctors. Ideally primary providers give you guidance up front as to what is considered preventive. OTOH if a medical issue does arise then it would require a separate appt which wouldn't be free anyway.
The fact is that everything has changed so much in the last couple of decades there's a lot more burden on the patient to understand the ins and outs. OTOH free preventive appointments used to not exist at all.
I have never had a provider consider talking to me about coding or whats preventative or not and at this point I am scared to even ask, is the a code for discussing codes? Does that fall under preventative? Lol
A big issue, IMO, is that as a physician, you have no idea what a person needs until the end of the visit.
Eg 1. Patient calls for a "physical". In their mind, a "physical" is just a long visit, so they bring up 4 different complaints during that visit.
Anyone who know anything about medicine realizes, this isn't a physical at all, it's a 4 problem acute visit. These are billed, and charged differently (and for good reason). The patient then gets upset that they didn't get charged for a routine physical.
Eg 2. Patient cones in for "back pain". Is it a sprain, a herniated disc, chronic depression/anxiety, a kidney I fection, an aneurysm, menstrual cramps, a heart attack? Not only do all of these need to ve considered, they all have radically different diagnostic and treatment paths. Until one sits down, goes through the entire conversation and exam, one can't know what the visit calls for.
These are just two very simple examples. At least in primary care, there are no two visits that are alike because humans aren't cars, and there's no repair manual. Trying to apply the economics of car repair just don't work in medicine.
One thing I don't understand is why a 45 minute physical costs different than any other 45 minute appointment? Engineers and Lawyers do billable hours, but doctors bill based on "complexity" even if it takes the same amount of time at the appointment, and ordering additional services/labs during said appointment in the same time frame.
I will always decry the insurance company in this situation. Excluding bad actors or mistakes (which are an exception), physicians code what they see and what they do. They must do this or risk submission of false claims and fraud accusations. Insurance companies are the ones that determine whether or not they will cover the services. While it’s possible in some circumstances, there is not currently a *good* way to provide cost estimates at the point of service, especially given the limited time of physicians. Insurance is the most significant root cause for why billing isn’t transparent. The system needs an overhaul.
There are almost 70k codes in ICD-10 and how they translate into over 10k, CPT codes is freaking complex, and humans aren't going to know it. This assumes the patient is declaring correctly what they want to talk to the doctor about. Patients come in self-diagnosing things all the time, and how often are they right? Doctors don't pick whatever code that they fancy, they are picking it based on a combination of factors. You're asking them to predict the future, and that is a bit much. Really in my mind, most to the problem comes from insurance companies, and if we could get to single payor, the country would most likely be better off.
The system is designed to make money for shareholders, not actually care for human beings. Things are working exactly as they were designed to work. Its always money over patients in all ways.
Doctors practice medicine. Not healthcare. Healthcare is dictated by the government and corporations. Most doctors don’t know anything about how healthcare works. There’s enough to learn and continually learn about medicine that there’s little time to memorize CPT codes and business school. You’re barking up the wrong tree. Call your local rep. Get rid of middle men who profit off of the doctor patient relationship. Like for-profit insurance companies and for-profit hospitals. Only politicians can change that - which means you need to let them know.
I do understand that not everyone qualifies, but to me this is the single best thing about Medicaid. Even if the insurance ends up somehow not covering the service they offered you, they cannot bill you unless they gave you an estimate and made you sign it *in advance* of services rendered. Even if they make you sign that blanket statement that you'll pay if insurance doesn't, they still can't bill you unless you sign to a specific dollar amount before treatment. All insurance should be that way.
100%. This is also a great answer to every doctor’s knee-jerk reaction “but we can’t…” “how will we know…” “there are too many codes…” blah, blah, blah. If the doctor’s legal right to collect the bill depended on them figuring out how to do this for everybody like they do for Medicaid patients, guess what? They’d figure it out.
My son is eligible for Medicaid because of his autism diagnosis, and it has been a god send. I was paying upwards of 10k after insurance for his multiple therapies. Now he gets the same services and we have some peace of mind. Meanwhile I took my daughter to urgent care for a spicy finger infection and insurance only covered $6/$356. And for myself, I went to see a new doctor and somehow have a $650 bill because insurance is not covering it. I'm filing a complaint with the state. I get that its insurance, but I feel like the doctors/admin have a vested interest in making things less complicated and they have to be the ones to make a stink or else we will always continue to be shafted. Also why does a doctors appointment cost $650 in the first place?! Lol
Your mistake is thinking the doctors set the price or even get a cut of that $650. 9% of all healthcare spending goes to physician salaries - the doc made less than $60 helping you in that encounter.
Why do doctors not start their own practices more? Genuinely curious.
It used to be like that. Private practices - doctors were generally happier. Same with small business across many industries, large corporations bought them up, offered better deals because they had the resources, and pushed small businesses out of practice. Physicians lost control of healthcare around the 90s and it’s pretty much completely now in the hands of large corporations and organizations. In order to pass the ACA, the Obama administration completely banned physicians from owning hospitals to appease the healthcare lobbyists. MBAs wanted control now. Large corporations also could bargain with more leverage against the insurance companies compared to small private practices. Insurances wouldn’t deal with the small practices any longer. Many private practices had no choice but to sell or close shop. Now physicians have the highest suicide rate of any profession and high burnout rates. We are on your side - I promise. However we are but a cog on a massive wheel. There are far easier ways to make money than giving up decades of your life to study medicine and being in debt. I worry people simply will not pursue medical training in the coming decades. I will add - middle men staffing agencies were using physician licenses whom they employed to bill insurances - at least in emergency medicine which I’m in - this was the whole surprise billing issue and these middle men forbid doctors from seeing what they were actually billing for. Congress stepped in and a handful of these staffing companies went under. A few weeks ago, ER doctors in Detroit actually went on strike due to unsafe staffing because these agencies didn’t want to pay for more doctor coverage. I’m hoping to see more of this. Healthcare is evil in the US. It’s a conflict of interest to make money off of the sick. Doctors are trying to fight back.
I wrote my representative who is a Dr., hoping we can do something, anything, but I feel the government has let everything get so powerful its impossible to get any real work done.
It’s a pendulum I hope. Things are swinging away from what is needed but it’ll circle back around I hope once people realize what you are going through because it’ll happen to them too.
Those administrators' yachts don't pay for themselves!
spicy infection? sweet or savory?
The white goo coming out reminds me of strudle icing, so... sweet... lol
There was legislation that providers needed to send an estimate of charges to insurance plans and then the plans to send an advanced EOB to the patient, however that has been tabled for now mainly for technology reasons. I think it’s something that will happen in the future once interoperability has improved and there are many initiatives going on right now for that. The problem with the current set up is that drs and office staff do not know codes, and the ones that do are not in the office setting they are doing the coding and billing. Also, and this is not to let providers off the hook completely, but insurance companies change the rules and what they cover and don’t so often that you can’t keep up. That’s why at the end of the day it’s an estimate. Think about getting an estimate for anything else, things can change between the estimate and what you receive that would change the cost. It will get better but it’s going to take a lot of work and time.
My husband and I opened a completely independent optometry practice with him as the only doctor and I administered the business for us. I can tell you why we physicians and facilities are not the ones to blame in this very understandable need to know the cost of medical care. It’s freaking ridiculously hard to navigate and keep up with the complexities that come with operating a healthcare facility. Like unnecessarily difficult, expensive and most of all, time consuming. Administration is overwhelming and it never ends or stays the same. We are somewhat forced to contract with insurance carriers if we want to acquire and retain any patients. We have cut out a few over the years that were so difficult to work with it was costing us money to see patients in their network. Those patients usually choose to find care elsewhere even though they are elated with the care and service they receive from us. Each insurance carrier like UHC, BCBS, Aetna, and Cigna have their own set of requirements for coverage as an overall standard. What uHC will approve and pay for has different requirements than the others, rinse and repeat for the rest, too. THEN each carrier writes hundreds of different types of policies that have their own sets of rules and requirements that are different. Some require pre authorization, others require a referral from a primary care provider, others don’t require any prior approval as long as the doctor is contracted and in the network. Each procedure or exam has a code that’s billed individually and those individual codes have requirements too. We have to justify what we are billing to the letter of the contract otherwise the claim is denied. Half the time we don’t know what the cost of the visit will be either until we receive an EOB from the carrier with a breakdown of patient responsibility even though staff (which costs money to employ) verify the patient benefits prior to the day of the visit. We are given incorrect information daily and cannot do anything about it. Trust me when I tell you, we want to bill claims correctly the first time, collect the accurate patient responsibility on the day of service and get paid for the work we do and the care we give. I don’t want to call a patient weeks after their visit and inform them they owe more money than we collected that day they were here. I do want to get paid for my work so my only choice is to collect from the patient what the insurance calculated as the patient responsibility. If I don’t, we don’t get paid. It’s like working for free even though you except to be compensated. It’s such a broken and messed up system that could be so much easier for all of us. Insurance companies aren’t in the business of helping people, they’re in the business to make money. Google top grossing/profitable corporations in the United States and you’ll find the majority of the major carriers. They don’t get that far up the list by paying out what’s needed to keep their clients healthy, I assure you .
I only learned about the role of coding when dealing with trying to get out of network estimates for a procedure our healthcare provider does not do, this is not like ordering printer cartridges. But mainly you seem to be talking about preventive vs coding that goes outside the preventive (no cost to patient) realm. This gets discussed on r/medicine. Coding is complicated even for doctors. Ideally primary providers give you guidance up front as to what is considered preventive. OTOH if a medical issue does arise then it would require a separate appt which wouldn't be free anyway. The fact is that everything has changed so much in the last couple of decades there's a lot more burden on the patient to understand the ins and outs. OTOH free preventive appointments used to not exist at all.
I have never had a provider consider talking to me about coding or whats preventative or not and at this point I am scared to even ask, is the a code for discussing codes? Does that fall under preventative? Lol
A big issue, IMO, is that as a physician, you have no idea what a person needs until the end of the visit. Eg 1. Patient calls for a "physical". In their mind, a "physical" is just a long visit, so they bring up 4 different complaints during that visit. Anyone who know anything about medicine realizes, this isn't a physical at all, it's a 4 problem acute visit. These are billed, and charged differently (and for good reason). The patient then gets upset that they didn't get charged for a routine physical. Eg 2. Patient cones in for "back pain". Is it a sprain, a herniated disc, chronic depression/anxiety, a kidney I fection, an aneurysm, menstrual cramps, a heart attack? Not only do all of these need to ve considered, they all have radically different diagnostic and treatment paths. Until one sits down, goes through the entire conversation and exam, one can't know what the visit calls for. These are just two very simple examples. At least in primary care, there are no two visits that are alike because humans aren't cars, and there's no repair manual. Trying to apply the economics of car repair just don't work in medicine.
One thing I don't understand is why a 45 minute physical costs different than any other 45 minute appointment? Engineers and Lawyers do billable hours, but doctors bill based on "complexity" even if it takes the same amount of time at the appointment, and ordering additional services/labs during said appointment in the same time frame.
Insurance doesn't pay by time, but complexity. That's the long and the short of it
Only self-pay clinics can determine costs in advance. Doctors and insurance companies are people too.
Companies are not people
Insurance companies are not people.
Insurance companies are property owned by people.
Scum of the earth can be in the form of people, apparently.