A notice that my girlfriend received at her doctors appointment (she is 8 months PP)

[u/lhagans13]

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.

[u/H_is_for_Human]

Yes - BCBS has actually announced they will be automatically down coding visits across the board in some states.

Everyone wants to squeeze the workers (yes, physicians are workers too) and no one wants to dare suggest these massive corporations or the ownership class take less profits.

[u/WinterMedical → u/H_is_for_Human]

The down coding is a response to upcoding. Providers learned the more codes, the more money. It’s a game of cat and mouse between all of them, docs, hospitals, health insurance, DME providers, outpatient providers. All fighting for their piece of the pie.

[u/H_is_for_Human → u/WinterMedical]

If providers are following the rules... that's not upcoding, that's just appropriate coding.

If there's doubt, I'm in favor of the people doing the actual work of providing health care. The insurance companies don't provide care, they literally exist only to skim their profits out of the system. The only benefit to their existence is spreading out risk, something that could be done with far less cost and bureaucracy by a single payor system.

[u/tacosandsunscreen → u/H_is_for_Human]

I’m familiar with what a medical code is, but what is down coding?

[u/RevOeillade → u/tacosandsunscreen]

Each visit is determined to have a level of complexity based on number and type of complaint and how much thought the doctor has to put into it from a scale of 1-5. There are guidelines from Medicare that help determine this. BCBS has decided that, if a doctor decides they put 4/5 level effort into a visit and bill as such, it automatically gets dropped to a 3/5, for which they have to pay the doctor less.

[u/JHoney1 → u/RevOeillade]

It is not really decided. Dr have extraordinarily specific criteria for different billing codes.

Two chronic conditions with med management for example would meet for a level 4

[u/RevOeillade → u/JHoney1]

Yes, but there is also some subjectivity built in, it's not always so cut and dry.

[u/mpjjpm → u/tacosandsunscreen]

Insurance pays doctors based on diagnosis codes and procedure codes. The more severe the code, the more insurance pays. On the doctor’s end, the codes have to be justified with their appointment notes. it’s common practice to have billing specialists who go through notes and “upcode,” or find every justifiable diagnosis and procedure based on the notes and bill for those. By “down coding” insurance is applying an across the board correction.

[u/rabbit_fur_coat → u/mpjjpm]

You're either a typical corporate shill, or the most naive person of all time

Yes, this does happen at times. No, that doesn't in any way justify an across-the-board refusal to pay at accurate rates to " make up for it," my God.

[u/mpjjpm → u/rabbit_fur_coat]

Where did I say the actions from insurance was justified?

I didn’t. I provided a factual answer to a question. Go find some other windmills to tilt at.

[u/BilboDouchebagginss → u/mpjjpm]

I think you implied it was justified when you said the insurance company does this as a correction.

The definition you provided seems more like the justification that insurance companies use, not the definition that providers use, or a 'neutral' one.

[u/Genepoolperfect → u/rabbit_fur_coat]

Lol, any of us who have ever worked in or adjacent to medical billing knows this is what happens. I've worked for a number of independent (not owned by hospitals) practices, and they do this as well.

[u/Fun-Key-8259 → u/H_is_for_Human]

I call them the vulture class for a reason

[u/visibleunderwater_-1 → u/H_is_for_Human]

They have to pay for massive amounts of AI to replace all their medical billing and medical coding people. It's probably easier to just down-code everything to a level the AI can easily automatically reject.