re: What in the hell is wrong with medical billing?

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What in the hell is wrong with medical billing?

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People are lazy. I'm currently in the midst of getting a telemed company to recode/rebill a telemedicine appt. They coded it as a walk-in. Getting them to change it is a fricking nightmare - so much so that I'm beginning to think there's a lot of financial advantages to these companies "miscoding" things.

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Most times for a single hospital visit with labs etc, you wind up with multiple items being billed. What most people don’t realize is that the lab may be contracted to a different company. The radiologist that reads images may be contracted. The cardiologist that reads the EKG may be contracted.

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And that all should be illegal. I work at a hospital and have health insurance thru that hospital. I went to the ER at said hospital and was seen by a contracted ER physician. I got a $800 bill from the ER physicians group because they were “out of network”. So the hospital was “in network” but the group inside of the building is “out of network”. How is the public suppose to know that? The contract is between the hospital and er doctors. Not the patient.

I’m not saying I agree with every piece of it. I’m simply stating the nature of it all.

Pros and cons exist in each model.

If insurance payouts fully covered provider costs, the hospitals wouldn’t need to subsidize private groups. On the other side, it’s a well known piece of information that organizations that employ internally staff at higher patient:staff ratios to cut costs and maintain profitability.

The big hospitals that get away with all and remain profitable are typically religious-based and/or non-profit making them tax-exempt.

I think the individual also holds responsibility for understanding their health coverage and what physician they are seeing. There is a No Suprises Act for a reason. It’s not difficult information to find, if one looks for it.

Over billing is a strategy not a mistake.

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Unpopular opinion: single payer will get rid of a lot of this confusion by streamlining the process. All you guys with private insurance are already paying for the freeloaders anyway.

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Single payer in the USA means traditional Medicare 4 all. Right now traditional Medicare only pays 80% of outpatient costs. The patient is responsible for the other 20%. However, that 20% is determined by how much Medicare reimburses. If a Medicare patient comes to my clinic for altered mental status and foul smelling urine. If I put the diagnosis as altered mental status and a uti I won’t get reimbursed for the visit because Medicare has decided that altered mental status due to UTI and UTI not a billable diagnosis anymore. If I call it acute encephalopathy of unknown origin and acute cystitis (urinary tract infection located in the bladder) then Medicare reimburses. If I call it acute metabolic encephalopathy secondary to acute cystitis without hematuria (aka urinary bladder infection without blood in the urine) Medicare reimburses even more because Medicare believes my medical decision making is higher. It’s not. The patient has a UTI and altered mental status and the most common cause of altered mental status in the elderly is UTIs and the treatment is the exact same. Basically Medicare is rewarding me for using big words instead of simple words. As I said before, Medicare requires the patient to pay 20% of outpatient costs. If Medicare reimburses a higher amount it means my office has to bill the patient more than their copay in order to maintain the 80/20 Medicare split. This all sounds sketchy but it’s completely legal (it is all in the fine print in the welcome to Medicare information). In fact Medicare encourages doctors to be specific as possible and use medical terminology when it comes to how we diagnose things because they believe it provides better care and helps reduce errors. The other insurance companies follow Medicare’s leave since they have to follow Medicare’s rules if they wish to participate in Medicare part C or Obamacare. Insurance companies usually lose money with Obamacare but they make a lot of money from Medicare part C so they play by Medicare’s rules.

The US medical system is broken and it is mainly broken because of Medicare. Medicare is the biggest insurance company in the country and the biggest part of the problem because it makes the rules and the other insurance companies copy them. How is Medicare for All going to fix this? Single payer is just another example of doubling down on a failed system because it sounds like a good idea if you don’t think about the causes of the problem.

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ut we got Obamacare?

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People who opposed Obamacare tried to tell everyone that Obamacare would not lower costs or make care easier. Now instead of your doctor being a business owner with people in the offices who cared about customer service and stuff like transparency your doctor works for a corporation and the corporations don’t give a shite about customer service.

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The US medical system is broken, but how is putting the people who broke it in charge of even more of the system going to fix it?

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What is the solution then? According to census.gov, approximately 92 percent of respondents were covered by some form of insurance and approximately 40 percent of those were medicare, medicaid, or both. That’s a huge number of people and for places like Louisiana i am guessing govt coverage is a larger share. It says about half of the insured have employer provided insurance. So 46% of us are covering the rest (medicare, medicaid, and uninsured.) in addition to ourselves. This thread shows what we go through with our own healthcare costs on top of it and the costs for both the coverage and out of pocket keep going up. With inflation and wage stagnation, more and more people are dropping out of the middle class, so that 46% who pay for everyone will shrink. The current system seems headed for failure.

If you have a copay you shouldn’t be billed for anything extra if just an exam. Always check to see if the lab they refer to is under your plan. And if I recall, any labs drawn at doctors office is billed to you. It’s jacked up how they do things.

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Weeding the illegals out would be a good start. Not sure why hospitals can’t refuse service to non-payers in all but serious cases.

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Fear of lawsuits i’m sure. Which might be another solution, as a lot of what is done in healthcare is for the purpose of defending against lawsuits.