RyanCare/TrumpCare

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sophie
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Re: RyanCare/TrumpCare

Post by sophie » Sat Apr 01, 2017 12:36 pm

Maddy, thanks for that pointer to the NY Times article. There is a lot of truth in it, but it's mixing up several different issues.

I've talked about billing/coding in prior threads. It is sheer overhead cost with no parallel in any other health system on the planet, and a natural response to the byzantine rules set up by Medicare that are just an invitation to gamesmanship. The Times article tried to pin the blame on the AMA, but for once it's not their fault. The private insurance companies are simply following Medicare's lead.

The 25% overhead cited in the article counts only a small part of the cost of this, namely the salaries of billing & coding staff & (I presume) charges by billing/coding companies. There's also the cost of EHRs whose main purpose is to facilitate the billing/coding games, physician time dealing with all these coding requirements, "training", extra documentation etc, and of course the extra charges that result from all the upcoding.

I don't know a single doctor who wouldn't be thrilled to pieces to have this whole billing/coding system done away with and replaced with something more sensible. I just have no idea how it could be done, given how far along the path we've traveled.
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Re: RyanCare/TrumpCare

Post by Pointedstick » Sat Apr 01, 2017 12:43 pm

sophie wrote: I don't know a single doctor who wouldn't be thrilled to pieces to have this whole billing/coding system done away with and replaced with something more sensible. I just have no idea how it could be done, given how far along the path we've traveled.
Cash-based practice, presumably. Don't accept Medicare, Medicaid, or insurance. Be like a dental practice: one doctor and one receptionist, with clear cash prices.
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Maddy
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Re: RyanCare/TrumpCare

Post by Maddy » Sat Apr 01, 2017 2:23 pm

sophie wrote: I don't know a single doctor who wouldn't be thrilled to pieces to have this whole billing/coding system done away with and replaced with something more sensible. I just have no idea how it could be done, given how far along the path we've traveled.
So why do you suppose cash-based practices been so slow to catch on? With $6,000 deductibles, I'd think that patients would be lining up at the door. So far, I've seen several surgery centers go all-cash, but so far nothing with any other specialty. With the family docs, the concierge model seems to be taking hold, but that's just another cost-shifting scheme.

BTW, it was PointedStick who posted the NYT article.
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Re: RyanCare/TrumpCare

Post by Pointedstick » Sat Apr 01, 2017 2:31 pm

Maddy wrote:
sophie wrote: I don't know a single doctor who wouldn't be thrilled to pieces to have this whole billing/coding system done away with and replaced with something more sensible. I just have no idea how it could be done, given how far along the path we've traveled.
So why do you suppose cash-based practices been so slow to catch on? With $6,000 deductibles, I'd think that patients would be lining up at the door. So far, I've seen several surgery centers go all-cash, but so far nothing with any other specialty. With the family docs, the concierge model seems to be taking hold, but that's just another cost-shifting scheme.
A truly excellent question. Is this just a simple missed market opportunity, or is some regulatory nightmare preventing it?
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Re: RyanCare/TrumpCare

Post by farjean2 » Sat Apr 01, 2017 6:02 pm

sophie wrote:I've talked about billing/coding in prior threads. It is sheer overhead cost with no parallel in any other health system on the planet, and a natural response to the byzantine rules set up by Medicare that are just an invitation to gamesmanship. The Times article tried to pin the blame on the AMA, but for once it's not their fault. The private insurance companies are simply following Medicare's lead.
On the patient side I've been caught in Billing Code hell a couple of times and it's one of several reasons I have for staying as far away as I can from the medical system. The first time was when a doctor finally convinced me that I was 10 years overdue for my first colonoscopy at age 60. When the wrong code was input, it was determined that not only was it not covered by the preventative medicine provision of my policy but it wasn't even eligible to be paid out of my HSA. I ended paying the whole bill after several threatening collection letters and then had to work with the doctor's assistants to get the code changed so I could get my money refunded. Life is too short for hassles like that so that will be my very last colonoscopy.

Another time was when I made an appointment for my wife for routine biometric screening required by my company according to some provision of Obamacare. That one ended up costing me over $1000 due to billing codes and I gave up trying to get it straightened out because the doctor's staff would not work with me. Said it was my problem and not theirs.
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Re: RyanCare/TrumpCare

Post by Maddy » Sat Apr 01, 2017 10:07 pm

Just a guess, but it may be an irrational fear that a cash-only practice would attract a high proportion of riff-raff. I say that because of the reaction I get nearly 100 percent of the time when asked whether I have insurance and I answer "No, I'm paying out-of-pocket." It's that look that screams, "Oh. You're one of those." Honestly, a couple of times I've responded to that look by saying, "You know, the way I figure it, it's people like me who are the only ones in the whole damned system who are paying their own way." Almost inevitably, that elicits a smile and an acknowledgment that what I've said is true.
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Re: RyanCare/TrumpCare

Post by dualstow » Sat Apr 01, 2017 10:38 pm

O0 We have catastrophic insurance only, so we're pretty much paying out of pocket...including the insurance.
RIP Charlie Daniels
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Re: RyanCare/TrumpCare

Post by pugchief » Sun Apr 02, 2017 12:01 am

Pointedstick wrote:
sophie wrote: I don't know a single doctor who wouldn't be thrilled to pieces to have this whole billing/coding system done away with and replaced with something more sensible. I just have no idea how it could be done, given how far along the path we've traveled.
Cash-based practice, presumably. Don't accept Medicare, Medicaid, or insurance. Be like a dental practice: one doctor and one receptionist, with clear cash prices.
I don't know about your dentist, but I am in network with a myriad of PPOs and HMOs and we have a quite a few codes to deal with. By no means the headache that physicians deal with, but still a royal pain in the rectum.

And if I went to cash only, I'd be out of business in 3 months time.
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Re: RyanCare/TrumpCare

Post by sophie » Sun Apr 02, 2017 8:55 am

Pointedstick wrote:
Maddy wrote:
sophie wrote: I don't know a single doctor who wouldn't be thrilled to pieces to have this whole billing/coding system done away with and replaced with something more sensible. I just have no idea how it could be done, given how far along the path we've traveled.
So why do you suppose cash-based practices been so slow to catch on? With $6,000 deductibles, I'd think that patients would be lining up at the door. So far, I've seen several surgery centers go all-cash, but so far nothing with any other specialty. With the family docs, the concierge model seems to be taking hold, but that's just another cost-shifting scheme.
A truly excellent question. Is this just a simple missed market opportunity, or is some regulatory nightmare preventing it?
Regulatory nightmare. If you have a $6,000 deductible, that $6,000 has to be accepted by the insurance company. Cash payments for visits wouldn't count. So if you have insurance it doesn't make sense to go to a cash-only practice, unless the per-visit price is no more than your copay, and your copay doesn't count toward the deductible. That severely limits your patient population.

Maybe a version of MediumTex care where instead of a $50,000 deductible, the government end of the program covers hospital, diagnostic and drug costs for expensive conditions and leaves routine office visits completely to the private realm.

Or hey what about this for an idea: make an Obamacare option to exclude coverage for office visits as a variation of silver & bronze plans. I bet that would seriously drop the price, and instantly expand the pool of patients who are free to choose a cash-only practice. What do you think Pugchief?
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Re: RyanCare/TrumpCare

Post by Maddy » Sun Apr 02, 2017 9:05 am

sophie wrote: Regulatory nightmare. If you have a $6,000 deductible, that $6,000 has to be accepted by the insurance company. Cash payments for visits wouldn't count. So if you have insurance it doesn't make sense to go to a cash-only practice, unless the per-visit price is no more than your copay, and your copay doesn't count toward the deductible. That severely limits your patient population.
I'm not sure I understand. If an insured person with a $6,000 yearly deductible pays cash for all the nickle-and-dime bills he incurs throughout the year, and there are no major catastrophes, he simply files away the cash receipts and moves on to the next year. If, on the other hand, he gets run over by a truck in late December, what's to prevent him from pulling out all the receipts he's accumulated during the past 12 months and submitting them to the insurance company in bulk as proof that he's met at least part of the deductible? Is there something in the policies nowadays that requires bills to be run through the insurance company concurrently with the service?
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Re: RyanCare/TrumpCare

Post by technovelist » Sun Apr 02, 2017 11:53 am

Maddy wrote:
sophie wrote: Regulatory nightmare. If you have a $6,000 deductible, that $6,000 has to be accepted by the insurance company. Cash payments for visits wouldn't count. So if you have insurance it doesn't make sense to go to a cash-only practice, unless the per-visit price is no more than your copay, and your copay doesn't count toward the deductible. That severely limits your patient population.
I'm not sure I understand. If an insured person with a $6,000 yearly deductible pays cash for all the nickle-and-dime bills he incurs throughout the year, and there are no major catastrophes, he simply files away the cash receipts and moves on to the next year. If, on the other hand, he gets run over by a truck in late December, what's to prevent him from pulling out all the receipts he's accumulated during the past 12 months and submitting them to the insurance company in bulk as proof that he's met at least part of the deductible? Is there something in the policies nowadays that requires bills to be run through the insurance company concurrently with the service?
I can think of at least one thing that would prevent that. O0
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Re: RyanCare/TrumpCare

Post by pugchief » Sun Apr 02, 2017 12:03 pm

sophie wrote:
Pointedstick wrote:
Maddy wrote:
So why do you suppose cash-based practices been so slow to catch on? With $6,000 deductibles, I'd think that patients would be lining up at the door. So far, I've seen several surgery centers go all-cash, but so far nothing with any other specialty. With the family docs, the concierge model seems to be taking hold, but that's just another cost-shifting scheme.
A truly excellent question. Is this just a simple missed market opportunity, or is some regulatory nightmare preventing it?
Regulatory nightmare. If you have a $6,000 deductible, that $6,000 has to be accepted by the insurance company. Cash payments for visits wouldn't count. So if you have insurance it doesn't make sense to go to a cash-only practice, unless the per-visit price is no more than your copay, and your copay doesn't count toward the deductible. That severely limits your patient population.

Maybe a version of MediumTex care where instead of a $50,000 deductible, the government end of the program covers hospital, diagnostic and drug costs for expensive conditions and leaves routine office visits completely to the private realm.

Or hey what about this for an idea: make an Obamacare option to exclude coverage for office visits as a variation of silver & bronze plans. I bet that would seriously drop the price, and instantly expand the pool of patients who are free to choose a cash-only practice. What do you think Pugchief?
I don't follow your logic. If annual physicals were dropped, all that would happen is less people would go annually if ever. In my practice, most insurance plans cover 2 exams/cleanings per year. The first thing that happens when people lose their insurance is they stop coming in for check ups. But as they avoid me for 3 years, the $200 filling caught early turns into a $2500 root canal and crown. How is that a good thing?
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