[aintgonnatakeit]

There are two problems here: 1) Hanlon’s razor 2) The author doesn’t understand health insurance data.

I’m not trying to excuse the other bad behavior, but within the data itself, he’s experiencing a combination of health insurers’ incompetence, the kludged up data models they’ve had to build to represent the output of the multiple generations of claims processing systems and other administrative processes, and the general mess that provider identifiers are. Every payor calculates values differently. Every payor uses different codes (beyond the standard CMS and CPTs). Every payor has different arrangements that are difficult to represent in standard schema, eg capitation in Florida, delegation in California, or the oddness that are Taft-Hartley plan.

There is a link in the article to a discussion with CMS. Another participant in the discussion works for IQVIA, a long-time claims data aggregator (and CRO and a bunch of other things), and clearly understands what’s going on. It would be extremely difficult to do this work at all without significant experience working with multiple payors’ data, which requires time and access, and pays well once you do have that specialized experience.

[yamtaddle]

Other countries manage to successfully wrangle healthcare billing & coding such that they can apply, to good effect, outright price controls on various procedures. See, for example, Japan.

I absolutely don't believe this complexity is inherent in the problem space, because it very much looks like it is not. I'd believe that one or more actors in our healthcare system really like for it to be this way, though.

[civilized]

The point of the author's exercise is to see if the requirement of public transparency enacted by Congress actually means anything.

If the meaning of these prices is only decipherable by an elite priesthood that is too busy to work on the problem, there is no real public transparency.

[aintgonnatakeit]

I agree with you. It is a failure on multiple fronts.

[sl-dolt]

I'm the author.

Take an example like this https://github.com/CMSgov/price-transparency-guide/discussio...

I don't know how closely you've worked with this data -- you clearly have some kind of expertise -- but how do you explain this?

The insurance companies had 18 months to talk to the CMS and ask for a better data model. If they're not able to explain how much things cost with 5 different negotiated types -- negotiated, percentage, derived, fee schedule, and capitation -- then they should have asked for another one.

The hospital and insurance rates are both fee-for-service base rates for items billed individually. If there's some nuance in interpreting how "fee for service" "dollar amount negotiated" goes, definitely write to me and let me know. I talked with experts in healthcare pricing before I published this.

You can write to me at [e-mail] if you wanna hit me with more questions.

[danaris]

Boo fucking hoo?

I've worked within the health insurance industry (workers' comp, specifically); I know what a shitshow it is. As a fairly green programmer, I was tasked with creating a flat file export from our IBM mainframe's database for a new/changed regulatory requirement, and within just a few weeks (including a bunch of time spent waiting for return files from overnight batches), my export complied with the stated spec better than the agency's own files did.

But the health insurance industry makes absolutely jaw-dropping profits. The only reasons they can't harmonize their systems and produce something at least resembling standard outputs are because it would cost them slightly (on their scales) more money than just continuing to do what they're doing now, and because the higher-ups are (as with many industries) chronically unwilling to commit to one particular standard if it will make it even a little bit harder for them to change their minds whenever they want.

[heavyset_go]

Hanlon's razor falls apart when there is money to be made by doing shitty things.

[yunohn]

But the given examples are basic procedures like “wrist x-ray” or “endoscopy”. Surely they have simpler rate calculations than the potential special cases you mention?

[aintgonnatakeit]

Let’s do wrist x-ray and keep it simple. I’m sure I’ll mess up the formatting here.

When you get an x-ray, you would expect to see 3 claims (again, simplifying).

—— One is the x-ray tech taking the picture. That gets a professional claim with a CPT code and is straightforward.

—- One is the interpretation by a radiologist of the imaging. That is a professional claim with a CPT and a modifier.

—- The last depends on the place of service. If it’s in a hospital, or at an outpatient facility, or at an ASC, then you get a facility claim to go with it.

Next, under what circumstances did the x-ray occur? Was it during an inpatient stay? If so, the payor might pay based on a DRG, which is basically a bundle of all the services that occur during the stay. How do you decide how much of the cost to allocate to the various parts of the x-ray? There are more variations on this.

Next, how are the providers contracted? Are they participating providers? Par vs non-par have different payment rates.

Next, was the service in-network or out-of-network, defined by the patient’s insurance benefits?

Does the patient’s PCP participate in a capitated arrangement (fixed fee to the PCP’s office per month)? If so, what is the allocated cost for the service based on the submitted encounter?

What about fees for network rental? Sorry, this one is esoteric, but it’s another factor.

And so forth and so on. It’s a mess.

[sl-dolt]

I'm the author. When I write articles I have to make a choice: make them readable by the public, or detailed enough to satisfy the experts. I try to strike a balance, but I can't have both.

Please take a look at the CMS Price Transparency Guide https://github.com/CMSgov/price-transparency-guide and familiarize yourself with the schema. You can also take a look at the federal ruling: https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-...

The metadata you're talking about is specified in the files themselves. I've limited my search to fee-for-service (non-capitated, non-derived, non-bundled) institutional claims.

You can write to me if you have more questions. [e-mail]

[aintgonnatakeit]

Forgot one. The doctor who looked at the X-ray practices under one ID on Sundays, another ID MWF, and another T,Th,Saturday. In each case he’s also part of a different provider group. He might still have more than 9 TINs or NPIs under which he bills, all with different rates. How much does it cost to have this doctor interpret your x-ray?

[JJanos]

I think you're far off base here. An X-Ray will never come on more than 2 claims. It only has two parts, an interpretation and a facility fee. You are right it is confusing. It is true that billing context (as part of a grouper/stand alone) needs to a part of the publication of the files. However, that has nothing to do with the author raising valid points of inconsistency that can make the data unusable.

[seventytwo]

Hanlon’s razor? Really? Across multiple actors each with motivation and means to act maliciously?

Riiiiiight…

[Ensorceled]

I really wish we could effectively apply Hanlon’s Razor in these cases and force the CEO and board of directs to literally chose between "are you and your CIO malicious" or "is your CIO so grossly incompetent that you have utterly failed in your fiduciary duty"

[polygamous_bat]

Isn't that the problem? In for profit healthcare being malicious IS the fiduciary duty. So long as everyone else is playing the same game, there's no reason for one insurance to suddenly "break good".

[nojito]

It's almost certainly the later.

This data should be verified by matching it against claims data.