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Why There Are Sometimes Issues With Health Claims Data

By March 2, 2023Commentary

It may be apparent that I enjoy getting into the weeds of health data and research.  Our system has issues around cost and quality.  The cost issues are not generally because we use too many inappropriate or unnecessary services; it is because the cost of each service is very high.  And because providers have gotten very clever about exploiting the coding mechanisms used for submitting claims to maximize reimbursement, by making cases look more complex than they are.  A Kaiser Peterson Health System Tracker brief explored this issue.  I found it hilarious that some papers and other media reported this as saying that people were showing up sicker for visits.  What the study really said was the “upcoding” to get more money from a case is widespread and growing.  The authors are hesitant to describe the practice as intentional, but every health system and even small physician practices have billing software and electronic medical records which together are used to maximize reimbursement.  And it is working.  The report indicates how billions in additional spending are attributable to the practice.  And because many members of health plans have deductibles or coinsurance they end up paying more as well.  Better technology doesn’t always mean a cheaper or more effective system.   (KFF Brief)

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