Two decades after a massive lawsuit forced insurers to kill the practice, Big Insurance is back to automatically downgrading doctors’ claims — this time under the guise of fighting “waste and abuse."
Paul Krugman would call this downcoding a zombie practice, meaning that it is something that was killed off years ago by the courts, but it keeps coming back to life.
Canadas healthcare system is rampant with its own abuse issues. It isn’t perfect either. Seen it and heard it. We likely need a tiered system with some level of universal healthcare and insurance companies competing nationally rather than regionally to bring prices down. Then simplify billing/PA for physicians so we get rid of admin people from healthcare. System saves money. Worth a try.
The insurance downcoding policy is going to affect independent practices more than larger health systems for several reasons:
- E&M codes are their revenue lifeline, so they are much better at coding accurately.
- Insurance companies don’t inform the practices that E&Ms have been down-coded.
- This means that practices need to invest in staff to find these codes and fight with insurance by submitting office visit notes
- For most independent practices, adding 1/2 to 1 FTE (or hiring a 3rd party vendor )to fight these downcodes is not worth it
Now compare that with large healthcare orgs:
- Employed docs are salaried and (mostly) don’t care about coding (yes, there is a wRVU bonus). Generally, most doctors under-code.
- Large orgs have an army of coders and data analysts that can stay ahead of the downcoding game and resubmit codes with visit notes.
- They can leverage contract negotiation to limit or prevent downcoding.
What all this means is that when you do a statistical analysis of outlier docs who “up code,” you are more likely to find independent practices—not because they are upcoding, but because most docs down code!
Some insurance executives will walk away with a big bonus, while more independent practices will close.
In Massachusetts, Universal Healthcare/Single Payer Bills S860 & H1405 would not only relieve doctors and their staff from hours of bureaucratic red tape and arguing over denial of care, it would provide predictability and transparency of reimbursement for care.
The Healthcare Trust created under S860 & H1405 to manage this system would determine reimbursement rates in full public view with input from critical stakeholders. No more squeezing providers to boost profits and outrageous executive salaries.
In ANY market where you have a private entity contracting for service from another private entity, the first place you would look to determine PROPER compensation is the CONTRACT they signed. But not in healthcare. Because that SECRET in-network Provider Contract would put all the power to ENDUCE providers to provide less expensive care in the hands of the insurer., i.e., a unanimous US Supreme Court 1990 decision. Get real people, it's a CONTRACT that allows an insurer to pay as little as they want in any particular case. So, the only way to prove inaducate compensation is through a MAJOR law suit aimed at proving systematic improper compensation. And the insurers certainly know it. Please Mr Potter, help your readers understand the REAL gane that's being played here. Or tell us where I;m wrong!
We spend twice as much on healthcare. Our private for profit healthcare has diverted $79 trillion from the working class to the wealthy one percent over the last 50 years.
Medicare for all acts are funded entirely by a progressive tax (so the wealthy pay their fair share)
Every other industrialized nation has universal health care except the USA. As Gloria Maloney says, let's get the predators out of our system. Universal Health Care (not to be confused with UHG) is better, faster, cheaper, and way more effective than predatory corporate medical industry sponsored by the AMA (American Manure Association) and by so-called health insurance (death assurance) corporattions.
Thank you for pointing out the irony that when the INSCOs upcode for Medicare Advantage that’s called business, but when doctors play by their rules and figure out the arcane industry parameters to fully reflect the work they’ve done, that’s called fraud.
Healthcare executives' (hospital, clinics, insurance) compensation is 3-5x that of physicians, and their numbers (in relation to physicians) have increased 7x since the 1980s. And their education and skill levels are much lower. Meaning ?
We at Sentia can fix this problem. We have a three pronged approach:
1. Automate health insurance and cut out half the cost. Provide the EMR to the practice, free, and charge the patient $10/month plus the cost of the risk (help desk, stop loss, only necessary things (you already pay for the risk by the way, that is what insurance is))
2. ERP Style practice management that pinpoints cash leaks and waste. Publicly traded companies must report this information.
3. Cut out an additional 25% of the cost from healthcare with an integrated health and wellness program. give the program teeth by offering discounts to the patient for complying with the health and wellness education.
These three things eliminate big insurance, take away the financial obfuscation of administrators and make patients more healthy and therefore less expensive to the entire system, saving an estimated 75%.
We have the EMR in production now. We have designed the ERP style practice management making financial reporting a one click operation.
Paul Krugman would call this downcoding a zombie practice, meaning that it is something that was killed off years ago by the courts, but it keeps coming back to life.
Single payer universal healthcare is the solution. Get the predators out of the system.
Single payer would be far worse…
Instead of downcoding, they can just arbitrarily decide to lower reimbursement across the board, with no competition to keep em in check.
Canadas healthcare system is rampant with its own abuse issues. It isn’t perfect either. Seen it and heard it. We likely need a tiered system with some level of universal healthcare and insurance companies competing nationally rather than regionally to bring prices down. Then simplify billing/PA for physicians so we get rid of admin people from healthcare. System saves money. Worth a try.
The insurance downcoding policy is going to affect independent practices more than larger health systems for several reasons:
- E&M codes are their revenue lifeline, so they are much better at coding accurately.
- Insurance companies don’t inform the practices that E&Ms have been down-coded.
- This means that practices need to invest in staff to find these codes and fight with insurance by submitting office visit notes
- For most independent practices, adding 1/2 to 1 FTE (or hiring a 3rd party vendor )to fight these downcodes is not worth it
Now compare that with large healthcare orgs:
- Employed docs are salaried and (mostly) don’t care about coding (yes, there is a wRVU bonus). Generally, most doctors under-code.
- Large orgs have an army of coders and data analysts that can stay ahead of the downcoding game and resubmit codes with visit notes.
- They can leverage contract negotiation to limit or prevent downcoding.
What all this means is that when you do a statistical analysis of outlier docs who “up code,” you are more likely to find independent practices—not because they are upcoding, but because most docs down code!
Some insurance executives will walk away with a big bonus, while more independent practices will close.
This is exactly what’s going to happen. Just another step in the march away from independent practice and towards institutionalized medicine.
In Massachusetts, Universal Healthcare/Single Payer Bills S860 & H1405 would not only relieve doctors and their staff from hours of bureaucratic red tape and arguing over denial of care, it would provide predictability and transparency of reimbursement for care.
The Healthcare Trust created under S860 & H1405 to manage this system would determine reimbursement rates in full public view with input from critical stakeholders. No more squeezing providers to boost profits and outrageous executive salaries.
Help enact Massachusetts Universal Healthcare/Single Payer Bills S860 & H1405. Sign the petition at https://actionnetwork.org/petitions/it-ought-to-pass and go to https://masscare.org/ to read the bills and learn more.
And thank you for pointing out that we already went through this with the Cigna lawsuit 20 years ago and INSCOs lost.
Duplicitous mofos think that now that most physicians are employees now rather than practice owners that we won’t notice.
I hope physicians, nurses and patients can unify to fight this system. We have to do it. They’re killing all of us
This sounds very much like Trump's method of lowering value of properties for getting insurance and raising value when trying to get loans.
In ANY market where you have a private entity contracting for service from another private entity, the first place you would look to determine PROPER compensation is the CONTRACT they signed. But not in healthcare. Because that SECRET in-network Provider Contract would put all the power to ENDUCE providers to provide less expensive care in the hands of the insurer., i.e., a unanimous US Supreme Court 1990 decision. Get real people, it's a CONTRACT that allows an insurer to pay as little as they want in any particular case. So, the only way to prove inaducate compensation is through a MAJOR law suit aimed at proving systematic improper compensation. And the insurers certainly know it. Please Mr Potter, help your readers understand the REAL gane that's being played here. Or tell us where I;m wrong!
Amok
Deja vu
Mike Johnson calls it complicated.
We spend twice as much on healthcare. Our private for profit healthcare has diverted $79 trillion from the working class to the wealthy one percent over the last 50 years.
Medicare for all acts are funded entirely by a progressive tax (so the wealthy pay their fair share)
Every other industrialized nation has universal health care except the USA. As Gloria Maloney says, let's get the predators out of our system. Universal Health Care (not to be confused with UHG) is better, faster, cheaper, and way more effective than predatory corporate medical industry sponsored by the AMA (American Manure Association) and by so-called health insurance (death assurance) corporattions.
John T. Cullen author
johntcullen.substack.com
https://www.johntcullen.com
My Pensive Pen
Thank you for pointing out the irony that when the INSCOs upcode for Medicare Advantage that’s called business, but when doctors play by their rules and figure out the arcane industry parameters to fully reflect the work they’ve done, that’s called fraud.
Duplicitous motherfuckers.
Healthcare executives' (hospital, clinics, insurance) compensation is 3-5x that of physicians, and their numbers (in relation to physicians) have increased 7x since the 1980s. And their education and skill levels are much lower. Meaning ?
We at Sentia can fix this problem. We have a three pronged approach:
1. Automate health insurance and cut out half the cost. Provide the EMR to the practice, free, and charge the patient $10/month plus the cost of the risk (help desk, stop loss, only necessary things (you already pay for the risk by the way, that is what insurance is))
2. ERP Style practice management that pinpoints cash leaks and waste. Publicly traded companies must report this information.
3. Cut out an additional 25% of the cost from healthcare with an integrated health and wellness program. give the program teeth by offering discounts to the patient for complying with the health and wellness education.
These three things eliminate big insurance, take away the financial obfuscation of administrators and make patients more healthy and therefore less expensive to the entire system, saving an estimated 75%.
We have the EMR in production now. We have designed the ERP style practice management making financial reporting a one click operation.
https://open.substack.com/pub/sentiahealth/p/saving-healthcare-a-three-pronged