My logic is that the Insurers shift more costs to individuals / small companies buying insurance to account for the large discounts afforded to the huge corporate / government plans. I have done consulting for 4 health insurers in 3 states. I don't know how much of what I have observed is state vs federal regulation.
Individual and small business (less than 50 covered employees) must use standardized plans based on "Community Pricing" Demographics and lifestyle cannot be considered, by law. Pricing and coverage are public and the same for everyone. These plans are not particularly profitable, partially due to higher administrative costs per member.
Large business plans are completely bespoke and very competitive. The majority (by number of insured, not number of companies) are self insured. The insurance company is only the plan administrator, the employer bears all of the financial risk. Pricing of these plans can consider almost anything. Coverage options are endlessly tweaked to get to the price that is needed to win the account. Since the insurer is only the administrator, these can be very profitable.
If you get rid of large group plans we will all end up in a small set of one size fits nobody plans which are overly expensive for most people.
The billing process is absurd. Consider just a few of the options for a bite on the ass. If it is incorrectly coded, the doctor won't get paid. Each of these has a different price. Hospitals hire coding specialists to find the most expensive plausible billing code.
S31801A Laceration without foreign body of unspecified buttock, initial encounter
S31801D Laceration without foreign body of unspecified buttock, subsequent encounter
S31801S Laceration without foreign body of unspecified buttock, sequela
S31802A Laceration with foreign body of unspecified buttock, initial encounter
S31802D Laceration with foreign body of unspecified buttock, subsequent encounter
S31802S Laceration with foreign body of unspecified buttock, sequela
S31803A Puncture wound without foreign body of unspecified buttock, initial encounter
S31803D Puncture wound without foreign body of unspecified buttock, subsequent encounter
S31803S Puncture wound without foreign body of unspecified buttock, sequela
S31804A Puncture wound with foreign body of unspecified buttock, initial encounter
S31804D Puncture wound with foreign body of unspecified buttock, subsequent encounter
S31804S Puncture wound with foreign body of unspecified buttock, sequela
S31805A Open bite of unspecified buttock, initial encounter
S31805D Open bite of unspecified buttock, subsequent encounter
S31805S Open bite of unspecified buttock, sequela
S31809A Unspecified open wound of unspecified buttock, initial encounter
S31809D Unspecified open wound of unspecified buttock, subsequent encounter
S31809S Unspecified open wound of unspecified buttock, sequela
S31811A Laceration without foreign body of right buttock, initial encounter
S31811D Laceration without foreign body of right buttock, subsequent encounter
S31811S Laceration without foreign body of right buttock, sequela
S31812A Laceration with foreign body of right buttock, initial encounter
S31812D Laceration with foreign body of right buttock, subsequent encounter
S31812S Laceration with foreign body of right buttock, sequela
S31813A Puncture wound without foreign body of right buttock, initial encounter
S31813D Puncture wound without foreign body of right buttock, subsequent encounter
S31813S Puncture wound without foreign body of right buttock, sequela
S31814A Puncture wound with foreign body of right buttock, initial encounter
S31814D Puncture wound with foreign body of right buttock, subsequent encounter
S31814S Puncture wound with foreign body of right buttock, sequela
S31815A Open bite of right buttock, initial encounter
S31815D Open bite of right buttock, subsequent encounter
S31815S Open bite of right buttock, sequela
S31819A Unspecified open wound of right buttock, initial encounter
S31819D Unspecified open wound of right buttock, subsequent encounter
S31819S Unspecified open wound of right buttock, sequela
S31821A Laceration without foreign body of left buttock, initial encounter
S31821D Laceration without foreign body of left buttock, subsequent encounter
S31821S Laceration without foreign body of left buttock, sequela
S31822A Laceration with foreign body of left buttock, initial encounter
S31822D Laceration with foreign body of left buttock, subsequent encounter
S31822S Laceration with foreign body of left buttock, sequela
S31823A Puncture wound without foreign body of left buttock, initial encounter
S31823D Puncture wound without foreign body of left buttock, subsequent encounter
S31823S Puncture wound without foreign body of left buttock, sequela
S31824A Puncture wound with foreign body of left buttock, initial encounter
S31824D Puncture wound with foreign body of left buttock, subsequent encounter
S31824S Puncture wound with foreign body of left buttock, sequela
S31825A Open bite of left buttock, initial encounter
S31825D Open bite of left buttock, subsequent encounter
S31825S Open bite of left buttock, sequela
S31829A Unspecified open wound of left buttock, initial encounter
S31829D Unspecified open wound of left buttock, subsequent encounter
S31829S Unspecified open wound of left buttock, sequela
S31831A Laceration without foreign body of anus, initial encounter
S31831D Laceration without foreign body of anus, subsequent encounter
S31831S Laceration without foreign body of anus, sequela
S31832A Laceration with foreign body of anus, initial encounter
S31832D Laceration with foreign body of anus, subsequent encounter
S31832S Laceration with foreign body of anus, sequela
S31833A Puncture wound without foreign body of anus, initial encounter
S31833D Puncture wound without foreign body of anus, subsequent encounter
S31833S Puncture wound without foreign body of anus, sequela
S31834A Puncture wound with foreign body of anus, initial encounter
S31834D Puncture wound with foreign body of anus, subsequent encounter
S31834S Puncture wound with foreign body of anus, sequela
S31835A Open bite of anus, initial encounter
S31835D Open bite of anus, subsequent encounter
S31835S Open bite of anus, sequela
S31839A Unspecified open wound of anus, initial encounter
S31839D Unspecified open wound of anus, subsequent encounter
S31839S Unspecified open wound of anus, sequela
ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2017/icd10cm_codes_2017.txt |
