Credentialism and Corruption: Medical Coding, Symbol Manipulation, and Symbol Manipulators

By Lambert Strether of Corrente.

Readers may recall this post, “Potential Phishing Equilibria Under Neoliberalism in the U.S. Medical Coding System,” from back in March, where I showed how medical coding — “the transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes” — is being used to game the health care system for profit by miscoding, upcoding, the creation of opacity, and the absurdity of expecting “consumers” to practice “smart shopping” in a system where they literally could not understand the language their bills are written in. Now Elizabeth Rosenthal was written an article in the Times Magazine, “Those Indecipherable Medical Bills? They’re One Reason Health Care Costs So Much,” that confirms this diagnosis, with the wealth of detail and analytical richness that only a major news organization can provide. The article’s deck? “Hospitals have learned to manipulate medical codes — often resulting in mind-boggling bills.”

Rosenthal uses one woman’s horror story — Wanda Wickizer — as a story hook to explain the medical coding system. (There’s a happy ending: A hard-working team of lawyers and medical activists gets Wickizer a sealed settlement with the price-gouging extremely persistent University of Virginia Medical Center.) In this post, I’ll start by briefly reviewing my post in March, comparing it to Rosenthal’s, granted so I can do a little happy dance. Then, I’ll look at the medical coding milieu as Rosenthal reports on it, from two aspects: The corrupt games coders play, and coding as a profession, including the credentials. Then I’ll put medical coding in its broader, political context, arguing that medical coding is the sort of “symbol maniplation” praciced by the “creative class” that was to be the salvation of the Democrat Party. I’ll conclude with an imprecatory prayer.

Medical Coding as a Phishing Equilibrium

Back in March, I wrote:

We might summarize Akerlof and Shiller [on phishing equilibria] as “If a system enables fraud, fraud will happen,” or, in stronger form, “If a system enables fraud, fraud will already have happened.”[1] And as we shall see, plenty of “opportunities for unusual profits” exist in medical coding.

And about those unusual profits:

Now, I’ll be the first to admit that I can’t quantify the impedance mismatches [from translating code systems], the miscoding, and the upcoding. Regardless, medical coding is the key dataflow in the healthcare system:

“Roughly $250 billion is moving through those codes,” [says Steve Parente, professor of finance at the Carlson School of Management at the University of Minnesota]. On top of that, about 80% of medical bills contain errors, according to Christie Hudson, vice president of Medical Billing Advocates of America, making already-expensive bills higher. Today’s complex medical-billing system, guided by hundreds of pages of procedure codes, allows fraud, abuse and human error to go undetected, Hudson says. “Until the fraud is detected in these bills … the cost of health care is just going to increase. It’s not accidental. We’ve been fighting these overcharges…they continue to happen and we continue to get them removed from bills.” These errors, which are hard to detect because medical bills are written in a mysterious code, can result in overcharges that run from a few dollars to tens of thousands.

That “mysterious code” is (now) ICD-10, and it’s the mystery plus the profit motive that creates the phishing equilibrium. Kaiser Health News quotes the Denver Post:

Experts say there are tens of thousands more like Dziedzic across the country with strangling medical debts. Medical Billing Advocates of America, a trade group in Salem, Va., says that eight of 10 bills its members have audited from hospitals and health care providers contain errors. It’s estimated that at least 3 percent of all health care spending – roughly $68 billion – is lost to fraud and billing errors annually. Some say new reform laws will only make things worse.” Others say that errors occur largely because of “the complexity of deciphering bills and claims weighted down by complex codes.”

Even if the “trade group” is talking its book, it’s still quite a book. NBC:

Accounts of medical billing errors vary widely. While the American Medical Association estimated that 7.1 percent of paid claims in 2013 contained an error, a 2014 NerdWallet study found mistakes in 49 percent of Medicare claims. Groups that review bills on patients’ behalf, including Medical Billing Advocates of America and CoPatient, put the error rate closer to 75 or 80 percent.

Gee, I wonder if the errors are randomly distributed?

As a humble blogger, I had to end with a rhetorical question. Rosenthal is far less circumspect:

Twenty-five percent of United States hospital spending — the single most expensive sector in our health care system — is related to administrative costs, “including salaries for staff who handle coding and billing,” according to a study by the Commonwealth Fund. That compares with 16 percent in England and 12 percent in Canada….

What’s less understood is the extent to which our current medical-billing system itself is responsible for the high prices patients are charged. There are, of course, many factors that have led to the United States’ record-breaking $3 trillion health care bill… But all of those individual price increases have been enabled — indeed, aided and abetted — by the complex system of billing and coding that underlies bills like those sent to Wickizer.

The ratchet only goes one way, doesn’t it? (Wickizer got a bill for $356,884.42 for services that her team estimated cost the hospital $60,000. Ka-ching.)

With that, let’s look at that process of “aiding and abetting.” I’m going to quote great slabs of Rosenthal’s piece (and without doing a lot of “But see me, here”) because it’s so well reported, and you should go read it and say nice things about it. And do read the comments.

Games Coders Play

Rosenthal describes the medical coding phishing equilibrium in detail:

Seemingly subtle choices about which code to use can have large financial consequences. If after reviewing a hospital chart of, say, a patient who has just had a problem with his heart, a hospital coder indicates the diagnosis code for “heart failure” (ICD-9-CM Code 428) instead of the one for “acute systolic heart failure” (Code 428.21), the difference could mean thousands of dollars. …

Each billing decision, then, can be seen as a battle of coder versus coder. The coders who work for hospitals and doctors strive to bring in as much revenue as possible from each service, while coders employed by insurers try to deny claims as overreaching…. Hospital coders teach doctors — and doctors pay to take courses — to learn how they can “upcode” their charts to a more lucrative level with minimal effort. In a doctor’s office, a Level 3 visit (paid, say, at $175) might be legally transformed into a Level 4 (say, $225) by performing one extra maneuver, like weighing the patient or listening to the lungs, whether the patient’s illness required that or not. [Let that sink in.] … E.R. doctors, for example, learned that insurers might accept a higher-reimbursed code for the examination and treatment of a patient with a finger fracture (usually 99282) if — in addition to needed interventions — a narcotic painkiller was also prescribed (a plausible bump up to 99283), indicating a more serious condition.

(Notice the caregivers backfilling the actual delivery of healthcare to game the codes for maximum profit. I suppose a smart shopper would be able to avoid that. Not.)

Coding as Symbol Manipulation

Rosenthal labels such games “strategic coding” — kudos! — and describes how they metastatized throughout the health care system:

[B]ecause strategic coding meant increased payment, that begot coding specialists and coding courses and coding degrees. There are now different increasingly complex coding languages that define payment for different kinds of services: CPT codes, for office visits delivered by doctors, as well as HCPCS, ICD-PCS-CM and DRG, for charges that are incurred in the hospital. There are tens of thousands of codes in each lexicon that have become increasingly specific.

And there are, of course, credentials for those who manage and create the “strategic coding” meritocracy:

Toward the end of the 20th century and into the next, as strategic coding increased, a new industry thrived. For-profit colleges offered medical-coding degrees, and internships soon followed. Because alphanumeric coding languages are as distinct from one another as Chinese is from Russian, different degree tracks are necessary, along with distinct professional organizations that offer their own particular professional exams, certifications and licensing. Hospital systems and insurers — which have become huge, Hydra-like enterprises — now all employ roomfuls of coding-program graduates to perform these tasks. Membership in the American Academy of Professional Coders has risen to more than 170,000 today from roughly 70,000 in 2008.

In fact, medical coders are, exactly and precisely, the sort of “symbol manipulators” that Thomas Frank’s 10%-ers, with their fetish for credentials, believe are the future of America’s economy (because that’s who they themselves are). Clinton Labor Secretary Robert Reich wrote in 2009:

[O]ver the long term, symbolic analysts will do just fine – as long as they stay away from job functions that are becoming routinized. … The global market gives them more potential customers for their insights [ha ha].

To be sure, symbolic analysts are popping up all over the world. … But apart from recessions, demand for symbolic analysts in the U.S. will continue to grow faster than the supply. … In decades to come, nations with the highest percentages of their working populations able to do symbolic-analytic tasks will have the highest standard of living and be the most competitive internationally.

America’s biggest challenge is to educate more of our people sufficiently to excel at such tasks.

“Have the highest standard of living and be the most competitive internationally.” Now it’s 2017, eight years on. How’s that working out, Bob? Average benefits evenly distributed, and all that? No downsides, given the actual symbols manipulated, and for what purpose?

Conclusion

A continuing theme of this series comes from Clive:

Increasingly, if you want to get and hang on to a middle class job, that job will involve dishonesty or exploitation of others in some way.

And “medical coding” is certainly one of those “good jobs at good wages” we keep hearing about. However, as Rosenthal shows — regardless of individual coders with good intentions, who do exist — systemically, in a for-profit system, “medical coding” = “strategic coding,” and that’s as dishonest or exploitative as, say, robosigning.

When Medicare for All is finally passed, there will still be a place for medical coding, redirected toward its original purpose, to deliver health care. (HR676, at least provides for retraining.) And I can’t help but think that when the medical coders don’t have to screw people over for profit any more, they’ll feel much like the cleansed soul described in The Screwtape Letters:

Just think … what he felt at that moment; as if a scab had fallen from an old sore, as if he were emerging from a hideous, shell-like tetter, as if he shuffled off for good and all a defiled, wet, clinging garment.

But as for the phishers of people who invented “strategic coding,” and did the training, and awarded the credentials, the people who ran the for-profit schools and the professional organizations, and cashed the fat checks, and built the system that tried to take the money Wanda Wickizer had saved for her kids to go to college, what of them? The corruption of this “creative class” is surely of a different order from the coding foot-soldiers; this creative class is not only corrupt, but enables corruption in others (“aid and abet”). If I were to wish that everything that happened to the West Virginia coal-miners happened to them, starting with the loss of their jobs and the savage destruction of their communities, would that make me a bad person? Probably. So instead, I’ll wish that they find continuing useful employment in the medical field: Emptying bedpans, for example.

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.

74 comments

  1. Kalen

    Great Post, touches everyone.

    Brilliant genocide, what it really is. Whole re-framing of health care and confusion what it really is.

    85% of people who never been to hospital or seriously ill likes their never used “heath Insurance” if they can afford it.

    85% who used Health insurance in serious illness in the US when ill hate it.

    How in the world this US cruel system of torture, physical and mental, could have even been called a health care system.

    Coding as a matter of fact is the least problem, it is just a way to add a slap in the face of a victim, and insult to medical injury that is a main menu of this cruel parlor of absurd.

    In reality in the US and unfortunately in some other countries, “successful” physicians’ true professional objective and purpose of their education, even if they deny it, has become to effectively seriously to moderately injure their heavily insured patients to the degree that would still allow them to cover exuberant fees and enormous drug costs, through private insurance or government or desperate family selling off all they got. Dying poor are left in pain to die, thrown out on the street pavements like dogs according to doctors Hypocritical, not Hippocratic oath as it was well documented on LA Skid Row few years ago.

      1. Joey

        Since healthcare (and education) can be protected as local activities (and credentialing can additionally be used as trade barriers), they are considered, by politicians and economists, to have potential to create local employment (not outsourced). Profit motive has been injected to these previously ‘honorable’ professions and has reduced these professions to crass money grubbing. Is a preferred channel for trickle down economics just like the over built defense industry.

  2. ChiGal in Carolina

    So only the U.S. has adapted the international disease classification system to the purposes of profit, and only the U.S. lacks national health care.

    Transparency of entirely the wrong sort. And a veritable pox on the AMA.

    One caveat, which is that the coders themselves are pretty low-level clerical workers who are gouged by the for-profit schools and function under horrible working conditions.

    Any 10%ers would be a good bit further up the food chain.

    1. scraping_by

      I thought from the beginning the ACA had a great potential for the legal profession. Unlike their usual job of arguing that ‘up’ means ‘down’, this would be more in the realm of trying to fit real world events into the sort of arbitrary tests common to law as it’s applied. There’s already a specialty of Social Security law.

      While the article talks about stand-along coding expertise companies, they could be captured by the legal profession through fiat or custom. Just as most courts only take legal filings on, say, probate from licensed lawyer, or in England all real estate transfers require a barrister, coding questions could need a legal firm involved.

      Not in the actual coding questions, of course. That would still involve clerical workers who can catch on to the system. But if a body of court decisions accumulated, lawyers could insert themselves into the process. Who would get lawyer-level fees while the actual workers kept working for not-starving wages.

  3. MedicalQuack

    Thanks for addressing this as it is always good to see some of this make it outside the normal Health IT readership. Indeed this entire deal was to make more money as risk assessments now with an entire bunch of new codes to help assess have grown. This big move was lobbied by United Healthcare too. For those readers who do not understand how the 300 or so subsidiaries of this company work, look at it this way, United Healthcare when written about is the old insurance claim business we all know; however, look at their Optum division and there’s where the money is made. Ingenix (now called Optum) has been around forever. They are the kinds of coding and Optum also owns a lot of MD practices as well. It owns a big chain of urgent care centers, it owns the huge PBM OptumRx, which makes more money than the company does selling Medicare plans!

    Everywhere you turn with healthcare algorithms and or billing fraud, it just all points right back to the Ingenix (now Optum) division of United Healthcare and former CMS Andy Slavitt director was the CEO of Ingenix and all this occurred under his watch. What the heck was wrong with Obama giving him that job and pardons from the Ingenix lawsuits, of which there are many…past and present. DOJ joins risk fiddler lawsuit again United Healthcare, as former director of finance blew the whistle on the coding game for more risk assessments so the government would have to pay them more with Medicare, around $70 billion over a period of years is the rough calculation. Cheating algos live.

    http://ducknetweb.blogspot.com/2017/02/doj-enters-whistleblower-law-suit.html

    All of the new ICD10 coding has not created any better care, but it sold tons of software to allow hospitals and doctors to do conversions to ICD10 from ICD9. New coding helps push drugs as well and I wrote about that one too. When you line up all these risks, the next step to treat them whether your need it or not sometimes.

    http://ducknetweb.blogspot.com/2016/08/icd-10-conversion-allows-insurance.html

    Speaking of drugs too, remember it was United Healthcare who created the first PBM and today they own their own named OptumRX which is their number one revenue stream of 4 they measure, the other 3 are insurance streams. For one lets’ get all of this out on the table not do the routine of selected perceptions when all of this is documented all over the place. Get into this next, your secret medication adherence prediction score that you can’t see but get every time you fill a prescription, 300 lame metrics, most of which have zero to do with taking meds, one example, are you a male seeing a female doctor..that’s a bad ding on your score, and these were all created by Ingenix. I get almost every pharmacist that chats with me on Twitter backs this up 100% as they get graded on these scores and they hate them as it’s flawed.

    http://ducknetweb.blogspot.com/2010/10/express-scripts-new-program-to-contact.html

    http://ducknetweb.blogspot.com/2015/06/medication-adherence-predictions-enter.html

    Coming back around it’s the coding that leads to over medicating sometimes I feel. The more ICD10 risk codes assessed to you, the more drugs that can be prescribed. Watch also for the verbiage with some of this as there’s also creative writing taking place in medical records. You will find wording like “we assume the patient had this condition as a child”..which is based on codes entered and may be totally false.

    With so many medical groups of doctors being owned by Optum, they tell them how to code things and consult with them to do that. Take Monarch healthcare in the OC where I am, they own and manage tons of doctors and they have to do it the Optum way or they are not in network. Being in network today for doctors with United Healthcare means their average pay with contracts is around 12 LESS then Medicare..yup you read that correctly and they even state it on their own website.

    Get a load of this with Mayo having Optum 360 do all their billing. Is this interesting? Optum 360 has a partner called Dignity Healthcare a hospital system in CA that makes money from this too. Mayo and United Healthcare are business partners now as well with another Optum company, Optum Labs too, so go search that one when you have time as they sell access to medical records for pharma and medical device companies so they can find patient values to help sell their drugs.

    http://ducknetweb.blogspot.com/2015/04/mayo-clinic-is-latest-to-outsource.html

    This rabbit hole is so much deeper than you even imagine and I could go on with more..well maybe one more as Optum/United Healthcare is doing all the billing now for Quest Labs…check that out. This comes back to more coding. They sold Quest a few years back some of those Ingenix data selling/scoring algorithms too, I covered a little of that as well.

    http://ducknetweb.blogspot.com/2016/09/quants-of-optum-carve-out-new.html

    What it comes down to as well is that health insurers have kind of ditches their actuaries to some degree and now use Quants to do a big share of their modeling of insurance policies, drug policies and who knows what else in addition to “scoring” doctors right and left. I wrote this post in 2014 but those with selective perceptions mostly decide they don’t want to see this as they would have to recognize the truth of what’s really going on. I get that a bit too with it being so ugly it scares people as it scares me too.

    http://ducknetweb.blogspot.com/2014/10/data-scientistsquants-in-health.html

    Medical coding is just one more adventure in the healthcare quantitative system of madness for creating a lot of noise for things that are just not true, but make a lot of money with software, over treating patients, etc. Coding is a huge tool that can be used to cheat, like VW and Uber did with sofftware…”with software you can do something about everything, but what really matters is what happens in the real world, not focusing only on virtual values”.

  4. none

    I went to a talk with a discursion about the history of computers. The speaker put up slides of early mainframes, then old home computers like the Commodore 64, then current PC’s and smartphones, and finally an NVidia GPU card which is essentially a miniature supercomputer (1000x faster than a PC at the computations it’s designed for) that’s sold to online gamers for a few hundred dollars.

    When he put up the GPU slide he said “this is the chip that will make millions of people unemployed. If the input of your job is bits and the output is bits, you’ll be replaced by a machine learning algorithm that does it better than you do”. Of course everyone in the room was in that type of profession, so we all felt the cold settling in. Good luck, symbol manipulators.

    1. reslez

      I am a software engineer. When I entered the field as a bright-eyed young coder many years ago, I was excited by the possibilities the internet appeared to offer. Watching these possibilities become corrupted into systems of mass surveillance and control — systems created by my colleagues in the field — has been the most disillusioning experience of my life.

      I personally have contributed to automation that will someday put hundreds of thousands of people out of work. They’re s***ty jobs, jobs I wouldn’t wish on an enemy, but there it is. I’ve contributed to systems that intensify the micromanagement of employees. Of course these were already s***ty jobs and the micromanagement was already there. If it were otherwise — if I were destroying “good” jobs or forging new slave chains — would I have the courage to walk away? It looks like none of my colleagues ever did. But I still remember my first year honors CS prof who told us how he’d once refused to work with the DoD on a nuclear project because it crossed, for him, an ethical line. He told us we’d someday be faced with the same decisions. It seems like that lesson never sunk in for 99% of my fellow coders. Most were probably distracted by the usual problems of modern life: how to avoid becoming homeless, how to prevent one’s children from starving. How to get rich off an IPO and retire in one’s 30s.

      If you were a blacksmith in the 1600s would you accept a commission for a torture device?
      If you were a programmer in the 2010s would you write the software that lets Amazon track its warehouse workers down to the millisecond with no breaks in between?
      I don’t think these are drastically different situations.

      1. Kalen

        Long time ago in a brief feat of sanity and only in few academic centers in the world some people understood that we cannot produce army of engineers, software, mechanical, nuclear, chemical, bio-chemical or physicians or physicists without communication to them enormous civilizational gravity that all those tools they would learn and devise bare tremendous personal responsibility of those who create and/or use them.

        Only in such centers a class called “Ethics and Methodology of Sciences” was required or suggested where young student could be asked ” Can you handle the truth and take full responsibility for consequences of your mind creations implemented recklessly which is most likely outcome?
        And many ethical questions about scientific methodology, and danger of compartmentalizing of scientific/engineering endeavors and a threat scientific elitism and knowledge dictatorship.

        In fetishized materialistic world of money interest critical importance of reason and motivation in science and engineering was lost. And here we are producing conscience-less PhDs with sole objective of “advising” or rather rubber-stamping policies of political stooges of industrial oligarchy.
        No Ethics course needed.

  5. cripes

    Recently I’ve had the dubious pleasure of needing several “referrals” from my PCP to various specialists or procedures via my over priced, ultra-narrow ACA HMO. It has a $5,700 out of pocket. I can’t use doctors in the HMO network, but only the doctors in the “hospital group” to which I’m attached.

    Not one referral I’ve gotten has been correct. The doctors aren’t in the HMO, or not in the group, or they’ve left the group, or retired…I’ve had to re-write every referral, including the diagnosis codes and the treatment codes. I’ve had to learn ICD10 in the course of doing this. And call and call the hospital appointments, the physician practice, the BCBS HMO over and over in an attempt to get prior authorization.

    Each one throws the responsibility off on the other entities, in an endless cycle of bullshit buck-passing.

    More than once I’ve been told to call the insurer when I ask to confirm “do you take XYZ HMO hospital group?” who also says to call the practice.

    Once I was actually told by a gum-cracking receptionist,
    “We don’t have time for this shit.”
    Bankrupting charges lurk in every transaction.

    Whoops, you’re it!
    Good luck shopping suckers.

    And this is what we’re asking sick or elderly, or panicked people to do when they need health care?

  6. Susan the other

    Thank you Lambert. As usual. This is becoming a chant; a ghost dance. Not for us because nothing will respond to us, but for the entire medical profession that avails itself to this immorality. Everything that financial capitalism touches becomes a crumbling ruin. One silver lining is that (as you once analyzed) “code is law” is reaching its existential end, at least where anything important is concerned. We have all come to hate the medical industry as it now exists. I for one do not care what happens to it as long as it is brought down. We need to import a decent medical industry, from the bottom to the top.

    1. Marco

      Well said. The “Insurance company is evil” mantra doesn’t cut it anymore. As you state it’s the entire medical industry. But try to have a conversation with a US doctor that maybe they make too much $$. The first thing he/she will throw in your face is their $250K debt from school.

      1. Lambert Strether Post author

        Well, the insurance companies are evil. But they’re part of a larger system. And I’d put medical debt under the larger heading of the financialization of everything. I think most doctors want to be doctors. They don’t want to be accountants….

        1. JTMcPhee

          Around where I live and worked as a nurse, more and more “doctors” sport an “MBA” right after the “MD” that we mopes assume is the symbol of their ethical profession and calling…

  7. Toolate

    What is the most perverse and dangerous about all of this is the amount of time and energy that medical professionals begin to devote to thinking about ways to game the system to increase payment like upcoding. The opportunity cost For this devotion is tremendous and involves a serious diminution in the providers thoughtful attention to the patient, diagnostic acumen, and caring skill.

  8. Tom_Doak

    A fabulous recap, Lambert. I wish we could get everyone in America to read it … BEFORE they need to use the system.

    However, I detect in the NY Times story just a bit of deflection — shifting the focus to coders, from doctors. But as your last paragraph implies, the doctors are a big part of the system that employs the coders.

    1. Lambert Strether Post author

      I didn’t write about doctors. In fact, I barely write about hospitals! The medical coding angle is good for me because it plays to some technical strengths I have from past careers, and the data structures provide a good place to look at the system as a whole.

      As I said elsewhere, I think doctors don’t go into the medical field to become accountants; I think the vast majority*, before the system beats it out of them, want to be healers. We should encourage that.

      *Sure, horrible counter-examples. I would imagine there are specialties that are, in essence, “diseases of the rich,” and doctors who are in it for the big bucks go there. I avoid the health care system generally, but issues I’ve had with doctors have been more with systems they are caught up in that (they at least feel) they are powerless to change.

      1. sunny129

        Doctors, as a group have lost the control of practice of Medicine as a profession. This started once the 3rd party payers like Medicare came into existence in 1965! Now the Medical-industrial complex competes with Military-industrial complex in flexing it’s muscle & power.

        It has become pure, cold BUSINESS under Corporate Medicine. They have become a cog in this vast machine tortured by numerous regulations, EHR.EMR. More time is spent in front of PCs as desktop entry clerks!

        Been there, seen and done that!

  9. LT

    Yeah, the problem is that Americans seek credentialism and go on to perpetrate frauds rather than be a victim of them. What used to be called a crook is now called a winner.
    You know how many people are in jail just because they were unable to commit crimes that well, used to be crimes until they were made legal? Like usory laws…whatever happened to those?

  10. reslez

    > In a doctor’s office, a Level 3 visit (paid, say, at $175) might be legally transformed into a Level 4 (say, $225) by performing one extra maneuver, like weighing the patient or listening to the lungs, whether the patient’s illness required that or not.

    So awesome. I can just see myself dealing with some catastrophic injury, forced to interrogate every medical professional who enters my hospital room, and if you’ve visited a hospital patient you’ve noticed how they stream in like mice visiting delicious cheese. An avalanche of suspicion because I can’t trust my health care providers not to gouge me for every penny, and my soulless insurer doesn’t give a crap because I pay the bill before they do. “Who are you? Why are you here? Do you accept my insurance? No, I don’t want to be weighed. GTFO!”

    Patients should be able to focus on recovering, not avoiding accidental bankruptcy. That’s not the way our system works because our system, objectively speaking, is evil. Our system is intentionally designed so that some people get rich, evade all responsibility, and other people die because of it.

  11. Enquiring Mind

    Medicine is not alone in the phishing. Dentistry has its own little games to pad bills. Take a detailed look at your bill next time you have any procedure done.

    Patient implies some agency and essence of humanity.
    Revenue Unit removes those.

    Gee, thanks. I always dreamt of becoming a Revenue Unit. Soon I anticipate finding out that there is some type of Prime Directive shifting in the medical and dental spaces.

    1. JEHR

      My dentist was x-raying my teeth once a year for a long time without any x-rays showing anything worthwhile. So the next time I was scheduled for an x-ray, I decided to say, No, thanks. The dentist then produced a piece of dated paper for me to sign saying that I didn’t want an x-ray (I suppose to get him off the hook–what hook, I don’t know). Now I don’t have an x-ray every time they need a little extra recompense for their effort(s). Finally, I was asked to come in for dental cleaning three times a year instead of two times but we compromised on every 5 months. Here, too, money seems more important than excellent patient care.

      1. Enquiring Mind

        The old dental two-step. Wait for them to recommend that quarterly deep cleaning, by quadrant. That is another way to soak up some extra cash at a hefty price. Cleaning used to be performed typically by a young non-dentist, and has migrated to the dentist side to rationalize the added expense.

        When our dental provider options seemed to change periodically depending on how the HR people negotiated for the upcoming year, we changed dentists. Each one, without fail, recommended some expensive treatment as a result of their initial exam. Some of that could be chalked up to covering the bases, while much seemed just greedy (with front-loading to cover the new patient intake cost?).

        Crapification takes many forms, including more time tax as patients get roped into more form chasing, referral searching and all-around haggling or tracking down mysterious people needed to review or approve some arcane steps. At least the bills are less than in medicine, so I’m supposed to be grateful for small favors. End rant!/

    2. Arizona Slim

      Tell me about it. I’ve been avoiding calls from my dentist.

      Reason: The $700 mouth guard that has been recommended.

      Yeesh. Seven hundred smackers for a piece of plastic that’s only worn at night?

      I’m in the wrong business.

  12. roxan

    I had a friend who was stuck with a coding job–it was horrible. She worked for some company that only did ER coding, and was forced to code 300-400 charts an hour, which seemed impossible to me. The charts were sent online and very blurry, hard to see. Some were dictated by foreign docs with poor English. If she didn’t make her quota, she was yelled at and her pay docked. As soon as she knew the job, they demanded she work at home several hours a day and on weekends, too. All that for the grand sum of $12 an hour or so. I think she did have to get some sort of certificate in coding, too, to get the job. A single mother with 3 kids, she was too desperate for a job to rebel.

    1. Marco

      Curious if obtaining the coding cert involved accruing debt at a “trade” school? My nephew recently investigated a 1 year “accelerated” CNA program and the cost in student loans was about $23K. That was just the debt. They also expected out-of-pocket of around $8500. Over $31K for a job maxing out at $20-25 an hour. Healthcare is Hell

      1. Louis

        I can’t speak for that particular individual; however, I do know that you can get a medical coding certificate, usually it’s officially called “medical billing”, at community colleges, so you don’t necessarily have to accrue mountains of debt to do so.

  13. Iowan X

    Lambert–Thanks as always for your work! I clicked through to the original article and I agree with you, it’s very good and well-reported. One parenthetical sentence stood out to me in the article as just-plain-wrong, however:

    “(One notable aspect of our commercialized health system is that for every person who is pushing to profit, there is another who is doing his or her best to protect patients.)” I do not believe this to be true, one little bit. I have no idea how this sentence made it into the article. Ms. Wickizer was just damn lucky to be able to build a team to help her out. Most overcharged patients won’t ever be so lucky.

    1. Disturbed Voter

      Any system that involves money, maximizing income or minimizing cost … will involve corruption. There are no medical professionals who work for free, but only for fee. The question is, how torturous is the path that the chicken money must flow thru, and be plucked along the way.

      Of course patients are paragons of virtue, so they have every right to complain.

      1. Edward

        No one is suggesting medical professionals should work for free. My takeaway is that we live in a sick culture, a sick society. How will this society fare compared with ones which can undertake projects or policies for the public good? We can’t even complete infrastructure projects anymore, for Pete’s sake. The U.S. is about war and death and prison these days.

        1. Disturbed Voter

          Correct in regard to the sickness that is post-modernism. I know plenty of people on-line who want costs curtailed … but part of that isn’t about drug company profits, it is about hating anyone who makes more than $15 per hour (the new minimum wage in the US). Socialism is driven by tribal peasant psychology. It increases when the peasants are tortured by a sadistic leadership. Part of the cultural disease is, everyone wants to join the rentier class.

          1. Edward/Long-Time Disturbed Voter

            “Socialism is driven by tribal peasant psychology.”

            Actually, I would say most politics is tribal and based on perceived interests.

            “It increases when the peasants are tortured by a sadistic leadership.”

            There is a class war in this country.

            “Part of the cultural disease is, everyone wants to join the rentier class.”

            What comes to mind when reading blog posts such as this one is some guerilla theater Greenpeace did back in the 1990’s. Some students pretended to be job recruiters at a college seeking to hire students to pillage other countries and do other terrible things. They were swamped with applicants.

    2. BeliTsari

      More’s the pity: we have issues like: “Potential Phishing Equilibria Under Neoliberalism in the U.S. Medical Coding System” (the closest the Internet’s come to an astute, relevant news article in some time); they’re soon going to have casinos blowing up, mass protests and cities aflame? http://www.counterpunch.org/2017/03/31/false-flag-dog-wag-warning/ http://www.resilience.org/stories/2017-03-28/warning-bc-methane-emissions-still-increasing-big-us-shale-play/ http://www.truth-out.org/opinion/item/40064-neoliberalism-is-killing-us-economic-stress-as-a-driver-of-global-depression-and-suicide

  14. dcblogger

    If indeed it could be proved in a court of law that the medical coding system was designed to enable fraud, could it not be subject to prosecution on RICO laws?

    1. Rhondda

      The incisive Kunstler article “Racket of Rackets” (in NC weekend links) brought this RICO aspect up quite forcefully. http://kunstler.com/clusterfuck-nation/racket-of-rackets/

      It’s well worth a read. I really liked JHK’s use of the term “hostage racket.”

      from the article:

      The US Senate needs to set up an equivalent of the Pecora Commission to thoroughly expose the cost racketeering in medicine, enable the prosecution of the people driving it, and propose a Single Payer remedy for flushing it away. The Department of Justice can certainly apply the RICO anti-racketeering statutes against the big health care conglomerates and their executives personally. I don’t know why it has not done so already — except for the obvious conclusion that our elected officials have been fully complicit in the medical rackets, which is surely the case of new Secretary of Health and Human Services, Tom Price, a former surgeon and congressman who trafficked in medical stocks during his years representing his suburban Atlanta district. A new commission could bypass this unprincipled clown altogether.

      It is getting to the point where we have to ask ourselves if we are even capable of being a serious people anymore. Medicine is now a catastrophe every bit as pernicious as the illnesses it is supposed to treat, and a grave threat to a nation that we’re supposed to care about. What party, extant or waiting to be born, will get behind this cleanup operation?

      1. craazyboy

        “hostage racket.” ???

        “Eh, Bub…you needa gonna buyfer yer life summa insherence fer yerselves. Yous might fall an’ breaka yer arm or sumthin’ like that!

  15. Dave

    A very well written article. But I think you omit a large driving force behind this constant coding fight, and that is insurers who constantly look to decrease reimbursement and increases patient load on providers. All the while deductable and premiums go up.

  16. Ahimsa

    Lambert and his commentariat seem to enjoy bashing physicians and make it sound that all physicians are unethical and corrupt. Physicians would rather not have a system that requires them to code and a system that measures the work they do by the number of clicks they generate. These systems have been devised by people who want to measure output and outcomes, almost certainly with an intent to reallocate resources. Obamacare and the HITECH act (a veritable windfall for Silicon valley) have accelerated the corporatization of medicine and forced doctors to go along against there better judgement. Investments in vehicles that make meaningful delivery of care increasingly inefficient and onerous reporting makes it impossible for doctors to set up independent practice. Those who do remain independent are a dying breed and with them will go the compassion and dedication that was the hallmark of the profession. Instead of directing venom at coders and physicians, patients and citizens need to get actively involved to reverse the process where power is not wielded by insurances and hospitals and PBMs and big pharma. As a physician myself, I would be happy taking a cash payment from every patient, be an advocate for them and render my services a lot more efficiently, inexpensively and meaningfully.

    1. Yves Smith

      Your comment is out of line. First, Lambert repeatedly described the primary actors in gaming the system as “coders” not the doctors. However, you choose to brush off the fact that, as Time reported, that doctors PAY to take courses to learn how to upcode. What proportion is an open question but it’s a real phenomenon.

      In addition, as a patient, I have found I regularly have to fight my doctor to avoid unnecessary testing, like EKGs when I am in the 1 percentile for heart attack risk.

      1. Ahimsa

        Let me clarify for you how the system works. A coder cannot code without appropriate documentation by the physician. A coder can request a physician to be more specific with his terminology to capture the complexity of the condition. Acute systolic heart failure alluded to is an example of a very specific kind of heart failure associated with more acuity and mortality and could not be coded unless there was evidence to justify the same. Physicians will not attempt to game the system by documenting incorrectly and against the facts. So when one criticizes the coder, there is implicit condemnation of the physician without ascertaining the facts.

        And yes, doctors like me do take courses to learn how to code as not doing so correctly can lead to all kinds of fines. And paybacks. We are not doing it to upcode. It is self preservation that compels one to do so as the system demands it.

        In so far as fighting your doctor to avoid an unnecessary EKG, I can only say that your doctor should not be obtaining an EKG unless it is reasonable to do so. But to imply that your experience constitutes the larger experience does not make it a fact.

        But doctors do on the other hand constantly face unlimited liability when the one percentile risk becomes an unexpected reality.

        1. Lambert Strether Post author

          > We are not doing it to upcode

          It’s a phishing equilibrium, so regardless of what you personally are going, the system encourages it, and others do it. There are courses offered for it!

    2. Norb

      To add a personal anecdote for what it’s worth. Last year my wife, an emergency room nurse for 28 years, experienced respiratory distress and had to be admitted to hospital via ambulance. The first problem arose when the ambulance arrived and it was determined that my wife’s condition warranted going to the nearest hospital. This hospital was outside of my insurance network. The next problem arose when in the emergency room. In all the confusion and bustle, the doctors are calling out a series of drugs to be administered. My wife, barely able to speak through lack of breath, refuses the drugs. She has one kidney and knows the possible side effects of the suggested drugs. I have no clue. There is a moment of calm as the doctors rethink their plan. This process takes just a few moments. Then they move on, NOT administering the drugs. Even at the time I thought WTF. Do you need the drugs or not? Apparently not.

      In the current system, citizens, or should I say customers, are sheep lead to slaughter. There is no polite way to say it. The system is designed for profit maximization, as is everything else. As for Doctors, welcome to the club of compromised souls. Doctors, as a professional class, currently have the power and political influence to hold onto their position in the capitalist hierarchy. But don’t kid yourself, your neck will be on the chopping block soon. Doctors primarily concerned about patient care will be driven out in favor of more business, profit savvy practitioners. Look at the nurses and the pressures they have been under. More techs, greater patient loads, management trained more from the business classes that the medical profession. Patient care used as a marketing tool instead of actual healthcare delivered. Risk associated with the use of lower skilled support staff can be offloaded onto the nurses. The question of who is responsible for poor outcomes is blurred. Build a scapegoat for failure into the system and sacrifice them by firing. The politics of healthcare will be how to protect you position and avoid negative personal outcome to job security and economic health. Healthcare will resemble, make your money and run for the winners, and a grinding, stressful burden for all the rest. Good nurses primarily concerned with actual patient care will be driven out of the system or will not last long in such an environment. Doctors will face the same pressures, acknowledged or not. None of this will be openly admitted to.

      Social standing requires acceptance of responsibility. For way too long, neoliberalism has taken advantage of the public trust for its own selfish interests. The arguments and rationalities of those at the top of the hierarchy no longer holds validity. As for healthcare, a new generation of talented, caring individuals concerned for patient care would be evident by a government that sponsored the training of individuals capable of providing the service- regardless of economic background or wealth. Cuba has done wonders in this regard.

      Healthcare has to change in a big way. For society as a whole, in America at lest, it is one big cash cow. If the elite want to finance their own private medical staff and system, so be it. A physician wishing to profit from participating in that world has every right to do so. But to blur the distinction between public health and the right for the healthcare industry to extract profit from the citizenry is beyond the pale. It is exploitive usury any way you cut it.

    3. Edward

      Every medical student I encountered in college was in it for the money, every one of them; some were more greedy then others. This label of greed is not an either-or question– that all doctors are avaricious or they are not. Rather there is a continuum of behavior. The question is what is the aggregate behavior. To be fair, greed is not isolated to the medical profession. However, medical greed has become a problem for the entire country, threatening the economy.

  17. MoiAussie

    I agree it’s over-the-top to suggest Lambert enjoys bashing physicians and “directing venom” at them. The thesis that “where fraud is possible it will occur” is so clearly true it’s almost a tautology. But it’s not a stretch to argue that most physicians and coders are not the real guilty parties.

    The role of doctor is being progressively crapified. Independent medical professionals are on the way out, more and more are working for sociopathic corporations that try to squeeze every last dollar of profit from their business, and will be keen to replace employees with AI wherever possible. Management is the primary actor trying to game the system and grow their own role (and compensation). Coders are just doing their job as instructed, and if they don’t, they will be quickly replaced. Some doctors undoubtedly collude in upcoding (perhaps they are greedy, perhaps have shares in the business).

    Good doctors order (probably) unnecessary tests to avoid unlikely outcomes and cover themselves against lawsuits. Good doctors prescribe (probably) unnecessary drugs, especially antibiotics, because most patients demand them, and will go elsewhere if denied them. These kinds of doctor behaviours are rational, not malicious, given the way the system works.

    1. MoiAussie

      Not sure why, but every now and again making a reply to a comment creates a new comment rather than a reply. The above was in reply to Yves.

      1. Foppe

        If you would like some inspiration, I would really recommend this video talk by an internist/GP who, last year, refused to go to a hospital for a complicated fracture he’d received from a nightly fall because he would be unable to protect himself from unnecessary heart catheterization if he had: https://www.youtube.com/watch?v=udADjqj3D7A
        Very exhaustive review of all the various perverse incentives involved in the business. Written, less exhaustive report can be found here: https://www.drmcdougall.com/misc/2016nl/may/heartsurgeons.htm

  18. stonecutter

    This misses several points. I. at present. require a series of blood tests for which I self pay (no insurance), periodically, which are identical. The price, from a single lab, has varied from $280 to $800 for the same test set (sample size four test series). My inquiries to the lab billing department resulted in a series of explanations; 1) self pay rate (discount?), 2) Medicaid standard billing, 3) Medicare standard billing, and 4) hybrid (corrected) combination of self pay and Medicare billing. The feds has so screwed the system that the service providers are confused to the point of incoherence. Bigger fed government (and state) regulation will surely save us, particularly with increased emphasis on EEOC and Affirmative Action (full employment for the left tail of the Normal Distribution in government jobs.

    1. Lambert Strether Post author

      I agree that there’s a Federal role in this mess; the ICD coding was adapted (force-fitted) to medical billing for Medicare and Medicaid (I forget the order this was done). But I’m very much inclined to put the ensuing clusterf*ck down to neoliberalism, rather than big gummint per se; other countries have managed to avoid the mess.

    2. Norb

      What point about the corporate takeover of our government don’t you get? The service providers are confused? They WROTE the legislation! The neoliberal order continues to thrive because citizens have been turned against their government. Why don’t you demand good governance with as much vehemence as you do degrading it? Corporations will never act with the best interests of the citizenry in mind. Their purpose it to generate profits and make sure you, as a worker, get as little of that share as possible. In their utopia, you would get just enough payment for subsistence, and freely be discarded like a worn piece of machinery when you were deemed unnecessary. That is the corporate friendly world you are helping to create and maintain.

      The article, and your experience proves, that medical corporations are gaming the system for obscene profits. The question to ask, is what is the true cost for performing a blood test and what is the best way to deliver that service for the least cost to society as a whole. As the article also points out, corporations do their best to hide their true costs in order to keep the gouging going.

      The answer to the nations healthcare problems are simple and obvious. Starting from the premise that healthcare is a right of all citizens and should be conducted in a non-profit environment- period. A system build on those principles would generate an entirely different response than what we currently have. I agree with you that the system is screwed up from the perspective of delivering healthcare to citizens, but turning to private corporations for the solution is as Orwellian as it gets. Gouging corporations are the problem.

      If citizens don’t start acting and demanding a more humane and higher moral standard of leadership from both our private and public sectors, the only bosses left will be of the Vito Corleone variety. Is that the world in which you would like to live and rise a family?

      1. craazyboy

        Very true. We shouldn’t underestimate the power and size of the “Fifth Column” of lobbyists, and also revolving door of insider administrators of any guv programs by either pragmatic profit optimizers and/or wingnut ideologists – which are often the same people.

        It’s hard to know the extent of it, because the details are hidden from the public, mainly due to lack of reporting and analysis of complex subjects.

        One recent example I noticed for Social Security was the troubled “disability” piece of the program did run out of money. It was separately funded from the “retirement” part of SS – which is good if you want to pick up on specific problems, or lack of funding. But the solution the Social Security hawks and concern trolls took was to raid the SS retirement cash flow and/or trust fund, as necessary, and divert the funds to disability reimbursements. This is an ongoing change to the law, but makes the SS retirement Trust Fund foot the bill, rather than fixing any problems with the programs as a whole.

        Also, a word on Med and Dental schools – the schools constantly tell students about the boatload of money they will make in the future as a means to justify outrageous tuition and the need to load up on student loans. They don’t stress what a wonderful, charitable and giving, career the students have chosen. ha.

  19. Jesper

    Even with single payer this kind of abuse happens, it is after the introduction of “New Public Management”:
    https://en.wikipedia.org/wiki/New_public_management
    (Thank you Margaret Thatcher….)

    All needs to be measured (because nobody can be trusted?) so therefore some incredibly arrogant people introduce systems for control. The arrogance comes from believing that they can design a system that can’t be gamed and that system will also be fair. Or maybe they’re just control-freaks selling their system on lies……

    1. Lambert Strether Post author

      NHS is a testimony to the amazing power of the health care as a universal benefit idea, in that it’s taken the neoliberals thirty years of hard work to even jeopardize it.

      1. Norb

        I would also add that the concept as a right was born out of the ashes of war. NHS was the right demanded after so much suffering was endured by the working class. It was the right the elite could not deny in the face of so much loss and suffering.

        I fear it will take another great calamity to relearn these lessons. The elite always believe they can hunker down and survive the storm. Humanities great strength and weakness is that these lessons must always be relearned. Power of education and history-no. Without that, everyone is forced to burn their hand in the flame to learn it is hot.

      2. JEHR

        “the amazing power of the health care as a universal benefit idea”

        Even though we have had our universal healthcare since 1962-3 (in Canada), there have been ongoing attempts at privatizing parts of it. We have to be vigilant every day to protect our system.

    2. john gleason

      I am an independent insurance adjuster whose clients are motor vehicle insurance companies. I handle claims made by accident victims on a daily basis. These claims range from minor strains to death. I receive medical bills from all types of medical professionals: doctors, psychiatrists, hospitals, homes for the mentally/physical disabled, Medicaid and Medicare etc. I am not a trained medical professional nor medical coder.

      Most bills are sent to a medical billing review company or an independent medical billing auditor which approve an amount to be paid by my clients (except for Medicaid and Medicare payments which are paid after determining whether the bills have already been paid by the insurance company). (Review companies and auditors base the approved amount on reasonableness and customary charges: Medicare and Medicaid approved amounts are based on cost plus profit, therefore do not to be audited for reasonableness and customary guidelines and they are usually three to ten times less than the medical bill charges).

      The approve amount for payments range from the amount shown on the bill to forty percent of that amount. For example, one hospital bill for $125,000.00 was reduced to $86,000.00; a doctor’s bill for $56,000.00 was reduced to $15,000.00. (Most medical bills are within ninety to ninety-five percent of the approved amount: one hospital will accept seventy-five percent of rather large bills if paid within thirty days.) I do not know whether the differences in the amounts are caused by coding mistakes or fraud. However, I do get to know which doctor, hospital, etc. consistently bill within the reasonable and customary charges, but their bills must be forwarded through a billing review process, since in a court of law (which I am in three to six times a month) a plaintiff attorney will rightly demand on what basis I did or did not have a bill reviewed.

      I agree with Jesper above “because nobody can be trusted?”

      1. craazyboy

        So…how many times have you reviewed billing for $10 Band-Aids and audited them for reasonableness? Are our hospital Band-Aids rational?

        I’m just making a joke. Not questioning the importantness of your chosen profession :)

        1. john gleason

          No joke. I just requested a check be issued for $10.40 after receiving an audit for a $23.00 bill from a radiologist. In this case reasonableness had nothing to do with it: this medical professional and many others agree to take less through a program with the review company called PPO

      2. Jesper

        I might add that my belief is that NPM was/is a precursor to privatisation. The situation now in Sweden with private practice where the bill is paid by the public we have a profit seeking/maximising private practice incentivised to code as expensively as possible.
        It used to be that doctors had two concerns:
        1. Do no harm
        2. Heal

        Now the situation is (in random order) for private practice doctors:
        1. Bill as much as possible
        2. Do no harm
        3. Heal

        I preferred the old way, there might have been inefficiencies in the public healthcare and/or difficult to measure which doctor dealt with the most complicated cases (am guessing that is reason for coding?) but at least the profit incentive wasn’t there. Do not lead into temptation….

  20. mf

    I came across this site awhile ago, around the time of the financial crisis. It seemed like a place where some independent analysis could be found. I no longer really come here though. I think all the writers here need to do some serious soul searching, as do the proprietors. By my reckoning, you have deteriorated into a form of a pseudo economic tabloid with a left wing bend, kind of similar to zero hedge, except that one has a fascist bend. Read your stuff and everything and everyone is just a fraud. it is all a giant, never ending theft and you, and you alone, understand the full wickedness of it all. Come on, get some perspective and get a life. Unless this is your gig, and this is the best you can do. If this is the case, then at least say that you are a big part of where Donald Trump came from. Are you pleased now?

    Yes, patients get weird bills from hospitals. Why? Because hospitals need to do cost shifting if they want to keep the lights on. If you do not understand this, you are not paying attention and/or you are entirely clueless. Hospitals do cost shifting because they are forced to treat many people for free or at a high loss. A good health care organization can barely break even on Medicare patients. And yet you make it sound like everyone is making money hand over fist.

    Health care costs a lot of money because health care can do a lot. My father died forty years ago, at the age of 48, of a congenital heart defect. Nothing could be done for him then. Today, he would have been treated and would have likely lived a long life. Everyone want this sort of service, and it must be “affordable”, preferably free. Because we deserve this right? It is our God given right. How did we get here, and how much it cost to offer these little miracles? This is other people’s problem. I just want to get what I deserve. Really?

    The subject of this article, coding. Coding is the way to quantify disease and medical service for the purpose of billing. This is a necessary step, whether one deals with private insurance or a single payer. It does not matter. Can it improved? Sure, everything can be improved. Should it be improved? Of course. Will it be perfect once it is improved? Hell no.

    Get a life and stop putting poison in people’s heads. Whether from the left wing or the right wing, poison is poison.

    1. Lambert Strether Post author

      I know this is argument from authority, but take your theoretical issues up with Akerloff and Shiller. Take your pragmatic issues up with Rosenthal (the concept you’re looking for is “strategic coding”). Take your issues with persons harmed with others on this thread and Wickizer.

      It’s a big Internet. I hope Doctor Pangloss is still out there, and, if so, you can find him. Best of luck.

  21. LaSherri

    This is my first time on this site. I am a medical transcriptionist, studied to be a medical coder and was a legal secretary for over 20 years (until laid off during recession of 2008). I have just been hired to work part-time for Walmart doing overnight stocking. I was 6 months away from taking the CPC coding exam after almost 2 years of part-time studying. I am finding more and more articles about the coding field going the way of MT, i.e., outsourcing overseas. Patient safety and security are no longer concerns with the MT companies. I recently worked for a company (and other companies are now following) that started docking the MT pays (usually $100 or more a week) if the DOCTOR dictated something wrong (i.e., if dictated wrong BMI – we were expected to actually do the calculations ourselves; medication error since doctors can’t seem to pronounce words correctly; sending work to QA for a “second look” if can’t understand the dictation as they are now basically all dictated by foreign doctors, etc.). There are soooo many MTs now making less than minimum wage, facing bankruptcy, losing homes… The final point came when I started getting docked on blanks that QA was able to fill in (even if they were incorrect). I could see the writing on the wall, so went into studying coding. According to articles I have read, the coding field is going the same way as the MT field and will actually disintegrate faster. I decided I am not going through this with the new profession of coding and am totally discouraged with having to do anything within the medical field now. I also have had personal experience in dealing with the insurance companies and doctors. I have been with United Healthcare since 6/2016 (previously was with BC/BS Anthem). I recently wrote to United Healthcare, my state medical board and providers (all within 1 group). I am healthy, except for being overweight and migraines. I detailed my treatment experiences with the providers from 2013. In particular, I went to an ER for dizziness for a week (3 days I had to move around on my hands and knees hugging the wall). I was there for 3 hours, and the bill was over $2,000 even tho there wasn’t any treatment rendered except some Zofran for nausea (and this was after markdown of costs in accordance with the insurance company). They did an EKG and a CAT scan since I have migraines. I was released with a prescription for meclizine and told I had benign paroxysmal positional vertigo and nothing could be done. I requested 3 times an explanation for the high bill (wanted the codes) as there were 2 ER charges, 5 chemistry charges, 2 med/surgical supply charges, 2 hospital services, among others. I was never supplied with anything. There were numerous similar instances listed in my 4-page complaint to the state medical board, etc. I was contacted via CM, RRR letter a month later by the physician conglomerate and informed they were requesting all reports from all departments and would schedule a meeting with me after receipt (and they gave a deadline for the reports). Over a month past the deadline, I received another CM, RRR letter from the physician conglomerate to inform me that the deadline was extended, and they still wanted a meeting. That deadline has also since passed. About 2 weeks after my complaint, I received notice from the state medical board that they were investigating. I think this is why I received the first CM, RRR letter to cover their butts. I also believe the extended deadline is to provide the physician conglomerate time to see who the state medical board finds in favor of. I am in favor of your articles stating that we need to step up regarding our healthcare, but who has the time to deal with it? Even with my experience as an MT, coding and legal secretary, I have a hard time getting to the root of any medical issue, and I think this is why the average Joe doesn’t even bother.

    1. Lambert Strether Post author

      Thanks very much for your note, and if I were working for your employer I might have migraines too.

      Reading what you have to say, it strikes me that “produce the codes” in medical billing plays a similar role to “produce the note” in foreclosure fraud.

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