Comment by candiddevmike
2 years ago
Everyone assumed there would be malicious compliance here but it's definitely eye opening just how malicious they made it. Speaks volumes for the perceived risk releasing this data, IMO. Still waiting to hear about someone using this data to negotiate down a hospital bill, seems like it's just insurance companies that can weaponize this data for better rates.
> but it's definitely eye opening just how malicious they made it
As someone familiar with insurer, provider, and facility IT systems, I'd offer an alternate explanation -- the data is bad because healthcare IT is understaffed (and often incompetent).
These are businesses that have squeezed most costs out, and IT is definitely a cost.
Imagine banking... if there were much less competitive pressure and an inability to offer services across state lines without substantial additional effort.
They received a mandate.
They tried to respond in the way that required the least amount of effort.
From someone in the industry, it's entirely plausible this is the best they can do.
Which usually means it takes CMS threatening to drop them for them to launch a multi-year project to finally fix the issue (somewhat).
I'm pretty sure the truth is a mix of malicious compliance and inability, but I'd weight it heavily in favor of malicious compliance, especially for the insurance data. Insurers know their costs, and when and why they pay specific charges.
(My qualifications to make this statement: 15 years in healthcare IT, including UHG/Optum, and 8 years as CTO of a large clinical organization that included primary through tertiary care, research, and an insurance operation.)
I'm not so confident from my experience in healthcare IT, admittedly shorter than yours. One of the issues seems very telling, the fact that one of the listed rates from the insurer matched the portion paid to the radiologist but not the total. Problems with matching up different line items are really ubiquitous in healthcare systems because, despite the standardization that theoretically exists, there's huge variation in how different accounting and analytics systems represent line items. It seems extremely plausible to me that all the numbers in these MRFs are real numbers, but aren't the numbers they're supposed to be. Probably the reports were generated by people using BI tools that didn't have the expertise in the underlying data to understand what values they should actually be reporting on, so it ends up being a hodgepodge of different dollar amounts that are often not the actual reimbursement amount but instead a subtotal or breakdown line items used for analytics.
Sure, insurance companies ultimately know what they paid, but consider that these MRFs are almost certainly not being prepared by the people responsible for that knowledge. They were probably tasked to one or two data analysts who quickly banged them out in whatever BI/reporting tool they use and did nothing to verify correctness. It's not like they had an accountant audit these if they weren't absolutely required to (they weren't). Most healthcare analytics tools are complete junk drawers of data from numerous systems and getting these MRFs right was probably never a priority for anyone. Just a total "I have no idea if these are right but they sure are numbers" exercise.
I mean, how many times have you seen some Tableau report that's all screwed up because some of the MRNs aren't actually MRNs (even though someone named the model field community_mrn) but file numbers from the scheduling system, and now you've got duplicate patients? BI systems just breed that kind of problem unless you are extremely careful about managing them, and since they're "not systems of record" (these are scare quotes) few people are.
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> Insurers know their costs, and when and why they pay specific charges.
I certainly don’t have your credentials, but my experience in being an insured person doesn’t match this. I’m willing to believe you, but having filled out forms for UHC to get reimbursed for an out-of-network doctor, it sure feels like they kind of make it up based on how they feel that day. I’ve submitted what appear to me to be identical forms for reimbursement (like the super bill the doctor gives me has the same codes, duration, etc.), and the reimbursement differs for no reason I can discern (had long blown past my deductible, etc.). It feels like sometimes you get lucky and the person evaluating your form gives you a break, and sometimes you’re unlucky and they don’t.
On the other hand, malicious compliance does seem par for the course for these assholes. So what you say makes sense.
If this is the best they can do maybe capital markets don’t work best for insurance companies and they should be taken over.
Dealing with them right now feels like dealing with the government might as well just have the government run it
Don’t take it too much at face value.
This is the best they can do when all their incentives align so that being as opaque and disingenuous as possible about costs (and understaffing and often screwing it up helps with that!) helps them.
Not going to argue. In their defense, I'd say insurers are more innovative (especially on the operations side and post-ACA) than the federal government.
IMHO, best of both worlds would be the federal government taking over and centralizing the most core services (rates, interchange, data systems, etc) and allowing private insurance companies to build offerings on top of that (customer service, servicing, product mix, etc).
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They received a mandate. They tried to respond in the way that required the least amount of effort. From someone in the industry, it's entirely plausible this is the best they can do.
Assuming this is true for the sake of argument, saying that this sort of thing isn't malicious compliance is a sad kind apologistics for bad behavior that seems to regularly appear on HN.
I agree.
How can these kinds of companies optimize their charge codes to get the max for the procedures, optimize their taxes to pay the minimum possible, and then do a poor job on these existential crisis kinds of things? I think they know what they're doing in all cases.
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>> These are businesses that have squeezed most costs out, and IT is definitely a cost.
What's the cost of an X-ray? Did you know they used to do a FREE X-ray at the shoe store back in the day to check fit? Yeah, don't tell me they squeezed out most of the cost.
They squeezed out most of the cost and gave the profits to healthcare administrators. Why did you think those savings would be delivered to the consumer (you)?
American healthcare not a free market.
cost =/= price
They don't seem to have any trouble sending out bills, though.
> seems like it's just insurance companies that can weaponize this data for better rates.
That’s because their negotiating power is mainly due to the size of their buying power, not special knowledge or skills. Health “insurance” is basically the lamest, most economically perverted form of collective bargaining ever.
And why federal governments make the best health insurance carriers.
Brokers, medical billing staff, and other middlemen serve no purpose other than increasing cost (in order for an inefficient, openly colluding private cabal to invest premiums, deny claims, and collect profit) because everybody needs access to medical treatment.
I live with free healthcare. The last three trips to the emergency department have been over eight hour waits. My father's cancer treatment was not covered so the last year of his life cost him everything.
On the other side my child's healthcare is amazing and all free. We get instant access to great services.
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Insuring massive populations isn't really insurance because of large numbers (there's no risk involved.) It's just an economic rent. It's a poker game where most of the players are cooperating.
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Don’t bet on it.
There is enough (potential) money and incentive here that almost any system will be perverted eventually.
NHS is not known for speedy treatment, for instance.
It’s about ongoing oversight and a willingness and ability to cut through bullshit to fix things. That’s in short supply here and everywhere else.
The stories (first hand from relatives who use it) of blatant profiteering and abuse of the system in Medicare is mind boggling.
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If you think government doesn't have those things, you don't know much about how it works.
Most of Medicare is administered by middlemen and private companies.
The current administration has basically decided that this will not be enforced so most of the carriers have ditched phase 3 - searchable 500 popular procedures. Really is a shame, I was very much looking forward to utilizing this, especially for HSA and or ASO clients.
t. licensed broker / agency owner
>That’s because their negotiating power is mainly due to the size of their buying power, not special knowledge or skills. Health “insurance” is basically the lamest, most economically perverted form of collective bargaining ever.
Now can you make a cogent argument for why more than one federal / national union should exist? Why does Europe allow multiple unions?
I don’t follow. What unions?
For a customer advocate, the pervasiveness of the artificial low rates seems to be an interesting opening.
You should be able to go back to the hospital and say - based on the hospital public fee schedule , total FFS for CPT should be (very low number) . Therefore, my deductible payment is overstated, please reduce my bill dramatically.
A lawsuit would follow, which would make it very interesting. Chief argument:
The customer can clearly say its fraud - he/she looked at the public rate schedule and believed the charges would be based off the public rate schedule.
Ultimately, the disconnect between published rates and the EOB is going to come back to bite hospitals, once people shop around using the data.
I wonder, does the law have any whistleblower provisions? Seems like a programmer who had been coerced to fudge the data, and kept receipts, could be in a good position...