Understanding Healthcare
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Wednesday ramblings:
Does anyone else think it’s odd that we invest so much time, resources, and energy into pleasure and temporary satisfaction, or at the other end of the spectrum, health and fitness, but the U.S. population knowns so little about how our healthcare system works?
I work in healthcare, specifically Revenue Cycle Management; the business side of healthcare, as opposed to the more commonly known clinical side. I deal with payor and entity contracts, Provider productivity and documentation education, coding, billing, compliance, Risk management, Patient Inquiries, payor processing and denials, payment trends, client integrations.. I could go on and on.
The general idea is that I live and breathe the business side of healthcare, and I often forget how little the average person actual knows about the system. How insurance works, in network vs out of network payor processing, delays in bills, etc. There is so much out there to know and learn and without that knowledge, how do we ever hope to change the healthcare system to prevent sickness, treating the symptoms instead of the disease, molding the Revenue Cycle to focus on care outcomes instead of profits.
I would love to know what kinds of questions the person who does not work in healthcare has!
Does anyone else think it’s odd that we invest so much time, resources, and energy into pleasure and temporary satisfaction, or at the other end of the spectrum, health and fitness, but the U.S. population knowns so little about how our healthcare system works?
I work in healthcare, specifically Revenue Cycle Management; the business side of healthcare, as opposed to the more commonly known clinical side. I deal with payor and entity contracts, Provider productivity and documentation education, coding, billing, compliance, Risk management, Patient Inquiries, payor processing and denials, payment trends, client integrations.. I could go on and on.
The general idea is that I live and breathe the business side of healthcare, and I often forget how little the average person actual knows about the system. How insurance works, in network vs out of network payor processing, delays in bills, etc. There is so much out there to know and learn and without that knowledge, how do we ever hope to change the healthcare system to prevent sickness, treating the symptoms instead of the disease, molding the Revenue Cycle to focus on care outcomes instead of profits.
I would love to know what kinds of questions the person who does not work in healthcare has!
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Replies
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I don't think it's odd.
Most people do not care how the business side of things work.
It's not important to their every day lives.
The only ones that care how it works are the ones paying or the ones getting paid.
Healthcare was, at one time, a noble calling but now it's just a business, nothing more.
I worked in healthcare for over 35 years and I have witnessed the changes.
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I have worked for insurance companies for 40 years both Health and Life insurance companies. And the fact is they are in business to make a profit. And if they were not in business to make a profit, what would happen with all of their employees? Meaning how would they get paid? But having said that. I think that in a country that is as rich as the USA is. It is a crime that we have homeless, and people that do not have medical care. That everyone has a right to basic medical care. Medicare by itself does not work and is not fair the way it is set up today. There are so many plans, so many levels. And the facts are many older people get ripped off on a regular basis. Government, senators/congress etc should not be in charge of the design of Medicare and drug benefits in my opinion.
I also think that while many people love to blame the insurance companies. The majority of people do not understand the fact that it is actually their employers that make many decisions of what they want to pay for and not pay for. What will be in network and out of network. Much is decided to keep costs down, and for what the employer part is going to cost of what they pay towards their employees health benefit each month.2 -
One thing I wonder, and I live in Ontario where basic healthcare is "free" is how the doctors bill things. Is it by problem? Often you see here posted in the waiting rooms (not sure about anywhere else) is "one problem per visit". Is it the time taken for the appointment? The service provided?1
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I don't think it's odd.
Most people do not care how the business side of things work.
It's not important to their every day lives.
The only ones that care how it works are the ones paying or the ones getting paid.
Healthcare was, at one time, a noble calling but now it's just a business, nothing more.
I worked in healthcare for over 35 years and I have witnessed the changes.
Working with 100s of Providers to strive to provide care, and then the business side, I can see both sides. The changing trends towards profits, and those fighting to make the care the focus.
But I think you hit the nail on the head when you said, "It's not important to their every day lives". That's troubling to me, that people don't understand or have application to something everyone at some point in their lives will interact with.0 -
Here is a story. I have a sister who is very wealthy. Her husband had an elderly aunt with neck pain very similar to that pain which afflicted my wife. My wife traipsed from one doctor to another for 4 years all of them knowing what was wrong and none of thing knowing what to do about it. Finally, one young fellow took one look at her scans and said, "Sure. I can fix that. You'll get 90% of your range of motion. Do you want that?". We literally had spent 4 years and untold hundreds of thousands of insurance dollars on searching for this. The surgical day began when she reported to the hospital at 5:00 a.m. By 2:00 p.m. she was discharged with a cervical collar to immobilize her head for 2 months. When the collar came off, she was healed and really doesn't notice any restriction in her range of motion. I asked the surgeon, on behalf of my sister, "How much does this cost?" He told me, "I don't know."
I can see in that story that there are many things that you can see were not done due to the ignorance of professional providers and could have delivered healing care for a tiny fraction of what ultimately was spent.0 -
i'm curious- being on the business side of things, do you agree that a single-payer/Medicare for all setup would make things run smoother and be more efficient? Do you see healthcare as a human right or just a commodity?
not to get too political, but it's just that for me personally, I don't think healthcare should ever be profit-driven. You can't put a price on peoples' lives and wellbeing. You're right about needing to focus more on outcomes. No one should have to die or suffer or go bankrupt because of their inability to afford treatment. Yet they do- all the time...
My opinion is less striaght forward. I think having a single payor, or just a different structure than we have now, would simplify a lot of the Revenue Cycle processes that have to be navigated and add to overall processing costs. So from a more utopian view, I think it could really work. However, we do not live in a world of an ideal state. There will always be someone wanting more, more profit, more power, more fame.
I will say it is a basic thing every one should have access to, hence emergency rooms, and laws like EMTALA. People used to be flat out denied ANY care, it was called patient dumping. And since business and people could not figure it out, law makers had to step in. I'm not saying it's ideal, just what the current situation is.
But emergency care has also become over used, because you cannot define for anyone what is emergent enough to visit an emergency department. It's why over half of all healthcare costs are delivered in emergency room settings. Good intentions, but poor outcomes of providing care regardless of your ability to pay...with the disclaimer (at time of service). The idea is someone has to pay for services, either a payor, or individual, or everyone though taxes.
Basically, my opinion is that from a pure processing perspective of Revenue Cycle active accounts receivable, yes, a single payor would clean up a lot of the noise. But it would not fix anything, there is too much else on that scale that would need to also be modified.
Here is a question, how can we modify something (through voting or voting though our dollars) that we don't fully understand?
I still learn something about our current healthcare system every single day.0 -
One thing I wonder, and I live in Ontario where basic healthcare is "free" is how the doctors bill things. Is it by problem? Often you see here posted in the waiting rooms (not sure about anywhere else) is "one problem per visit". Is it the time taken for the appointment? The service provided?
I'm not as knowledgeable about healthcare outside the US. Or office visits. In the US, I know you usually care for what is present/presented. That's moreso for emergency medicine. General E/M codes and the ancillary procedure codes that would constitute additional care outside of general care. It also depends on if your care codes arw time sensitive or not.1 -
JeromeBarry1 wrote: »Here is a story. I have a sister who is very wealthy. Her husband had an elderly aunt with neck pain very similar to that pain which afflicted my wife. My wife traipsed from one doctor to another for 4 years all of them knowing what was wrong and none of thing knowing what to do about it. Finally, one young fellow took one look at her scans and said, "Sure. I can fix that. You'll get 90% of your range of motion. Do you want that?". We literally had spent 4 years and untold hundreds of thousands of insurance dollars on searching for this. The surgical day began when she reported to the hospital at 5:00 a.m. By 2:00 p.m. she was discharged with a cervical collar to immobilize her head for 2 months. When the collar came off, she was healed and really doesn't notice any restriction in her range of motion. I asked the surgeon, on behalf of my sister, "How much does this cost?" He told me, "I don't know."
I can see in that story that there are many things that you can see were not done due to the ignorance of professional providers and could have delivered healing care for a tiny fraction of what ultimately was spent.
Most Coding and Billing of medical services are removed from the Providers view. The care to coding to billing cycle has become so complex that there are many corporations that manage each a piece of the puzzle.
This may not help, but think about it this way, there are two pieces of the care, the Services, which are Provider billing, and the Supplies, which are facility billing. Each part has it's own rules and regulations.
If you wanted to start, you could see what the basic DRGs are that were used for care, then what those CPT codes would result, and then Google the CMS charges for those CPTs. Finally take that calculation by if you have a contracted insurance with both those Billing entities, and a bunch of calculations later you'd be close.
But if someone is billing for either provider or facility over and over, they have a avg idea of the cost. There are just so many variables. It's discouraging I know. Care is just as unique as people are. There are 80,000 different ICD codes to describe each unique piece of care. So I can see why that provider would not know.
I am sorry that it took so long for your wife's care to be rendered. But I am so glad she has relief!0 -
Here is a question, how can we modify something (through voting or voting though our dollars) that we don't fully understand?
I still learn something about our current healthcare system every single day.
i don't think we have to wait around until we understand it 100%. By then it could be too late. We just need to understand enough to know that the system is severely broken and needs to be rebuilt.
and yeah,i get called overly idealistic all the time for arguing that we need socialized medicine. But it's a much, much more popular proposal than a lot of people realize. The last polls i checked had a VERY strong majority (70%!!) in favor of medicare for all. So voters do want it- and not just progressives/socialists like me!
Heck, if it were up to me, I'd just absolutely GUT the military's budget and tax the ever-loving *kitten* out of the wealthy in order to cover universal healthcare. A lot of people would hate me for it, sure, but it would be so worth it.
Exactly! Understand it enough! That is what I would love to be able to share with people, what I know to help them just enough so they can make those votes.
And it's people (like you) who are willing to pose the idea to get people thinking. Even if it's not the final outcome, it's enough to change the idea of what we have always done. Love it!1 -
tinkerhellraiser wrote: »One thing I wonder, and I live in Ontario where basic healthcare is "free" is how the doctors bill things. Is it by problem? Often you see here posted in the waiting rooms (not sure about anywhere else) is "one problem per visit". Is it the time taken for the appointment? The service provided?
This is in my experience, YMMV:
You usually make an appointment for a problem or well check, and are seen for one thing. As far as how they bill things, it's a bunch of different codes that are covered (paid for by insurance) differently depending on your insurance plan and your insurance provider. The two main categories are diagnostic and preventative care. So say you go in and get a colonoscopy. It could be coded as diagnostic because the doctor suspects a problem based on symptoms, or preventative if you have a history of colon cancer and need routine screening. One might be covered at 50% and the other at 80%, so it makes a big difference in what you pay.
And then it gets really crazy.
The doctor will bill an amount for the colonoscopy, say $2000, and submit it to insurance. Insurance then comes back and says "We'll only pay $1200" and then the doctor adjusts the amount and you owe the difference, in this case, $800. But likely you also usually have a deductible that needs to be met before they pay anything, maybe $4000 a year that you must pay out of pocket before insurance "kicks in". So in the end you pay the full $2000 for the procedure.
But if you go to a doctor and say "I don't have insurance, I want to do self pay," they will often bill you a special "self pay" amount that is less than what they request from insurance, in this case, maybe $1200. So not having insurance would cost you less.
Also if you have a doctor or specialist that is "out of network", usually insurance won't pay anything (some plans pay a fractional amount). Its a huge problem because if you go to the hospital in an emergency and then all the doctors you see are out of network, you are left owing a small fortune.
Also taking a ride in an ambulance costs like $900, and usually isn't covered unless you are literally dying.
But the paramedics who drive the ambulance make around $15 an hour to start (now the same amount as an Amazon warehouse worker and the lowest wage of a Disney World employee).
Anyways.
I disagree that people don't pay attention to the business side of healthcare because it "doesn't affect their lives". It's incredibly convoluted and difficult for most people to understand, and then the more you learn about the more disillusioned you become until you just start avoiding the doctor altogether.
Wow, you brought up some scenarios and comparisons I've never considered.
We have a "free" (but limited) public health care system. Apparently wait times are bad compared to a "paid" system, and there are more "private" health care providers becoming available here where people pay out of pocket for service in a quicker time. I know people who have the money that travel to the US for quicker treatment too.
I'm not complaining, honestly I don't know any different.
I don't have insurance through my job, so I pay out of pocket for all dental, eye care and prescriptions. If I ever need physio or chiropractic...or to take an ambulance ride, its all on me. Basically everything besides going to a GP or a walk in clinic or emergency room, I pay for.
I am considering getting personal health insurance (or going back to school and taking like one class at a time, it will be fun for me and health benefits are included with tuition!)
I do know different dentists I've been to offer different prices based on whether or not you have insurance. It also varies significantly on the community they are located in.
I work in animal health care and for us we have fee guides for prices, insurance the client has has no impact on our fees, it's just being 'competitive' within the community that you are located.1 -
@DeadliftsAndSprinkles !!
I typed this sentence and wondered...
Is this wrong? Or just awkward?
Saying 'has has'?
You're my go to for grammar!
"I work in animal health care and for us we have fee guides for prices, insurance the client has has no impact on our fees, it's just being 'competitive' within the community that you are located."
0 -
@DeadliftsAndSprinkles !!
I typed this sentence and wondered...
Is this wrong? Or just awkward?
Saying 'has has'?
You're my go to for grammar!
"I work in animal health care and for us we have fee guides for prices, insurance the client has has no impact on our fees, it's just being 'competitive' within the community that you are located."
off the cuff here....
[ the client's insurance has no impact ...
[ the client's specific insurance plan has no impact....
[ the insurance plan, carried by the client, has no impact...
[ Potato.
I think the last one here works best.1 -
One thing I wonder, and I live in Ontario where basic healthcare is "free" is how the doctors bill things. Is it by problem? Often you see here posted in the waiting rooms (not sure about anywhere else) is "one problem per visit". Is it the time taken for the appointment? The service provided?
I'm not as knowledgeable about healthcare outside the US. Or office visits. In the US, I know you usually care for what is present/presented. That's moreso for emergency medicine. General E/M codes and the ancillary procedure codes that would constitute additional care outside of general care. It also depends on if your care codes arw time sensitive or not.
To me that makes sense, and fair enough1 -
also.... many pharmaceutical companies have indigent care programs which provide meds to patients at little or no cost.
This is from a government website, and the government never lies... so it's gotta be true, amiright?
https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/PAPData.html1 -
Motorsheen wrote: »@DeadliftsAndSprinkles !!
I typed this sentence and wondered...
Is this wrong? Or just awkward?
Saying 'has has'?
You're my go to for grammar!
"I work in animal health care and for us we have fee guides for prices, insurance the client has has no impact on our fees, it's just being 'competitive' within the community that you are located."
off the cuff here....
[ the client's insurance has no impact ...
[ the client's specific insurance plan has no impact....
[ the insurance plan, carried by the client, has no impact...
[ Potato.
I think the last one here works best.
lolololololol!!!!
....so true!!!
I just shrug my shoulders and bite my tongue...sometimes say something vague0 -
DeadliftsAndSprinkles wrote: »One thing I wonder, and I live in Ontario where basic healthcare is "free" is how the doctors bill things. Is it by problem? Often you see here posted in the waiting rooms (not sure about anywhere else) is "one problem per visit". Is it the time taken for the appointment? The service provided?
I'm not as knowledgeable about healthcare outside the US. Or office visits. In the US, I know you usually care for what is present/presented. That's moreso for emergency medicine. General E/M codes and the ancillary procedure codes that would constitute additional care outside of general care. It also depends on if your care codes arw time sensitive or not.
To me that makes sense, and fair enough
I think you're okay saying that. If you were to write it on a report or something someone might not like it but I don't think there's anything grammatically wrong with it.
Thanks!! Good to know!0 -
I am Canadian and the nuttiness of the American system boggles my mind.
I am pretty certain however in North America at least, all doctors are working off the same standard health codes. This allows them to cross compare outcomes regionally not to mention allow health care software to be standardized.
Instead of a network of health care insurers doctors here only have to deal with a dozen across the country (one per province).
Costs for procedures (using this health care codes) are negotiated with each province.
I have only ever paid one doctors bill, when I asked for a typewritten letter. Not covered.1 -
tinkerhellraiser wrote: »One thing I wonder, and I live in Ontario where basic healthcare is "free" is how the doctors bill things. Is it by problem? Often you see here posted in the waiting rooms (not sure about anywhere else) is "one problem per visit". Is it the time taken for the appointment? The service provided?
This is in my experience, YMMV:
You usually make an appointment for a problem or well check, and are seen for one thing. As far as how they bill things, it's a bunch of different codes that are covered (paid for by insurance) differently depending on your insurance plan and your insurance provider. The two main categories are diagnostic and preventative care. So say you go in and get a colonoscopy. It could be coded as diagnostic because the doctor suspects a problem based on symptoms, or preventative if you have a history of colon cancer and need routine screening. One might be covered at 50% and the other at 80%, so it makes a big difference in what you pay.
And then it gets really crazy.
The doctor will bill an amount for the colonoscopy, say $2000, and submit it to insurance. Insurance then comes back and says "We'll only pay $1200" and then the doctor adjusts the amount and you owe the difference, in this case, $800. But likely you also usually have a deductible that needs to be met before they pay anything, maybe $4000 a year that you must pay out of pocket before insurance "kicks in". So in the end you pay the full $2000 for the procedure.
But if you go to a doctor and say "I don't have insurance, I want to do self pay," they will often bill you a special "self pay" amount that is less than what they request from insurance, in this case, maybe $1200. So not having insurance would cost you less.
Also if you have a doctor or specialist that is "out of network", usually insurance won't pay anything (some plans pay a fractional amount). Its a huge problem because if you go to the hospital in an emergency and then all the doctors you see are out of network, you are left owing a small fortune.
If you’re me, you spend over a year battling with your insurance company to get them to agree to cover the treatment your medically fragile kid’s immunologist has been saying for several years that he needs and also says he can prove he needs with the enormous file of records of lab values and infection/treatment histories and lung function tests and such. During this time, they require you to subject the poor kid (who has experienced more needle sticks already in his 7 years of life than many people do in decades) to multiple more sticks to be without a doubt sure that it’s necessary. THEN, they approve the coverage but even though the medical insurance and the prescription insurance are through the same company, they pull this stunt:
1. Send the letter of approval, but for the prescription coverage to be in effect, the medication must be provided by this one specific pharmacy/home health agency.
2. The medication must be given by a home health nurse every month...but tell the patient AFTER the first infusion is done that while the company the nurse works for is the only one the prescription part of the insurance will cover getting the med from, that same company is out of network for the medical part of the insurance.
3. Engage in a weeks long battle over one part of the insurance or the other needing to suck it up and either pay for a different pharmacy to provide the med or for this home health company to give it, because this situation is obviously not going to work and they’re the ones who picked this company in the first place.
4. They luckily did eventually decide to pay for both the drug and the nursing care...but the bag of IV fluids he needs with it? Thankfully only $10/month, because no way are they paying for that, even if it’s necessary unless we want days on end of him not being able to move thanks to horrible headaches as a side effect if they don’t pre-hydrate him - and oral hydration doesn’t cut it. We learned that the hard way the first couple of months. 🙄4
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