For folks who aren't healthcare tech nerds, what happened in this case is called "unbundling" which is a fraudulent practice that can have steep penalties from CMS.
CMS maintains a service and set of tools to help prevent payers from getting hit with this called the National Correct Coding Initiative (NCCI) [1]. NCCI only applies to provider services and outpatient billing codes, but is still applicable for emergency room services.
There are a bunch of technical details for implementing the edits in the NCCI, but I think it's worth taking a moment to reflect on this.
It's pretty popular to point to the insurance company as the "bad guy" in healthcare, but this is the sort of stuff they deal with thousands of times per day.
As frustrating and horrible as this story is, it's not unique to an uninsured individual. A big problem in US healthcare is provider overbilling.
One of the most tragic jobs I held in healthcare tech was developing software for billing negotiation between providers and insurance companies. It was pretty eye-opening how terribly everyone behaves, and I learned to have a lot more sympathy for what insurance companies/government payers have to deal with.
As a patient trying to have necessary treatment paid for, it's incredibly frustrating to have a claim denied, and these are what we see in the news and experience personally.
As an insurance company, building robust systems that authorize necessary care while catching overbilling, overutilization and outright fraud is unfathomably complex and error prone.
This one of the reasons I've become a fan of DPC (direct primary care) models [2] with HSAs and supplement high-deductible catastrophic insurance to protect against hospital stays. It puts primary care back into a direct relationship with the patient, and lets insurance companies do what they are good at: pricing risk.
Some of the unintended consequences of how insurance companies are currently regulated is that in some states it can be difficult or impossible for an insurance company to provide a low cost, high deductible plan. They are forced to cover things that drive the costs up, so it's hard to do a DPC + catastrophic insurance option.
CMS maintains a service and set of tools to help prevent payers from getting hit with this called the National Correct Coding Initiative (NCCI) [1]. NCCI only applies to provider services and outpatient billing codes, but is still applicable for emergency room services.
There are a bunch of technical details for implementing the edits in the NCCI, but I think it's worth taking a moment to reflect on this.
It's pretty popular to point to the insurance company as the "bad guy" in healthcare, but this is the sort of stuff they deal with thousands of times per day.
As frustrating and horrible as this story is, it's not unique to an uninsured individual. A big problem in US healthcare is provider overbilling.
One of the most tragic jobs I held in healthcare tech was developing software for billing negotiation between providers and insurance companies. It was pretty eye-opening how terribly everyone behaves, and I learned to have a lot more sympathy for what insurance companies/government payers have to deal with.
As a patient trying to have necessary treatment paid for, it's incredibly frustrating to have a claim denied, and these are what we see in the news and experience personally.
As an insurance company, building robust systems that authorize necessary care while catching overbilling, overutilization and outright fraud is unfathomably complex and error prone.
This one of the reasons I've become a fan of DPC (direct primary care) models [2] with HSAs and supplement high-deductible catastrophic insurance to protect against hospital stays. It puts primary care back into a direct relationship with the patient, and lets insurance companies do what they are good at: pricing risk.
Some of the unintended consequences of how insurance companies are currently regulated is that in some states it can be difficult or impossible for an insurance company to provide a low cost, high deductible plan. They are forced to cover things that drive the costs up, so it's hard to do a DPC + catastrophic insurance option.
[1] https://www.cms.gov/national-correct-coding-initiative-ncci
[2] https://www.aafp.org/family-physician/practice-and-career/de...