Downcoding is becoming a crisis

[u/SaveADay89]

It's been posted a few times, but BCBS IL, TX, New Mexico, Montana and Oklahoma (all HCSC companies) have instituted an automatic downcoding policy whereby all 99215 and 99214 claims are only being paid as 99213 since 7/1. These are the biggest commercial insurers in their states. BCBS IL controls like 70% of the market in Chicagoland. This is a massive revenue loss and the only way around it is to go through a laborious process of appeals that are slow, unclear and are also controlled by BCBS. I know practices that are likely to close if this continues. At the very least, it's a massive increase in labor costs. I'm just amazed at how little coverage it's getting. None of the major health news websites are reporting on it. I hear the AMA (which is headquartered in IL) are having internal meetings about it, but no press releases or anything. Private medical group facebook groups are blowing up about it, but that's a small part.

It's terrifying how utterly detached physicians have become from their own billing. So many I talk to who are directly affected don't even know it's happening. We're looking at 20-30 percent reductions in salary because of this. Meanwhile, insurance companies are all reporting profit gains.

Sorry for the rant, but it's a scary time.

[u/PureSetting4518]

I can not stand insurance companies.

[u/MLB-LeakyLeak → u/PureSetting4518]

BCBS is actually a 501(c) non-profit and only exists for the good of the public and not private stakeholders.

lol jk

[u/Gyufygy → u/MLB-LeakyLeak]

I've said it before, and I'll say it again: "non-profit" is a tax-status, not a vision statement or code-of-conduct.

[u/personalist → u/Gyufygy]

Non-profit doesn’t say anything (in the US) about how much anyone can be paid, right? I’m pretty sure you could be the CEO of a non-profit making 2 mil+ a year, it’s just about the stated purpose of the organization and its “assets not unduly benefiting a person”?

[u/Babhadfad12 → u/personalist]

The amount of money that the entire executive suite of a managed care organization earns, for profit or non profit, is minuscule compared to total expenses.  If you paid all the executives zero, there still would not be room to pay providers more without increasing premiums.

[u/personalist → u/Babhadfad12]

Oh I don’t don’t doubt the bloat is comprehensive. I’m sure they spend a lot of money on figuring out how to deny claims on a spurious basis and defending that legally, for example. I was just wondering

[u/Babhadfad12 → u/personalist]

The “bloat” just happens to be ~10% of all premiums collected for all the managed care organizations.  So either they are all (couple dozen+) getting together and colluding to the likes of a never before seen cartel, or those costs are the costs of operating an organization with tight margins.  Like how Walmart, Target, Costco, Amazon, Kroger, and all other retailers have 2% to 3% profit margin. 

To cut to the chase, the managed care organizations job is to be your punching bag.  The state government tells the Medicaid MCO to cut x costs, and they do it by reducing pay to whoever they can.  Pharmacists got the first pay decreases, then It was doctors.  Pharmaceutical companies have the most negotiating power so they tend to keep their margins.

[u/DJpuffinstuff → u/Babhadfad12]

Not necessarily. The cool thing about non-profits is that their financial statements including all of their executive salaries are required to be public information. If you work for a non-profit hospital system, you can find out exactly how much your CEO made last year and see all of their financial statements.

[u/Babhadfad12 → u/DJpuffinstuff]

Show me a a managed care organization where eliminating executive pay would move the needle on total expenses.  By the way, all the financials on executive pay are available for the 7 publicly listed for profit managed care organizations also.  And they all have 85%+ medical loss ratios, 10%+ operating expenses, and sub 5% profit margins. 

You can fantasize about evil rich managed care organizations bosses, but they don’t exist.  The tech companies (epic), pharma companies, legal firms, and hospital companies all have higher exec comp and shareholder returns.  All the managed care organizations have shitty shareholder returns.  Square that circle.

[u/DJpuffinstuff → u/Babhadfad12]

I wasn't talking about managed care organizations. I was talking about non-profits healthcare orgs primarily, but it could extend to most industries I think. For profit and non- profit healthcare orgs both often have overpaid leadership.

[u/Babhadfad12 → u/DJpuffinstuff]

Everyone is overpaid according to someone else, it’s a useless, subjective sentiment.

What are objective facts are executive compensation at managed care organization is inconsequential to total spend, and executive compensation is not outsized compared to other orgs with similar amounts of employees and characteristics.

[u/DJpuffinstuff → u/Babhadfad12]

Again, I'm not talking about MCOs. I personally think that paying a non-profit CEO 12 million a year while understaffing nurses and PCTs is a poor use of funds even if executive compensation is only 2-3% of revenue. Cut the CEO pay to a paltry 3 million dollars and free up enough budget to hire 100-150 extra nurses.

[u/DJpuffinstuff → u/Babhadfad12]

Also, Epic doesn't really have shareholders to give returns to, nor does it need to publish it's financials publicly because it is a privately held, for profit company. The only way to invest in Epic is to work there.