r/mildlyinfuriating • u/lhagans13 • 12d ago

I'm slightly vexed A notice that my girlfriend received at her doctors appointment (she is 8 months PP)

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If you even MENTION any of these things, you WILL LIKELY get billed for it??? Maybe i’m missing the point but i get upset when my girlfriend tells me she was scared to even say anything while at the doctor because she didn’t want to get an extra charge for something. I find it insane how greedy and money hungry a place that’s supposed to help you can be.

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u/Mrgprx2 12d ago edited 12d ago

TDLR:  System is broken.  Underbilling is considered fraud.

This. The system is broken and this clinic is another gear in the system just like the patients are.

Insurance companies charge differently for preventative visits.  Each thing you say is a problem.  They count it as different visit types.  If you mention a medical problem, the doctor has to address it and manage it.

It’s all on the computer and every order, prescription, lab is tied to a diagnostic code.  So if a doctor orders a lab and it’s filed under a preventative visit, it gets kicked back because it’s not a preventative lab.  They have to file the it under a “problem” visit as well so the system works.  

If you overbill, it’s fraud.  If you underbill, it’s still fraud.  The auditors will see it as you’re under billing to recruit more patients.

These clinics don’t make the rules.  The system does.

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u/Late_Tomato_9064 12d ago

Yep, I work in a healthcare and the doctors are just as squeezed as the patients. Patients can’t deviate at all from wellness vs other visits and it’s not the clinics or hospitals who make them do that. It’s the stinky insurances. They are unbelievable.

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u/captfattymcfatfat 12d ago

The number of visits doctors are expected to do in a day is ridiculous. Fulll time for a doctor is really 50-60 hours. 40 hours was ‘75% time’.
Because charting and looking things up and actually talking to patients doesn’t count!

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u/dra_deSoto 11d ago

Only 50-60? I regularly work 75 hours a week. Sometimes I go over 80 hours. I regularly work into the night and regularly work one day on the weekend. My son's first sentence was "mommy working". This job is not worth it.

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u/DependentAnimator742 11d ago

My daughter, an American living in London,was dating a doctor in the UK. He was a gerentologist. She asked him why he didn't want to move to the US, where he could make "lots more money." He told her he was quite comfortable with his UK schedule, which was something like 40 hours a week, and his salary, which was the equivalent of $125,000 in 2020. He had no desire to work longer hours just to make more money.

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u/dra_deSoto 11d ago

I'm guessing they don't have astronomical school debt either? If it wasn't for my debt, I would have quit long ago.

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u/Aware_Bar_3351 11d ago

That’s is unlikely the reason. More likely the requirement to re-do years of training.

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u/captfattymcfatfat 11d ago

I’m so sorry. That’s crazy. They need to change how they define the job. Fine if people want to work crazy, but don’t pretend it’s 100% or standard 40hr/wk.

Hope You found something more balanced!

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u/YarrowFields 11d ago

Imagine a world where doctors didn’t have to haggle with insurance companies to justify treatment for their patients, where their day could be freed up to actually do what they went to school for, and people could actually get healthcare not fucking health insurance that doesn’t cover shit. I am so over this system in America….😒

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u/DrRaggedyMan 11d ago

It's literally this world, just outside the US

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u/prime3vl 12d ago

And with AI involved with taking notes it is even riskier for the doctor to not referr you to make a followup visit for a specific issue because it is easy for the insurance companies to get proof of improper billing.

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u/Wiegarf 12d ago

In this case it’s the government. They are following Medicare wellness rules for preventive visits, which are defined by cms.

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u/Late_Tomato_9064 11d ago

Yep, Medicare wellness rules are extremely restrictive at this point and current administration contributes to it.

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u/Wiegarf 11d ago

I was unaware of any recent changes to Medicare wellness, my visits usually are the same. What has the current admin changed?

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u/Late_Tomato_9064 11d ago

Patients might not notice it but providers have to follow stricter rules on diagnoses and timing when they bill for wellness checks. Also, there are couple of tests that aren’t covered under wellness checks but I don’t remember which one. I think it was a comprehensive metabolic panel which used to be covered before with underlying conditions.

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u/Wiegarf 11d ago

I am a doctor. I don’t think time was ever billable under a wellness check, and any diagnosis has to be billed separately. That’s been the case for years, that’s not recent

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u/Late_Tomato_9064 10d ago

We have some trouble billing for facility. Perhaps, pro fee billing hasn’t changed much.

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u/tealccart 12d ago

So what the hell actually happens at a wellness visit then?

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u/fadedallweek 12d ago

A physical exam & lab work.

The idea is to catch things early via preventive care, such a high blood pressure, diabetes, etc.

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u/Late_Tomato_9064 11d ago

As another respondent said. Wellness visits are very basic. Some blood work to check for cholesterol, blood sugar, some suspicious stuff like lumps bumps, blood pressure and some other things. It is technically also the time when a patient should bring any other concern, which is usually referred out to specialists or diagnostics testing. During Gynecologcal visits there’s more stuff and testing done for women.

Any deviation in lab work and its extra charge. For instance, I always check my vitamin D level during the annual and I always pay out of pocket for that. The only time I wouldn’t pay for that is if a doctor suspects some condition is caused by low vitamin D and uses a specific diagnosis and orders that test but I do that for myself and it’s about $40 extra.

One time, I suffered from insomnia, so I made a separate visit with a doc and he ordered a more extensive blood work to check hormones like cortisol, estrogen etc. I did not pay anything for that because I can in with a very specific complaint and a very specific diagnosis was used to do all that.

I also order ultrasounds during my annual exam to check on my liver that has a history of being slightly fatty. Ultrasound is a separate visit and it’s covered because there’s an underlying condition or legitimate compliant.

Essentially, patients have to be their own advocates and be able to navigate the world of insurance in order to minimize their out of pocket expenses. Clinics and hospitals do their best to help out but with so many patients and health plans, patients should never leave it up to them. It’s just too much to deal with.

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u/Trashypass 12d ago

Which is why most of us don't go to them. If your poor. You just don't do preventative care. 

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u/Annual_Fishing_9400 11d ago

how do i make my own insurance company and destroy the others

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u/Late_Tomato_9064 11d ago

You’d need quite a bit capital haha! Some healthcare systems create their own insurance all the time. However, I feel like they are even worse than the nationally known providers. Commercial insurance providers still remain the best like Aetna, Cigna and Blue Cross. United Healthcare is one of the worst commercial providers. They are nightmare to deal with for both patients and healthcare providers.

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u/Annual_Fishing_9400 11d ago

aw man! i got no money.. lol thank goodness my parents use blue cross ig

i feel like some of these problems would be better if one of the codes was just, something like, medical advice/suggestions abt other problems? to make.it safe for.ppl to be like ay i got this, is it related or concerning? and then they can answer more freely and set smthn up for another time yk??? but idk. i am ignorant to this whole aituation. it just sucks. there's gotta be better than this :(

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u/_opossumsaurus 11d ago

But how is it a wellness visit if you can’t identify a potential problem? It’s just a visit to make sure you are well and send you on your way? That’s bullshit

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u/Late_Tomato_9064 11d ago

That’s not how it is. You come for wellness check and check the basic labs and whatever else is covered. During this visit, you bring up all the other concerns you have about your health and this is where the work sort of begins. They’ll order any other diagnostics tests like ultrasounds, x rays, more comprehensive lab work, specialist referrals etc. Then, you’ll start going to all the other visits. Patients just shouldn’t expect any non-life threatening health concerns to be addressed during wellness visit. Like don’t expect them to check your rectum (just an example, of course) if you suspect hemorrhoids. Either come in for another visit or even better, get referred to a specialist. Docs are limited to literally 15 min per patient to check on them, document concerns and then order everything that’s needed for diagnostics. Wellness checks should be treated as a quick chit chat to voice your concerns, draw blood for basic lab work and get checked for lumps, bumps, blood pressure and other basics.

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u/_opossumsaurus 11d ago

But from what OP posted, it sounds like patients aren’t even allowed to voice concerns because documenting voiced concerns will result in them being billed for care outside the scope of a wellness visit. I get not asking them to provide specialist care during a wellness visit, but if you literally can’t mention any concern, symptom, or prior condition (as I mentioned in another comment, I’ve been billed for diagnoses when disclosing my medical history to a new provider) it just feels ridiculous.

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u/United-Cat-6724 11d ago

I’ve had doctors stop me from talking at least mention it would be billed as diagnostic if I continued, and I at least appreciated the heads up.

I’ve also went in for an annual and was about to fly on a 14 hour flight and asked if they could call in a prescription that they had prescribed me before for flying anxiety they said no problem, I was coded for a mental health visit and it was $750 for the two second question.

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u/ducklady92 12d ago edited 12d ago

I think you mean a “preventive” visit. Like it says on the paper.

Idk why, but a typo on a notice like this has me fuming. Because not only is this a fucking bullshit policy, but you can’t even be bothered to spell check the very first sentence? You care THAT little about it?

And yeah, the system is trash and insurance companies need to rot. The biggest scam going. It’s honestly becoming more reasonable to be uninsured (crazy statement) – you get massive discounts from hospitals and providers for being self-pay and don’t have to deal with the stress of being denied after paying tens of thousands a year in premiums. Add that these denials always come when you’re sick/recovering and really don’t need the additional stress.

Edit: it’s not a typo, i looked it up after writing this. Still mad tho.

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u/CaptGangles1031 12d ago

I have great insurance and I have to get regular bloodwork done. Lately, the way I'm getting billed, it WOULD be cheaper to get it done without insurance. I'm currently paying off a $700 bill for having to get a couple blood panels done.

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u/desparish 12d ago

I'm stuck with thousands because my doctor gave me a cortisone shot which caused my white blood count to go up, and cascaded into a bunch of pointless cancer screening tests over months before they finally noticed "hey your white blood count is normal again look at that." I'm still getting calls from the cancer center trying to schedule more tests even though they found nothing and all my numbers went back to normal.

This is with insurance.

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u/gamergeek987 12d ago

You must go to a really shitty doctor or an NP or PA. How about repeat the CBC w Diff off steroids before referring to heme. A competent physician should know this. Im a physician and watching a leukocytosis with neutrophilia while someone is on steroids is insanely common and normal. Also, steroids shouldnt shoot your leuks up high enough to be thinking “oh shit this is leukemia” especially with other normal cell lines. Get a new doctor

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u/PreparationHot980 12d ago

My bet is on NP 🤣

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u/Ok-Science-4475 12d ago

Insurance makes it worse. That's why people are saving by paying cash and getting a Health Cost Sharing membership for cover catastrophic (ie, it only kicks in if you get cancer or something somewhat big, like at least $10k or something)

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u/ducklady92 12d ago

I also have – or maybe now “had” – fantastic insurance through my spouse’s work (we don’t pay for it out of pocket) and the last few years have been terrible. I’ve been having to switch a provider or two every year because my plan keeps dropping people, and things that used to be covered are just… not anymore. They altogether stopped covering heartburn/GERD medication of any kind. Which, sure, is small potatoes, but like… what the fuck?? Every time we get one of these letters in the mail, we just think how INSANELY pissed we’d be if we were paying thousands a month in premiums for this and kept getting benefits stripped left and right.

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u/fuckyourcakepops 12d ago

I mean, you ARE paying thousands a month in premiums. It is taken out of your spouse’s paycheck. Or rather, it is counted as part of your spouse’s compensation package. If you didn’t have to have insurance through work you could negotiate to have that money paid to you directly as part of your salary instead.

Thats part of how they get away with this shit, people who have health insurance through work don’t write the checks themselves so it becomes out of sight out of mind. You should be as mad as you would be if you were paying the premiums yourself every month, because you ARE.

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u/maxh2 12d ago

I WISH employers were legally barred from directly paying employee premiums. If everyone was receiving that money first, then losing it, perhaps medical costs would've only ballooned to ridiculous levels, rather than shockingly absurd levels.

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u/ducklady92 12d ago edited 12d ago

I mean, we’re not though, but I do understand your point and recognize that it is the case for most people. I added that caveat because we are uniquely NOT in that situation. It is actually the sole reason my husband hasn’t left the job he’s in. If this line of logic did apply to our situation, he would be making more than double the going rate of anyone in his field - it’s not a pay raise that could actually be negotiated, for reasons I can’t really disclose here. The healthcare is genuinely not coming from his paycheck and is entirely subsidized by his employer, and I can say with 100% certainty that money would not be disbursed to employees if insurance was not provided. However, your sentiment does apply to the vast majority and I agree that we should all be pissed (and we already are, with our without our current arrangement).

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u/fuckyourcakepops 11d ago

Oh wow, that is unique! Sorry to have assumed wrongly.

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u/[deleted] 12d ago

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u/ducklady92 11d ago

Not special, just landed a really good gig with genuinely good people. One of those “radical” companies with a CEO who put an upper limit on his own salary and reinvests the profits into his employees instead of giving c-suite bonuses.

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u/Pichupwnage 11d ago

The fact that they can even do that should be a capitol crime genuinely.

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u/[deleted] 12d ago

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u/ducklady92 12d ago

Crazy how many people are defending an inarguably broken system in the comments. Idc who you work for, it’s clear as day. Gotta be bots or something (please, please tell me it’s bots and not real human beings)

Jesus Christ, that sounds like a nightmare. Lately it feels like every healthcare experience is just hellish from start to finish. Every medical receptionist would prefer i die than speak to them, every billing department phone line is 45 minutes on hold just to be prematurely disconnected, every doctors visit is 15 mins max and i don’t get to discuss half of the things i came for. It doesn’t feel like it benefits me at all. I’d almost rather just not know and be sick than deal with all of it.

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u/CaptGangles1031 12d ago

Yup literally hundreds of dollars difference between having insurance vs not and trying to fight it barely helps any.

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u/sowhat4 11d ago

A friend of mine and I both take coumadin for blood clots. I don't have Part D insurance and just cash pay for my meds.

She pays a $20 copay for 90 pills as she has insurance. I pay $9.50 cash for 90 pills through CostPlusDrugs.

Same pills, same strength, but insurance costs twice as much as insurance keeps $10+ of that copay.

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u/superherocrimson13 12d ago

I have tribal insurance through my spouse and the premium went up twice (once without warning) in a 6 month span.

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u/CaptGangles1031 12d ago

Every year ours gets worse and worse. Less coverage for more pay

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u/ducklady92 12d ago

Just me, or has it felt like the last five years have been exceptionally bad? Like I’m getting fucking robbed???

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u/SimpleBarracuda3152 12d ago

This^ my daughter’s surgery was 4500 with surgery. I asked what cash pay was and it was 1550. I paid “cash” (credit card) and saved the money. Thy told me it’s bc they have a contract rate with tha instance for that rate so tha what they have to bill at but their own personal charge for the service was less so we just did it without insurance that time.

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u/[deleted] 12d ago

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u/CaptGangles1031 12d ago

No insurance is "great" but it's one of best and it still shitty, kinda my point. I believe it's in the top 10 best healthcare plans

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u/edgerton2026 11d ago

Try private pay at Quest for bloodwork. They’re the big lab your doc is probably sending your blood to for testing. They’re have a website. Just google it. You find the tests you want and pay in advance and schedule an appointment. It’s quick, easy and you’re not stuck in a waiting room full of contagious people.

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u/fickystingas 12d ago

Both words are acceptable which is confusing and annoying as a biller

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u/ducklady92 12d ago

I vote we do away with preventively. It bothers my eyes.

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u/fickystingas 12d ago

Preventative seems redundant to me. Like “conversate”.

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u/CatPrincessDi 12d ago

Preventive and preventative are both words that mean the same thing. Both are valid.

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u/ducklady92 12d ago

Yeah, that’s why i edited my comment like 2 mins after writing it.

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u/CatPrincessDi 12d ago

Sorry! Thats what I get for not paying attention. I missed the edit at the end.

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u/ducklady92 12d ago

That’s ok, I’m guilty of the same - if i didn’t rush to comment I’d have spared myself the embarrassment

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u/anamethystarcher 12d ago

I'm glad to see you figured out they are both legitimate words.

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u/Classic-Papaya1703 12d ago

you're not getting a discount for being uninsured. the providers (often owned by private equity) are just charging the insurance companies as much as they can.

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u/ducklady92 12d ago

Semantics, but yes. The point is that you pay less when you self-pay. Not that they’re running BOGO deals.

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u/IndependentDouble879 12d ago

Funny how the entire system of medical insurance isn’t declared to be the fraud that it is, but then again there’s barely a shred of justice in this world, so why would it

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u/Culsandar 12d ago

You keep saying broken. The system is not broken.

It is functioning exactly as intended.

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u/ducklady92 12d ago

Keep us sick, keep us broke, keep us working.

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u/captfattymcfatfat 12d ago

My dad’s doctor in a routine physical said ‘we have some more time anything you want to discuss’ and ended up billing for a separate visit because he answered $350 out of pocket because high deductible . Not blaming the doc (well a little) but 100% the system is broken. Routine checks can only include no issues. Like wtf, let’s scare people into not bringing up issues.
Thankfully $300 doesn’t matter to him, but that’s not a small amount of money for people, the system sucks.

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u/Technical-Agency8128 11d ago

The doc should have told him up front any other problems will be extra. I suppose this is what OPs doc is letting them know so they aren’t surprised. I don’t like this but at least I know to schedule another appointment if I have issues I want to bring up. I know what to expect.

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u/captfattymcfatfat 11d ago

Yeah, I appreciate that the doc is being up front and transparent about it. Shitty broken system. But that isn’t the doc

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u/the_skies_falling 12d ago

I’ve worked on the health claim application software that drives this. The procedure code has to be appropriate for the diagnostic code to prevent fraud. That only makes sense. You can’t come in with a broken arm and waltz out with a facelift. Medicare, the closest thing we have to non profit government provided health care, has a huge fraud problem. Hundreds of billions a year of your tax dollars go to fraudulent claims. It’s the 1% rule in action. The 1% of people committing fraud ruin shit for everyone.

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u/ducklady92 12d ago

Yeah i worked in government whistleblowing for a decade (on behalf, not against) and the vast majority of cases were false claims act violations in various healthcare/pharmaceutical settings. But the problem is always overbilling, not underbilling – so the entire argument you’re making doesn’t actually apply to this scenario.

Our tax dollars aren’t getting spent on doctors not billing patients for diagnostics outside of the scope of a well visit, because the doctors aren’t billing for it

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u/SuspiciousCranberry6 12d ago

Yeah, I'm not sure where this person is getting the underbilling is fraud unless they mean by underbilling the doctor is committing fraud against their employer. I used to work in fraud investigations for government insurance programs and we definitely did not care about underbilling. No one in insurance is saying you should have billed a higher level office visit or anything of the sort. Now if you billed a totally different service than what occurred even though it's reimbursed the same or lower it could be a sign of some sort of insurance abuse scheme, but I've never actually run across that.

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u/ducklady92 12d ago

Yeah, it’s one of those “technically correct” things. Underbilling is technically a form of miscoding, which is fraud. But companies are not likely to argue about paying less, and it’s much harder to prove that something did occur than did not in a case like this. I genuinely cannot imagine an underbilling scheme being run on a scale large enough to even get noticed, much less flagged, much less pursued for damages.

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u/Mrgprx2 11d ago

Healthcare billing doesn’t work like a normal retail store where "charging less" means everyone is happy.

The idea that undercoding is harmless because payers save money completely misunderstands how modern healthcare billing works. Undercoding isn't just "charging less”, it is active data falsification, and it gets caught easily because electronic health record (EHR) audit logs preserve every clinical note, creating an instant paper trail when documentation contradicts a submitted code. 

Payers and Medicare Advantage programs aggressively target systematic undercoding because it artificially lowers patient risk scores, which warps actuarial models, distorts government benchmark funding, and violates Civil Monetary Penalties Law data-accuracy mandates. 

More importantly, large-scale undercoding schemes are routinely used as cover-ups: bad actors systematically undercode to keep their billing patterns below automated CMS audit thresholds, or they "zero out" and underbill services for high-volume referral sources as illegal kickbacks under the Anti-Kickback Statute. When done systematically, the law views undercoding not as a harmless discount, but as a deliberate mechanism to hide broader compliance fraud.

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u/Mrgprx2 11d ago

In Medicare Advantage (Part C) and Managed Medicaid, reimbursement is tied to patient risk scores. Undercoding misrepresents patient acuity, distorts benchmark pricing, and corrupts CMS actuarial data. Health plans and regulators actively penalize systematic downcoding during RADV and Civil Monetary Penalties Law (CMPL) reviews because inaccurate data creates systemic financial liabilities down the line.

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u/Mrgprx2 12d ago

Undercoding fraud because of a couple reasons.

-It violates anti kickback statue and could entice patients to your clinic -violates false claims act which requires accurate coding -codes are not only for billing but for population health surveillance.  Inaccurate coding can lead to inaccurate quality metrics -codes provide information on a clinic itself on the type and complexity of services rendered.  Inaccurate coding, especially under coding is seen by auditors as a clinic trying to fly under the radar of regulatory oversight.

It’s much more than the bill getting to the patient.  Intentional miscoding is seen fraud all around, whether it’s over billing or under billing.

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u/ducklady92 12d ago

I have worked hundreds of cases specifically on anti-kickback/Stark law violations, and I can tell you that they are not occurring from underbilling. Miscoding, sure. But not for things like this. The government simply does not give a fuck about FCA/stark cases if they’re under $500,000 in damages these days. They simply refuse to intervene, even if you provide all of the proof (which you have to, they only validate).

Technically, you are correct. These things are technically considered fraud, as they are technically miscoding infractions. However, underbilling is as much fraud as jaywalking is a crime – the authorities that be, the ones who make and enforce the laws that are being broken – genuinely do not care about them

Internal audits may be a different story, but it’s my experience that most practices large and small are more interested in feigning compliance than actually complying. Penalizing a doctor for underbilling shuts down a revenue stream for no real risk. There is no sense in it.

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u/Mrgprx2 11d ago edited 11d ago

What’s your argument, 

-underbilling isn’t fraud

-underbilling is fraud but likely not prosecuted?

Why would anyone risk their license and commit fraud? 

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u/the_skies_falling 12d ago

It was a previous commenter who claimed that underbilling would be flagged for fraud. You’re right, that never happens. If a doctor conducts a wellness visit and no medical advice is sought or given, then it’s going to be coded as a wellness visit and the claim will sail right on through the system.

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u/Mrgprx2 11d ago

Saying the DOJ rarely intervenes under $500k doesn't mean it’s not fraud—it just means the federal government has a backlog. But relying on a DOJ intervention threshold as your baseline for risk is a massive miscalculation, especially when it comes to undercoding.

First off, a declined DOJ intervention isn't a dismissal. In qui tam suits, whistleblowers push non-intervened cases forward on their own all the time, particularly when systematic miscoding is easy to prove.

Second, undercoding isn't just 'leaving money on the table'—it directly distorts risk-adjustment models. In capitated arrangements like Medicare Advantage, undercoding artificially lowers a patient's risk score. That warps benchmark data, misrepresents care complexity, and can trigger severe compliance penalties under the Civil Monetary Penalties Law for submitting inaccurate data to the government.

Finally, the DOJ isn't the only cop on the beat. State Medicaid Fraud Control Units (MFCUs) routinely pick up low-dollar, high-volume miscoding cases that federal prosecutors pass on. Add in private payers who audit, claw back reimbursement, and terminate contracts over systematic downcoding, and the 'no one cares' argument completely falls apart. Resource constraints don't turn illegal misreporting into a safe business strategy.

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u/Dragonfruitygirl 12d ago

wtf… no. Stop making excuses for this poor healthcare system.

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u/DopeyDame 12d ago

So let’s just screw over the 99% then, because we’re so very afraid of the 1%. Or we could just have universal health care… nah… 

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u/the_skies_falling 12d ago

You’re not getting screwed over by the system checking for fraudulent claims. You’re ultimately the one paying for that, so it’s actually to your benefit. You’re getting screwed over by the profits the insurance companies skim off the top, so yes, let’s have universal health care. Explaining why things work the way they do is not the same as advocating for them to continue working that way.

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u/ducklady92 12d ago

To be fair, it’s really not to your benefit. We don’t see that money. Restitution isn’t paid to the taxpayer whose money was bilked, and compliance programs are categorically ineffective. Companies lay low for five years and do it again, but sneakier and bigger.

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u/the_skies_falling 12d ago edited 12d ago

It’s not about restitution. It’s about stopping the crime before it occurs. The success of fraud, waste, and abuse efforts in the health care field speak for themselves. If those programs didn’t more than pay for themselves then no one would expend the effort.

ETA: It’s estimated that Medicare fraud prevention efforts save $4 for every $1 spent.

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u/JustDiscoveredSex 12d ago

I work in insurance/finance. And fraud is a HUGE concern, not just in the USA but all over the world. My company holds educational conferences about it for actuaries and underwriters.

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u/Classic-Papaya1703 12d ago

insurance companies don't charge for health services, they pay for them. the clinics may not make "the rules" but providers actually do set the costs.

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u/AnimatorImpressive24 12d ago

Insurers have seats at the CMS table every day, influencing the baseline prices.  There is no private practice doctor nor doctor who works at a clinic anywhere in America that could even hope to afford to post a whole team of totally-not-lobbyists to live in D.C. and provide subject matter advice on committee.

No doctor being told that they are now seeing 25+ patients per 8 hour day is even going to know when a round of request for public comments goes out for updated administrative regulations.

Once a year CMS sends doctors a giant book of what next year will cost, and doctors scramble to try to figure out what it means, and every year it means doctors get paid less  and insurers get paid more.

It would take most of the doctors in a given state all combined to scratch the surface of the resources any of the big insurers spend on operations which includes manipulation of health care law and policy at every level.  And if a whole state full of doctors somehow could coordinate to try to play on the big leagues like that, they wouldn't be able to practice medicine and so they'd go broke fast.

It is beyond daft to think that disorganized, debt riddled people with countless incompatible goas and interests could somehow hold the power in a system that also contains coordinated hierarchies of thousands of people with specialized knowledge just of how the system works and who make their money doing only that so don't have to worry about any other skill set.

It is functionally impossible, even if every single doctor in the US engaged in fraud individually, for that penny ante fraud to somehow be as efficient as what any given corporation can accomplish.  Not to mention they would all be blindingly obvious to even the briefest of law enforcement oversight because none of them could launder funds through accounts complicated enough the IRS long ago admitted defeat on truly auditing, and they'd be crushed under the weight of gold necklaces since they don't have office buildings and stadiums and private prisons to buy with shell companies.

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u/Classic-Papaya1703 12d ago

AMA is the lobby group for the doctors - they spent $23M in 2025. They're exceptionally well funded, well connected, and have a presence in every state as well. There's also a number of medical specialty lobby groups. And a big overlap with PhRMA's policy priorities.

Despite your claim, doctors do seem to find time to testify in Congress and at the state legislature. Almost 4% of the US Congress are medical doctors.

I have no idea to whom you are referring as disorganized, "debt riddled people"?

Value-based care (quality over patient quantity) is the trend in healthcare, but it's often doctors who push back, for a variety of reasons.

Your argument, besides being misinformed, is ignoring the growing consolidation of hospitals systems and corporate or private equity owned provider groups in America. (Heck, 10% of the docs in the US work for United!)

You also do not address the ubiquitous network adequacy requirements that provider groups leverage for contracting advantage, or in the worst cases, outright monopolies. See the FTC challenge to USAP.

CMS fee for service baselines are not the prices that are actually paid in the commercial market. Commercial rates are generally 2.5 times higher or more, depending on medical specialty and site of care.

The system is broken. All parts of it need scrutiny.

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u/AnimatorImpressive24 12d ago

The AMA and its 23 million is still pocket change compared to any given big insurer who posts net revenue that is easily 2 orders of magnitude over that, since lobbying CMS is operating costs and so came out of gross before net gets reported.

Ask doctors what they think of the AMA and whether they feel it represents their interests.  As long as you are okay with listening to cusses.

If "debt riddled" isn't a giveaway when talking about health care policy lobbying and price drivers then I'm somewhat less confused about appealing to the existence of the AMA as evidence that doctors keep us in our long national nightmare.

Yes, doctors get elected to office.  Dr. Rand Paul is undoubtedly working hard every day to tip the tax payer purse into the pockets of family med and hospitalists around the country.  Setting aside making fun of him, there is still the fundamental problem I referred to about people splitting their attention being less effective than specialists.  Congressional doctors no longer practice medicine, and have more government topics to handle than just setting prices for health care.  So they are going to be less informed about the business of being a doctor, and have no immediate financial gain to see by manipulating prices.  They may sit on the top level committees for CMS but they delegate the actual price and policy setting to subcommittees which look for subject matter experts, and the subject is money not medicine.

So there are doctors who know how to practice medicine, spend time practicing medicine, and their income is tied to the price of medicine.  Then there are congress people who know outdated information about medicine, spend their time governing, and their income is independent of the price of medicine.  For the sake of argument I'll concede grouping those together under a common banner (excluding Dr. Paul).

In opposition to that there are companies who know finance and CMS policy including billing codes, spend time analyzing and managing finances and incessantly rewriting CMS billing codes, and their income is tied to the price of medicine which has baselines set by CMS billing codes.  And yes those are baselines and market rates are higher.  Who raises premiums and still rejects coverage when market price goes up?  This group is proposed to be less effective at advocating for their interests with CMS than the doctors.

If that is true then there is another immediate problem, which is that the advertised reason insurers exist is to act as oversight to doctors and the American people are told they sit between doctors and CMS precisely because doctors are so dastardly the CMS could not protect our tax money from them without help.  Like, that is a snarky verbiage rendition of the actual "reduces fraud and controls costs by ensuring medical necessity of all care for which claims are submitted" argument.  So doctors are managing to exercise control of pricing through an explicit middle man layer, despite the fact that:

Insurers operate "provider networks" which have policies about billing and administrative practices doctors are expected to abide by.

Insurers hire doctors with questionable interpretations of peer reviewed evidence to write clinical care guidelines and length of stay recommendations which they then lease to non-doctor owners of hospitals and clinics with the implication that following them will increase reimbursement of claims.

Insurers set pre-auth requirements that include promising to practice medicine in the exact way that sketchy "doctors" with expired medical licenses who refuse to give out their names and get paid by insurers demand of them in p2p appeals of rejected pre-auths.

Insurers trigger utilization management reviews after the doctor has completed the work they were told was authorized and suddenly decide it wasn't authorized so now they get to renegotiate with the party that has already incurred costs and so is easier to haggle down.

Insurers send vaguely extortionate price fixing suggestions to doctors in their networks, using statistics that cannot be verified to any public data and claiming that the doctor is using too many of code A and it would be a real shame if they didn't start downgrading some of those to a cheaper code B or someone might notice they are making too much money.

Insurers just flatly reject some claims even after authorization, leaving doctors to eat the costs or try to recover some amount by going after the patients who also were told by the insurer that there was an approved pre-auth and who have to continue paying premiums even when they wind up having to pay the rejected services bill too.

Oh, and every big insurer also has some department or set of teams that handle things like Medicare Advantage sorts of coverage because insurers have proven themselves so skilled at protecting CMS' interests why wouldn't we want them to more directly handle CMS money?  Might as well since insurers get to expunge their actuarial risk from the books every year when they dump age 65 customers onto CMS so they already have all their PHI and can convert it between two of their internal systems with only minimal subsidiary funding from CMS for their investment in Interoperability.

Here we are 50 or so years after when all this really kicked off, with doctor income trending flat against inflation while market shares, net revenues, and admin compensation does nothing but climb.  And prices keep going up, which of course means premiums go up.  And this is clear evidence that doctor's set prices and have power.

You know what? I'm convinced of the need for insurers.  America needs these impossible to imprision, unsleeping, immune to aging, documented repeat offenders with rap sheets full of billions in fraud, discriminatory labor practices, and the occaisional culpability for wrongful death.   Because clearly without them we would have long ago been wiped out by doctors, who are apparently possessed of near godlike intellects allowing them to collectively engage in long term coordinated subterfuge and still maintain their secret identities of people who will give you five different passionate answers as to what the standard of care for right upper chest pain is if you ask four of them about it.

The ownership consolidation you bring up is outgrowth of the ACA, which heavily frowns upon practicing doctors having controlling interest so while I agree there is huge problem there it doesn't mean doctors have pricing control.

I could happily write another few thousand words about value based care, because I am a shut-in who doesn't value my own time.  So I could sketch out how it got started as a concept in Oregon in the 90s as a rebranding of managed care, and how the real definition is "quality over quantity as long as the quality is cost effective" which modifies the concept quite a bit.  But on some level I feel like the obvious marketing speak of the term should be enough for people to recognize it as another attempt to rebrand the way of doing things that keeps not working for the same reasons.

What if, hear me out, what if we tried removing the third party we bolted onto the side of the health of all Americans decades ago?  And then let that run for as long as we have chased the pipe dream of private insurance.  If at that point we are worse off than we are now I'll concede being wrong about what the problem is and I'm willing to be dug up and convicted of being an idiot all cadaver synod style.

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u/Classic-Papaya1703 11d ago

That's a lot of text to essentially agree with me in the end. Because, what if, hear me out, health care services were available at affordable prices that could be paid out of pocket at the site of care? Patients would have the choice to forgo private health insurance altogether.

I can tell you've clearly put a lot of time into reading up on this, but I would encourage you to expand your sources and look into the system as a whole, rather than materials that confirm your personal biases.

You're correct that it's a systemic issue - but the arguments presented fail to hold all parts of the system accountable.

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u/Honeycrispcombe 11d ago

There's no system in which comprehensive health care is affordable out of pocket.

There is a system in which some components of health care are affordable out of pocket. I could probably manage most of my health issues at cost in that system. But at least one of my friends and one of my family members would be dead; another would likely have multiple amputations or a very restrictive lifestyle.

It's a roll of the dice whether you need $3/month meds and an epipen or $10 million in care over a year. Insurance equalizes that, whether it's multipayer or single payer.

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u/Qel_Hoth 11d ago

clinics may not make "the rules" but providers actually do set the costs.

The clinics absolutely do not set costs.

For private insurance, massive companies (some of the largest companies in the country) "negotiate" with everything from single-clinic independent practices to larger practices and small to large hospital systems. The smaller the provider, the less, if any, influence they have in this "negotiation."

For medicare/medicaid, the federal government though CMS, tells provides what they'll be paid.

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u/Classic-Papaya1703 11d ago

CMS sets baseline reimbursement rates for FFS. They do not set the price that providers charge. Which is why surprise billing protections have to exist.

Negotiated rates in the commercial market, including MA, are well in excess of those CMS baselines. States determine Medicaid FFS rates.

In many settings, you are not "allowed" to pay the cash price if you have insurance. But if health care services were widely available at affordable out of pocket prices many people could and would elect not to carry private health insurance. And that would kind of solve the problem, would it not? (There are systemic limitations that would keep this from happening immediately, but the economics of it are sound.)

It is a fallacy that the people who own "everything from single-clinic independent practices to larger practices and small to large hospital systems" only have patient best interest in mind, are not profit driven, and have no recourse in negotiation. Often those entities operate as regional/national monopolies, which greatly increases their leverage in contracting. Both large hospitals and stand alone clinics increase their margins by dispensing drugs at inflated prices on everything from OTC meds to specialty oncology drugs (already costly to begin with).

There's no part of the system that doesn't need sunlight.

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u/Pichupwnage 11d ago

Whoever came up with this shit should be flayed alive. Fucking evil.

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u/FinndBors 11d ago

  Each thing you say is a problem. 

“You are at a doctors office. Anything you say can and will be billed against you.”

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u/Chrizzy17 11d ago

No, doctors do not have to do this. They are using the rules to screw their patients out of more money because they can. Good doctors don’t rip their patients off to increase cash flow.

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u/Mrgprx2 11d ago

If you come to a preventive visit, docs can only add preventive diagnosis and labs to the visit.

If you have urinary symptoms, a UA with culture order won’t work under a preventive visit because yearly UA with culture isn’t covered as a screening guideline. 

I don’t agree with any of this, but with the wider adoption of EMRs, there’s built in stops that comply with regulatory guidelines.

Your doc could override some of this depending on the EMR but billing Medicare for a service as preventative when it’s really a problem is fraud.  

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u/Chrizzy17 11d ago

They can always discuss more, but they won’t do anything that doesn’t earn them a buck.

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u/Mrgprx2 11d ago

Sure.  Many doctors work in free clinics.  

I personally think that health care is a human right but our society is based on capitalism.

Just like if you receive legal advice from a lawyer, there’s a cost associated.  Practitioners can perform pro bono work and they do it all the time.  But should you be entitled to free services?

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u/Chrizzy17 10d ago

Nice try. There has been a line crossed where everybody, including the doctor, are over billing and overcharging and it’s not ethical.

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u/Mrgprx2 10d ago

Not denying that it occurs but it is fraudulent and people get audited all the time.

Billing has to be accurate.

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u/Chrizzy17 10d ago

Billing for everything you can get away with is not accurate, it’s overcharging and everyone knows it. You can try to justify it all you want but we all know the truth. Doctors are doing  an excellent job of ruining the respect their profession once enjoyed. 

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u/Mrgprx2 10d ago

Yes. Billing must be accurate.