In a sense, the whole claims system is a game. The insurers do everything they can to come up with excuses to deny or delay paying the fair amount on claims.
My doctor's office had a claim denied because they had not stated explicitly that the coding was in ICD-
10 (the current coding system) rather than ICD-9, which had been
obsolete for years. They had to refile with no changes, just a declaration that it was coded correctly.
Medicare Advantage insurers game the government by trying to make their customers appear as sick as possible. The way the system works, "To provide an incentive for insurers to cover sicker patients, the plans are paid commensurately more for their care."
So the insurers push customers to accept a one time in-home visit from an insurer's clinician to find any condition that would get the insurer more money. Of course that's not what the insurers tell their customers the visit is for. And it raises all our costs.
"If you are healthy and the visit results in an increased risk score, you won’t have to pay more for your care. But the higher Medicare reimbursement your insurer receives may contribute to the nation’s rising health care costs."
https://www.health.harvard.edu/blog/medicare-advantage-when-insurance-companies-make-house-calls-201512168844In this game, I find I'm more on the side of the providers. Especially PCPs, where as
@sma3 noted, margins are razor thin. Which is not to say that I haven't seen gross abuses of the system by providers. But I haven't seen nearly the level of nickel and diming that the insurers do that drives up administrative costs. Just MHO.