The added complication is also because insurers refuse to pay providers unless every procedure, billing code, time of service, justification, physician notes, physician network accreditation, etc, etc is to their standards (which changes often) Health care providers have teams of full time admins who doing nothing but chase after insurers for missing payments and billing discrepancies. Insurers will delay payments, change billing codes, and refuse to pay pending audit, and then may decide not to pay at all. Doctors are pulled into doing extra admin work mostly because insurers wont pay them if the paperwork is not to their standards, or the patient doesn’t qualify.
I think this is closer to the truth. The problem is rarely "outdated regulation" (although that's what the organizations that build these systems will say) and more that there's so many cooks it becomes impossible to build anything worth anything. Everybody has an opinion about their little corner of the system, and no one is willing to understand anyone else's opinion. If you bring up some fundamental disconnect between the wants of different stakeholders they point to the current system and say "It works there", and ignore the fact that it doesn't actually work.
It's a problem of too many unfounded opinions, and too little actual engineering.
> Everybody has an opinion about their little corner of the system, and no one is willing to understand anyone else's opinion
This is true. If you talk to someone in insurance, fraud is a huge problem, and doctors providing expensive treatments for the wrong conditions is also a huge problem. They are society's defense against doctors prescribing exotic $20k/month cancer medicine for allergies because they heard a rumor it was 5% better than Claritin, and sending every patient with a cough to their brother-in-law's MRI clinic. And this is true to some extent (especially about the brother-in-law's MRI clinic.)
If you talk to a doctor, they won't outright say it, but they're committing insurance fraud on the daily so they can provide basic care. If they talk to a patient about how they've been eating differently since their spouse died, or they spend ten minutes coaxing details about pain from somebody who is reluctant to talk about it, they're going to bill that time as something they're 100% sure the insurance company will pay for. So it might go down as a consultation about blood pressure. Maybe they even think there's a good chance the insurance company will pay for it, but between the insurance companies constantly changing things and the doctor not having complete confidence in their office staff to figure out the right code, they just write down something that they're sure about.
I don't know what happens if you put a doctor and someone from an insurance company in a room together. They probably have a system of polite lies to tell each other.
