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A promising vaccine on the horizon? Even Dr. Fauci is encouraged by the results so far

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4 minutes ago, Hlitner said:

It is not as crazy as you might think.  Most third party payors (Medicare, Medicaid, private insurance) base inpatient hospital payments on Diagnosis Related Groups (DRGs).   Most hospitals play the coding game where they do their best to code claims to maximize reimbursement.  While auditing claims does catch many of the "coding errors" there are a lot of gray areas pursued by the hospitals.  This is nothing new with COVID-19 and has been an ongoing issue since the advent of DRGs back in the early 80s.  

 

Hank

Nearly every medical practitioner has at sometime played coding games.They do it with procedure codes and well as codes for diagnoses’.

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Just now, lenquixote66 said:

Nearly every medical practitioner has at sometime played coding games.They do it with procedure codes and well as codes for diagnoses’.

Yep ).  My background is at the government insurance and regulatory end.  I used to give some hints to my own physician's office manager on how to code some claims for which she and her boss were grateful.   I am retired so have not bothered to look at some of the codes/payments.  But one can be sure that coding pneumonia with complications from COVID will pay more then just coding pneumonia   I guess it would be DRG 312.9 (unspecified viral pneumonia vs 312.81 (which is pneumonia due to SARS associated coronavirus).   A good friend, who now makes lots of money consulting to hospitals on coding, likes to say that coding claims is more of an art then a science :).

 

Hank

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26 minutes ago, Hlitner said:

It is not as crazy as you might think.  Most third party payors (Medicare, Medicaid, private insurance) base inpatient hospital payments on Diagnosis Related Groups (DRGs).   Most hospitals play the coding game where they do their best to code claims to maximize reimbursement.  While auditing claims does catch many of the "coding errors" there are a lot of gray areas pursued by the hospitals.  This is nothing new with COVID-19 and has been an ongoing issue since the advent of DRGs back in the early 80s.  

 

Hank

 

The fact remains that it is NOT a reliable source.

 

A supposition is not the same thing as evidence, much less a fact.

 

We have to get out of the habit of reading something and thinking, "Yeah, I could imagine that happening."  Instead we should verify that it actually DID happen.

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42 minutes ago, Hlitner said:

Yep ).  My background is at the government insurance and regulatory end.  I used to give some hints to my own physician's office manager on how to code some claims for which she and her boss were grateful.   I am retired so have not bothered to look at some of the codes/payments.  But one can be sure that coding pneumonia with complications from COVID will pay more then just coding pneumonia   I guess it would be DRG 312.9 (unspecified viral pneumonia vs 312.81 (which is pneumonia due to SARS associated coronavirus).   A good friend, who now makes lots of money consulting to hospitals on coding, likes to say that coding claims is more of an art then a science :).

 

Hank

Can you define government insurance ? Do you mean a State Insurance Fund ? I worked for Government Insurance in the 60’s setting up Medicare .

Edited by lenquixote66

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1 hour ago, Hlitner said:

It is not as crazy as you might think.  Most third party payors (Medicare, Medicaid, private insurance) base inpatient hospital payments on Diagnosis Related Groups (DRGs).   Most hospitals play the coding game where they do their best to code claims to maximize reimbursement.  While auditing claims does catch many of the "coding errors" there are a lot of gray areas pursued by the hospitals.  This is nothing new with COVID-19 and has been an ongoing issue since the advent of DRGs back in the early 80s.  

 

Hank

I'm a former actuary and my wife is a retired clinical psychologist who maintained a private practice for about 40 years. After I retired from the business world just to keep busy I ran my wife's back office operations for a couple of years, which means most of my time was spent on patient and insurance billing. To make a long story short I have a pretty good idea about what I'd call "clever" billing practices.

 

Yes, this stuff goes on...but as you said it's not exactly anything new or unique to COVID-19. My problem is with the politicized slant of a foreign-based website that is supposed to be mostly focused on entertainment news. It's hard enough to find reasonably straight fact-based reporting in US media. I would question the motives of the site's picking up on this snippet of testimony. There's a clear political motive to citing this . It's hardly a secret that those with certain political leanings are continually trying to discredit data about the pandemic...number of positive cases...number of deaths, etc. 

Edited by njhorseman

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1 hour ago, lenquixote66 said:

Can you define government insurance ? Do you mean a State Insurance Fund ? I worked for Government Insurance in the 60’s setting up Medicare .

Have no clue about your State Insurance Fund which can mean different things in different States.  But the primary payment system between insurance companies (government and private) have been DRGs for over 30 years.   I believe the original DRG system was actually developed for the Medicare Program and quickly adopted by just about everyone in the industry.  At the time it was seen as an incentive payment system which encouraged hospitals (and their staff physicians) to get patients out the hospital as soon as possible.    But not sure the details of the payment system (there are even books on the subject) are worthy of a CC discussion.  The relevancy is that there are incentives (I would not call them perverse) for hospitals to code claims in a way that generates the highest reimbursement income.  Experienced (and good) claims coders are considered very valuable among hospital administrators ).  There are also various computer programs (some are quite expensive) and many independent consultant organizations (paid by both hospitals and some medical practices) that specialize in finding the most profitable way to code claims.

 

Hank

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1 hour ago, cruisemom42 said:

 

The fact remains that it is NOT a reliable source.

 

A supposition is not the same thing as evidence, much less a fact.

 

We have to get out of the habit of reading something and thinking, "Yeah, I could imagine that happening."  Instead we should verify that it actually DID happen.

I have no clue as to whether or not the publication is a reliable source but actually saw some of that testimony on CSPAN (it was a boring day).   But you can take it to the bank that coding claims to maximize reimbursement is the norm in every hospital and medical practice.  COVID-19 has little to do with the story other then claims would generally reflect COVID if it resulted in more reimbursement and there was some basis to use a COVID associated code.   So, for example, a victim of an auto accident gets admitted (as an inpatient) because of injuries sustained in an accident.  Subsequent testing shows that the victim is positive for COVID-19.  This may well be viewed as a complication and the coding of related invoices would likely use that COVID complication as justification to file with DRG codes that have a higher relative value (a technical term that leads to higher payments).  For a hospital and insurance provider this would all be viewed as normal business.   I am not sure of the relevance if the patient dies since this actually would not necessarily change the DRG code.   For many years there has been a school of thought that "outcomes" should be some or all of the basis for payments/reimbursement but that idea has yet to catch fire in the industry.  But for argument sake just imagine a system where a hospital was paid for for a successful outcome (patient discharged cured) and less for a bad outcome (patient died or developed morbidities.   Developing that kind of system might be enough to get me out of retirement :).

 

Of course the downside of an outcomes based system would be that medical centers (and physicians) might be reluctant to take the most serious cases (with higher percentages of bad outcomes).  

 

Hank

 

 

 

 

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I just read something that there is word in and outside of the government that a vaccine be rushed and approved by the FDA for October release.

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41 minutes ago, Hlitner said:

Have no clue about your State Insurance Fund which can mean different things in different States.  But the primary payment system between insurance companies (government and private) have been DRGs for over 30 years.   I believe the original DRG system was actually developed for the Medicare Program and quickly adopted by just about everyone in the industry.  At the time it was seen as an incentive payment system which encouraged hospitals (and their staff physicians) to get patients out the hospital as soon as possible.    But not sure the details of the payment system (there are even books on the subject) are worthy of a CC discussion.  The relevancy is that there are incentives (I would not call them perverse) for hospitals to code claims in a way that generates the highest reimbursement income.  Experienced (and good) claims coders are considered very valuable among hospital administrators ).  There are also various computer programs (some are quite expensive) and many independent consultant organizations (paid by both hospitals and some medical practices) that specialize in finding the most profitable way to code claims.

 

Hank

You said your background is in government insurance. I was asking you to define that.In the 60’s I was indirectly working with the Federal Government in setting up Medicare.

 

Edited by lenquixote66

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1 hour ago, njhorseman said:

I'm a former actuary and my wife is a retired clinical psychologist who maintained a private practice for about 40 years. After I retired from the business world just to keep busy I ran my wife's back office operations for a couple of years, which means most of my time was spent on patient and insurance billing. To make a long story short I have a pretty good idea about what I'd call "clever" billing practices.

 

Yes, this stuff goes on...but as you said it's not exactly anything new or unique to COVID-19. My problem is with the politicized slant of a foreign-based website that is supposed to be mostly focused on entertainment news. It's hard enough to find reasonably straight fact-based reporting in US media. I would question the motives of the site's picking up on this snippet of testimony. There's a clear political motive to citing this . It's hardly a secret that those with certain political leanings are continually trying to discredit data about the pandemic...number of positive cases...number of deaths, etc. 

interesting,prior to my wife working as an RN she was an Actuary.At one time I was an Industrial Psychogist working in the insurance field .I was also a health insurance frauds investigator .The average person has no idea what is going on .

 

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31 minutes ago, lenquixote66 said:

You said your background is in government insurance. I was asking you to define that.In the 60’s I was indirectly working with the Federal Government in setting up Medicare.

 

60s.  My goodness I was not born (I wish).  But I did not get involved in healthcare until the mid 70s.  In the 60s I was fighting our battles (Vietnam).

 

Hank

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