Wanted to see what everyone thought of this opinion, especially those in administrative roles or on the insurance end.
I would like to ask healthcare administrators to please stop falling for insurance company antics to increase providers revenue generation. There are some simple coding techniques to make sure providers are billing at the top of the service they are providing. Beyond that everything else feels like a ploy to use up provider bandwidth so they can't see as many patients or provide a good patient experience.
From a financial perspective the ideal customer for an insurance company is one that pays their premiums but utilizes few healthcare services. That customer generates revenue (pays premiums) and has little cost (few health care costs). I know insurance companies have mission statements and good people working in them trying to advocate for customers, but ultimately the financials look the best when patients aren't using healthcare services. Regardless of everyone's best intentions this reality influences insurance company decisions.
This means few labs, few imaging, few medications, few completed appointments with rehabilitative services, few completed appointments with specialists.
Providers are approached and asked to document and bill for smoking cessation, advanced directives, CCM notes, additional time code modifiers, or improve HEDIS or other quality measures, or whatever because it improves reimbursements. When we have to do all that it degrades the doctor patient relationship and the patient experience.
Don't get me wrong, if a patient makes an appointment to quit smoking, we should talk about quitting smoking.
If the patient makes an appointment about their knee pain, however, we shouldn't be talking about quitting smoking, doing a PhQ-9, reviewing their diabetes, and pulling in the info from their last CCM note into the assessment and plan, or whatever else. When we have to cram all that stuff in, all we have time to do is say the knee is sprained and will get better in 6 weeks, and if it doesn't come back. We don't have time to order or explain imaging, discuss medications, discuss bracing, do a thorough exam to see if there is something more serious, or discuss a litany of other things that could improve their pain. We just say come back in six weeks, no tests, no meds, really no help. We do that often enough and patients stop coming back... and that is very profitable for insurance companies.
It's like going to Jiffy lube to get your oil changed but they won't do it until you replace your windshield wipers, air filters, flush your transmission, and rotate your tires... and they may not have time to get the the oil changed... but you will still be charged full price for it annnnd all the other stuff, and come back in six weeks to do all this again if your oil still needs to be changed. That's good money for Jiffy Lube.
Don't fall for the BS, if the healthcare company can't make margins with the reimbursements for 1-2 E/M codes per visit and the ICD codes for the diagnosis the patient came to talk about, then don't enter into a contract with that insurance company. Trim overhead, stop running on a wheel to jump through all the insurance hoops, it will never happen. Moving from a medicare 3 star to a 4 star company requires a MASSIVE amount of overhead, moving from 4 to 5 stars is literally a pipe dream only achieved by the most elite health systems in the country. Other quality based reimbursement programs are similarly not cost effective. The time it takes to train up, consistently document then code appropriately for all the other stuff is a money losing endeavor. Insurance companies have all the financial data. Unless they want to be more transparent about their financials and what they reimburse, we should assume that any time they offer something to "increase reimbursements" it ultimately decreases the insurance company's payouts. Decreased insurance company payouts and increased insurance company profits should not be correlated with improved customer health. There is a logical connection there I understand, but it is a faulty correlation missing a lot of confabulating factors.
Okay there's my rant, I have said my piece.
Tell me where I am wrong so I can re-evaluate my opinion.
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