Tweet
Re: Rep Retirement Lodge 201: A State You Don't Expect
Not much to add to this other than "yup". I work on the clinical side of the outpatient world, so I get my tendrils into everything from booking to treating to billing (from an IT perspective, that is). One of my jobs is to update the diagnosis code lists every 6 months (they're available quarterly but f that). I'm working on the yearly regulatory update and it's a 6 week project all in itself. Isn't that insane? The diagnosis code list is so complicated and integrated into everything that it takes me weeks and weeks to process it.
However, it does lead to some hilarious dx codes:
A human being was paid to add these to a potential diagnosis code list.
Originally posted by leswp1
View Post
This is true. I I think there is a difference between making informed choices for care and being able to shop for what you want like it is burger king. The patient should be an active participant and partner in making decisions but they aren't the managing partner. They don't have enough knowledge. We should not be a service industry where the client is always right and you have to make the client happy no matter what it takes. The insurance industry markets to the patient the nonsense about how they care and make sure the patient will get what they want and then they tell us we cannot consider what the patient really needs, only what the insurance company decrees is OK. The culture promotes the idea that this is an adversarial relationship that the medical person will be trying to screw the person out of what they are owed. They blame the Medical pro instead of the insurance that is actively working to provide as little care as possible to save $.
The financial side is a fiasco all around. The ACA was supposed to change that. They gutted that part of the bill and what they didn't gut the current admin is not enforcing. The insurance co are having a party.
You, as a pt, can't shop around for cost, find out what is covered, get a list of codes that will be covered by your plan. If you call to ask what the correct code is to get it reimbursed they refuse to give it to you because the Provider should know. (The provider can't find out the correct code when they call to ask either!) Some insurances arbitrarily decide that routine health maintenance tests/exams/procedures are not covered, even when they are standard of care. Or they only cover it at certain intervals that are not evidence based. They refuse to give a list or tell you they won't pay until after it is submitted. If you have ever had a diagnosis it cannot be on the slip or they can claim it is a diagnostic test and charge you. The minute a woman tells them she has a lump they charge her a diagnositic test and her 'free yrly mammo' is not covered. Most people don't know any of this. mr les just had a health maintenance procedure. It was billed by the Doc and the facility as Health Main. The anesthesia weasels billed him. I said this isn't right. He said it must be because of the deductible. I say no. He argues. I lose it and he calls to check. Sure enough it was not supposed to be billed to us. Don't you wonder how many of their patients are billed and pay blindly?
We can't get a comprehensive list of codes or what is covered easily. They make a habit of changing codes, procedures for submitting billing and what is covered all the time. It is like a massive shell game. Example- Billing for something simple like a Physical is not simple. To get the most reimbursement you need to separately code for the physical, the breast, prostate, gyn exam, each lab you did, the fingerstick, the performance of the fingerstick, each immunization, for the administration of the immunization, additional administration of anything past one immunization, certain other screening tests, interpretation of certain tests. They don't tell you any of this. If your billing people aren't good or well hooked in you can miss a ton of reimbursement. Then they get you again because they keep back the withhold claiming you didn't do any of the 'measures' because they weren't billed. No matter that they are clearly documented as having been performed. If you didn't code it right it didn't happen.
There are literally college programs with degrees for medical billing. Think about that.
The financial side is a fiasco all around. The ACA was supposed to change that. They gutted that part of the bill and what they didn't gut the current admin is not enforcing. The insurance co are having a party.
You, as a pt, can't shop around for cost, find out what is covered, get a list of codes that will be covered by your plan. If you call to ask what the correct code is to get it reimbursed they refuse to give it to you because the Provider should know. (The provider can't find out the correct code when they call to ask either!) Some insurances arbitrarily decide that routine health maintenance tests/exams/procedures are not covered, even when they are standard of care. Or they only cover it at certain intervals that are not evidence based. They refuse to give a list or tell you they won't pay until after it is submitted. If you have ever had a diagnosis it cannot be on the slip or they can claim it is a diagnostic test and charge you. The minute a woman tells them she has a lump they charge her a diagnositic test and her 'free yrly mammo' is not covered. Most people don't know any of this. mr les just had a health maintenance procedure. It was billed by the Doc and the facility as Health Main. The anesthesia weasels billed him. I said this isn't right. He said it must be because of the deductible. I say no. He argues. I lose it and he calls to check. Sure enough it was not supposed to be billed to us. Don't you wonder how many of their patients are billed and pay blindly?
We can't get a comprehensive list of codes or what is covered easily. They make a habit of changing codes, procedures for submitting billing and what is covered all the time. It is like a massive shell game. Example- Billing for something simple like a Physical is not simple. To get the most reimbursement you need to separately code for the physical, the breast, prostate, gyn exam, each lab you did, the fingerstick, the performance of the fingerstick, each immunization, for the administration of the immunization, additional administration of anything past one immunization, certain other screening tests, interpretation of certain tests. They don't tell you any of this. If your billing people aren't good or well hooked in you can miss a ton of reimbursement. Then they get you again because they keep back the withhold claiming you didn't do any of the 'measures' because they weren't billed. No matter that they are clearly documented as having been performed. If you didn't code it right it didn't happen.
There are literally college programs with degrees for medical billing. Think about that.
However, it does lead to some hilarious dx codes:
- Sucked into jet engine [with further options for initial, sequala, etc.]
- Excessive consumption of juice
- Walking dead syndrome
A human being was paid to add these to a potential diagnosis code list.
she is still trying to get home.
) The total is now $636,917,305.46.
Comment