The Healthcare System Is Broken and I Helped Lay The Foundation

If you are one of the lucky ones to have health insurance, you already know something is wrong.

The cost keeps rising. The coverage keeps shrinking. And somewhere along the way, going to the doctor stopped feeling like getting care and started feeling like navigating a bureaucracy designed to wear you down.

Most of us have felt it without being able to name exactly what changed. It can be named — by someone who was part of the team that built one of the foundational pieces of the modern billing system.

This is not a story about villains. It is a story about how a system built with good intentions became something that works against the very people it was supposed to serve.

A Personal Experience That Started This Conversation

Two years ago, cataract surgery was needed on my left eye. The same surgeon who had successfully performed the same procedure on my right eye eight years earlier was chosen — an excellent physician with a strong track record.

The process around the original surgery was straightforward: two pre-surgery evaluation visits (all done by the doctor), the surgery itself, and two follow-up appointments. Five visits total. Efficient, thorough, done.

This time the same surgery required a separate visit for every individual pre-surgery test, followed by the surgery, followed by a series of follow-up appointments that stretched out across six months. Every visit meant time away from work. Every visit meant another copay. Same doctor. Same surgical procedure. Same patient.

When asked what had changed, the doctor’s answer was that Medicare will not allow two procedures to be done in the same visit. He was just as exasperated. That answer stayed with me, because the origin of that process change was already known to me.

What I Saw from the Inside

As a project manager at one of California’s largest insurance companies, the assignment came to lead a major multi-year enterprise project: the implementation of ICD-10 — a sweeping overhaul of the medical billing code system used across the entire U.S. healthcare industry.

To understand the scale of what this meant: the previous system, ICD-9, used roughly 14,000 diagnosis and procedure codes. ICD-10 expanded that to approximately 144,000 codes — a tenfold increase. Every insurance company, every hospital, every doctor’s office, every billing department in the country had to rebuild their databases, retrain their staff, and overhaul their software systems to accommodate the change. It went live on October 1, 2015.

The stated goals were legitimate: greater precision in diagnosis coding, better tracking of health outcomes, reduced billing errors, and improved data for medical research. These were real problems that needed solving. ICD-9 was a 30-year-old system that no longer reflected modern medicine and that many countries had moved on from years before. In fact, ICD-10 was not even the most current billing system in use at that time, but was the one that the U.S. decided to go to.

After that role was complete, other projects followed. What came next was not visible firsthand — but word traveled from others still on the project. And the research since then has documented it thoroughly.

What Happened After the Switch

The transition created significant disruption across the entire healthcare system — and much of that disruption landed on doctors and patients.

In the months following the October 2015 launch, coding productivity dropped dramatically. Studies found that medical coders were working 20 to 50 percent below pre-ICD-10 productivity levels. Claim denials spiked. One study of an ophthalmology practice — the same specialty as the experience described above — found that coding-related claim denials nearly doubled in the year following the transition.

Nearly half of all physicians surveyed in 2016 reported that ICD-10 had detracted from their practice efficiency. The increased complexity required more documentation, more time, and more administrative staff — costs that fell directly on medical practices.

But the deeper problem was not the coding system itself. It was what happened around it.

The rules that govern what doctors can bill for are set primarily by the Centers for Medicare & Medicaid Services (CMS) — the federal agency that administers Medicare and Medicaid. Medicare does not pay for two evaluation and management visit codes billed by a physician for the same patient on the same day. The rule is codified in the Medicare Claims Processing Manual, Chapter 12, Section 30.6.7.B. There is a narrow exception: a physician may bill for two same-day visits only if they document that the visits were for completely unrelated problems that could not be addressed during the same encounter — for example, an office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of a leg injury. Anything short of that standard is denied.

What makes this particularly troubling is that CMS itself has acknowledged that restricting same-day visit codes means providers may be forced to schedule visits on separate days, leading to delayed care and added expense for the patient. In other words: the government wrote the rule, acknowledged the rule harms patients, and kept it in place anyway.

Think about what that means in practice. It means the billing system — not your doctor — is making judgments about what care you need and when you can receive it.

The result is visit fragmentation: procedures and tests that could be completed efficiently in one or two appointments get spread across multiple visits. Each visit requires your time, your travel, and a copay. Each visit creates another opportunity for a claim to be denied. And each visit adds to the administrative burden already crushing medical practices. And we wonder why it sometimes takes months to get a doctor’s appointment.

There is a technical workaround — a billing code called Modifier 25 — that allows a physician to indicate that two visit codes billed in one appointment are genuinely distinct and both medically necessary. The American Medical Association recognizes this as a legitimate and well-supported coding practice. And yet insurance companies routinely challenge or deny these claims, leaving doctors to fight through appeals processes while patients wait.

Cigna is the clearest example of how this plays out. Cigna announced a policy requiring doctors to submit their full office notes — upfront, with every single claim — any time a visit code was billed with Modifier 25 alongside a minor procedure. If Cigna did not receive that documentation, the visit code line was automatically denied. The AMA and more than 100 physician organizations wrote to Cigna’s CEO urging immediate rescission of the policy — noting that requiring documentation for every such claim would force physicians to submit an enormous volume of office notes. Cigna had previously admitted it would only review about 10 percent of them. The AMA called this “pointless administrative waste.” Even more damaging to patients: the policy created a direct disincentive for physicians to provide unscheduled, same-day care — meaning patients who needed immediate attention might be told to come back another day simply because the billing paperwork was not worth the doctor’s time. After sustained pressure from the AMA and state medical societies, Cigna delayed implementation — but did not rescind the policy, stating it would continue to review it for future implementation. Cigna is not the only insurer with policies like this. It is simply the one that drew enough attention to be publicly named.

Why This Is Not Simply About ICD-10

It would be easy — and inaccurate — to blame the coding system itself. ICD-10 was a necessary modernization. The problems that followed were not inevitable consequences of better coding. They were choices made by the institutions that shape how the coding system is used.

CMS could allow same-day billing for medically necessary services without requiring physicians to jump through procedural hoops. Insurance companies could honor legitimate Modifier 25 claims rather than systematically denying them. Congress could mandate reforms that put medical judgment ahead of billing convenience. Hospital systems and large medical groups could resist the temptation to treat fragmented visits as a revenue opportunity.

None of these choices have been made. And patients are paying the price — in time, in money, and in care that arrives later than it should.

Your Doctor Is Caught in the Same System

Before drawing any conclusions about this situation, it is worth saying clearly: most physicians are as frustrated by this as their patients are.

Doctors entered medicine to provide care. The modern billing environment asks them to spend enormous amounts of time on documentation, prior authorizations, appeals, and administrative compliance — time that comes directly out of patient care. A physician who could thoroughly evaluate, test, and clear a patient for a procedure in a single efficient visit is instead required by billing rules to spread that care across multiple appointments.

It costs the physician time and revenue. It costs the patient time and money. It delays care. And in some cases, fragmenting care across disconnected visits leads to worse outcomes because the complete clinical picture never gets properly assembled in one place.

What Can Be Done

This series is going to keep following this thread — through the specific billing policies that drive visit fragmentation, through the institutions responsible for those policies, and through what meaningful reform would actually look like.

But change in systems like this one does not happen without pressure from outside the system. Here is how to make your voice part of that pressure:

• Contact your Congressional representatives. Call or write your U.S. Senator and House Representative. Tell them you want same-day billing restrictions examined and reformed. Constituent contact on specific policy issues gets attention.
• File a complaint with your state insurance commissioner. In California, the Department of Insurance at insurance.ca.gov accepts complaints. Every complaint is logged and patterns are tracked. Volume creates accountability.
• Talk to your doctor. Ask them directly how billing rules affect the care decisions they make. The conversation may surprise you — and it gives your physician an opening to be honest about a system that rarely invites that honesty.
• Share your experience. If you have experienced unnecessary visit fragmentation, delayed care, or unexplained claim denials, share your story in the comments. Real experiences are the most powerful evidence there is.

This Is Just the Beginning

Years inside the healthcare insurance industry, followed by becoming a patient navigating the very system that had been built — that combination provides a perspective that needs to be shared in order to be understood and, ultimately, fixed.

The system is not broken because the people in it are bad. It is broken because the incentives are wrong, the rules are outdated, and the institutions responsible for fixing it have not been sufficiently pressured to do so.

That is what this series hopes to change.