Welcome to DU! The truly grassroots left-of-center political community where regular people, not algorithms, drive the discussions and set the standards. Join the community: Create a free account Support DU (and get rid of ads!): Become a Star Member Latest Breaking News Editorials & Other Articles General Discussion The DU Lounge All Forums Issue Forums Culture Forums Alliance Forums Region Forums Support Forums Help & Search

Coventina

(28,013 posts)
Thu Dec 5, 2024, 03:14 PM Dec 5

Murdered Insurance CEO Had Deployed an AI to Automatically Deny Benefits for Sick People

Just over a year before United Healthcare CEO Brian Thompson was murdered this week in Midtown Manhattan, a lawsuit filed against the insurance giant he helmed revealed just how draconian its claims-denying process had become.

Last November, the estates of two former UHC patients filed suit in Minnesota alleging that the insurer used an AI algorithm to deny and override claims to elderly patients that had been approved by their doctors.

The algorithm in question, known as nH Predict, allegedly had a 90 percent error rate — and according to the families of the two deceased men who filed the suit, UHC knew it.

As that lawsuit made its way through the courts, anger regarding the massive insurer's predilection towards denying claims has only grown, and speculation about the assassin's motives suggests that he may have been among those upset with UHC's coverage.

https://www.yahoo.com/news/murdered-insurance-ceo-had-deployed-175638581.html

***************************************************************************************

Not shedding any tears over that motherfucker.

95 replies = new reply since forum marked as read
Highlight: NoneDon't highlight anything 5 newestHighlight 5 most recent replies
Murdered Insurance CEO Had Deployed an AI to Automatically Deny Benefits for Sick People (Original Post) Coventina Dec 5 OP
Error rate is a feature, not a bug dalton99a Dec 5 #1
Fortunately, a "90% error rate" does not mean 90% of care was denied. It means that of the 8% or so of claims/authorizat Silent Type Dec 5 #7
Are you saying that all that is okay with you? Am I misunderstanding? niyad Dec 5 #22
No, niyad, I'm saying doctors do cheat. HHS estimates $100 B a year on fraudulent and unneeded care, and that Silent Type Dec 5 #24
At a minimum? Very interesting, given what I have been reading. niyad Dec 6 #80
The fraud has been documented and addressed to some degree. Not as well as it should/could be. Passages Dec 6 #82
There is it Cirsium Dec 5 #25
Well try voter preferences for one. Silent Type Dec 5 #26
Easily resolved Cirsium Dec 5 #32
I agree, but it didn't work under Obama and it's even less likely to work now. If Obama had insisted ACA not use Silent Type Dec 5 #33
Obama did not try Cirsium Dec 5 #35
He didn't once it was obvious it wouldn't pass and might bring the whole ACA down. Silent Type Dec 5 #39
That's the story Cirsium Dec 5 #42
Chamber leaders can count likely votes. We are lucky McCain gave thumbs up for what we got. Silent Type Dec 5 #43
Yep Cirsium Dec 5 #44
Unfortunately, more true now than then. Silent Type Dec 5 #45
How about you? Cirsium Dec 5 #46
We got the best we could get and should be thankful for it and hope that some day in the future it's improved. Silent Type Dec 5 #48
Yes we should be so glad that our betters choie Dec 5 #52
So, how do you plan on pulling this off say in the next decade? Silent Type Dec 5 #53
I don't know, but certainly not sitting in our duffs choie Dec 5 #54
So, you think we can totally reform the healthcare system without leaders and the votes. Good luck. Silent Type Dec 5 #55
Do you realize what you are saying? Cirsium Dec 5 #65
Call up Democrats and get a bunch on board if you think you can, I'll support that. Silent Type Dec 6 #67
You seem almost pleased Cirsium Dec 6 #68
My point is that it's unlikely to happen nowadays, but if you figure out a viable way I will support it. Silent Type Dec 6 #69
I don't believe I said that. choie Dec 5 #66
It has been there Cirsium Dec 5 #61
So Gallop poll that show 53% do not want private insurers, even if under universal healthcare Silent Type Dec 5 #64
OK Cirsium Dec 5 #59
Voter preference elected trump choie Dec 5 #51
The American public has been brainwashed, period lonely bird Dec 6 #79
Like Medicare Advantage which is not Medicare but a privately owned insurance compay.. Historic NY Dec 6 #89
IMO, until Congress decides to provide similar "extra benefits" for original Medicare beneficiaries, we should not Silent Type Dec 6 #90
Why are they shooting the company ex .that sells Medicare Advantage if its so good. Historic NY Dec 6 #94
First off, the shooter looks too young for Medicare. Second, MA is the only potential Silent Type Dec 6 #95
I worked in a doctor's office, the insurance companies puts up all kinds of crazy hurdles AdamGG Dec 5 #34
I'm assuming you also dealt with Medicare coverage policies with crazy hurdles, especially Silent Type Dec 5 #40
I didn't work in billing AdamGG Dec 5 #41
I'm finding this pretty hard to understand MadameButterfly Dec 6 #71
Some. Started out working for a state's Medicaid agency in 1970s and have done similar work since, but not for Silent Type Dec 6 #91
DuRec leftstreet Dec 5 #2
FAFO gay texan Dec 5 #3
Those damn immigrant AIs taking all those jobs from Americans. Jit423 Dec 5 #4
Predatory Capitalism at it's finest, killing Americans. Emile Dec 5 #5
You have to control capitalism Farmer-Rick Dec 6 #78
No tears here either. BannonsLiver Dec 5 #6
I hear ya... I have more sympathy for all the insurees who got screwed, sick, or died under that prick's authority. InAbLuEsTaTe Dec 5 #28
To Borrow from World History Channel on youtube rpannier Dec 5 #8
Worst mistake he ever made. miyazaki Dec 5 #9
The insurance industry is quickly... dchill Dec 5 #10
Why am I not surprised? We need national AI regulation and we need it fucking yesterday. Karasu Dec 5 #11
Every claim denied, was another buck in his pocket. Happy Hoosier Dec 5 #12
Not really true after the ACA EdmondDantes_ Dec 5 #60
All kinds of ways to cook the books Happy Hoosier Dec 5 #62
Is this the start of a French Revolution 2.0? Asking for a friend. NotHardly Dec 5 #13
I certainly hope not. That was a shitshow. Coventina Dec 5 #14
It was indeed a shitshow, but when the alternative is marching quietly into the night for unmitigated fascism... Karasu Dec 5 #18
Blue Cross Blue Shield reversed policy fast womanofthehills Dec 5 #57
It's a hopeless hope. HappyLarge Dec 6 #73
Here's hoping NickB79 Dec 5 #49
Roll out the guillotines!!! moondust Dec 5 #56
This is just BAD johnnyfins Dec 5 #15
has elon delivered his opinion as yet? onethatcares Dec 5 #16
Maybe he got shot by a hologram Prairie Gates Dec 5 #17
We might be at the point where people are so Klarkashton Dec 5 #19
That explains the words written on the bullet that killed him: "deny," "defend" and "depose" Liberty Belle Dec 5 #20
For profit healthcare? theplayer Dec 5 #21
Kansas decided the turn over their Foster Care to a for profit company, a while back... HappyLarge Dec 6 #74
This is alarming and needs some investigation? Merrick? Evolve Dammit Dec 5 #23
If there is a Hell, he's in it. nt SunSeeker Dec 5 #27
Fuckim!! InAbLuEsTaTe Dec 5 #29
So, he didn't even want to pay for quack doctors who couldn't make it practicing medicine to rubber stamp denied on case Attilatheblond Dec 5 #30
Social media is collect gems of responses soldierant Dec 5 #31
BWAHAHAHAHAHAHAHA!!!! AZ8theist Dec 5 #63
Glad you liked it. soldierant Dec 6 #70
I'm not shedding any tears for this evil fatcat slightlv Dec 5 #36
These are sickening denial stats LetMyPeopleVote Dec 5 #37
Two questions about these stats. LAS14 Dec 6 #84
Humana was also found to be using nH Predict... ultralite001 Dec 5 #38
Dude got AI'd right back:Assassinated Intently RedWhiteBlueIsRacist Dec 5 #47
AI is cancer Blue_Tires Dec 5 #50
Only if it's abused, otherwise the potential benefits outweigh the potential cons. cstanleytech Dec 6 #86
I've only ever seen evil and abusive applications of AI Blue_Tires Dec 6 #87
That's probably because AI is still in its infancy and it really has a long way to go before its true AI. cstanleytech Dec 6 #88
That's exactly what worries me 😐 Blue_Tires Dec 6 #92
Don't forget the insider trading probe.. raising2moredems Dec 5 #58
Thanks for pointing out the bogus claim of threats. John1956PA Dec 6 #76
He deserved it. Cne99999 Dec 6 #72
Two years ago, czarjak Dec 6 #75
I cried over John Lennon orangecrush Dec 6 #77
Interesting information. Martin68 Dec 6 #81
Well the 90% error rate was the feature Cthulu on call Dec 6 #83
I wonder if we should start a defense fund 🤔 cstanleytech Dec 6 #85
Well, isn't that swell! City Lights Dec 6 #93

dalton99a

(84,881 posts)
1. Error rate is a feature, not a bug
Thu Dec 5, 2024, 03:16 PM
Dec 5
https://arstechnica.com/health/2023/11/ai-with-90-error-rate-forces-elderly-out-of-rehab-nursing-homes-suit-claims/

UnitedHealth uses AI model with 90% error rate to deny care, lawsuit alleges
For the largest health insurer in the US, AI's error rate is like a feature, not a bug.
Beth Mole – Nov 16, 2023 5:37 PM

UnitedHealthcare, the largest health insurance company in the US, is allegedly using a deeply flawed AI algorithm to override doctors' judgments and wrongfully deny critical health coverage to elderly patients. This has resulted in patients being kicked out of rehabilitation programs and care facilities far too early, forcing them to drain their life savings to obtain needed care that should be covered under their government-funded Medicare Advantage Plan.

That's all according to a lawsuit filed this week in the US District Court for the District of Minnesota. The lawsuit is brought by the estates of two deceased people who were denied health coverage by UnitedHealth. The suit also seeks class-action status for similarly situated people, of which there may be tens of thousands across the country.

The lawsuit lands alongside an investigation by Stat News that largely backs the lawsuit's claims. The investigation's findings stem from internal documents and communications the outlet obtained, as well as interviews with former employees of NaviHealth, the UnitedHealth subsidiary that developed the AI algorithm called nH Predict.

"By the end of my time at NaviHealth I realized: I'm not an advocate, I'm just a moneymaker for this company," Amber Lynch, an occupational therapist and former NaviHealth case manager, told Stat. "It's all about money and data points," she added. 'It takes the dignity out of the patient, and I hated that."

...

Silent Type

(7,333 posts)
7. Fortunately, a "90% error rate" does not mean 90% of care was denied. It means that of the 8% or so of claims/authorizat
Thu Dec 5, 2024, 03:59 PM
Dec 5

ions were initially denied fully or partially, and the vast majority were approved when doctor or other provider sends additional info.

Usually this is because the doctor's office did a poor job of requesting authorizations. For example, a doctor requests 3 additional hospital days for a patient that just finished an uncomplicated hernia operation. Insurer says pending additional info, we believe the 3 days aren't necessary for an uncomplicated hernia op. Then doc's office goes, oh chit we forgot to mention the patient developed pneumonia. Lets send in additional info. Almost always, that would be approved.

"In 2022, insurers fully or partially denied 3.4 million (7.4%) prior authorization requests. Though insurers approved most prior authorization requests, the share of requests that were denied jumped between 2021 and 2022. The share of all prior authorization requests that were denied increased from 5.7% in 2019, 5.6% in 2020 and 5.8% in 2021 to 7.4% in 2022."

https://www.kff.org/medicare/issue-brief/use-of-prior-authorization-in-medicare-advantage-exceeded-46-million-requests-in-2022/

Other examples would be a provider asks for approval for 14 encounters of physical therapy, but plan says 10 are sufficient -- usually based upon standards of care -- and we will reevaluate that if patient needs additional care as therapy approaches end.

In any event, the idea this justices killing someone is, well, trumpian. Call up your Congressman and tell them to enact legislation for a better healthcare system. I bet money they'll say -- if honest -- there is no way to enact health care reform that doesn't include private insurers.

Gallop Poll 2023

WASHINGTON, D.C. -- A 57% majority of U.S. adults believe that the federal government should ensure all Americans have healthcare coverage. Yet nearly as many, 53%, prefer that the U.S. healthcare system be based on private insurance rather than run by the government. These findings are in line with recent attitudes about the government’s involvement in the healthcare system, which have been relatively steady since 2015.

https://news.gallup.com/poll/468401/majority-say-gov-ensure-healthcare.aspx

And if you don't think doctors and hospitals cheat, spend a little time on this CMS/Medicare site:

https://oig.hhs.gov/fraud/enforcement/

Silent Type

(7,333 posts)
24. No, niyad, I'm saying doctors do cheat. HHS estimates $100 B a year on fraudulent and unneeded care, and that
Thu Dec 5, 2024, 05:37 PM
Dec 5

is just for Medicare and Medicaid. The order services that aren't need, especially if they profit from it. I've seen doctors order say one MRI per hundred patients from a freestanding facility when they couldn't profit from it. Then, when they get an MRI in their own office --where they can make money of the technical component and professional component -- utilization shoots up to 400%. So, it wasn't needed when they couldn't profit from it, but suddenly is needed when they can bill $1000. Don't think so.

I've seen doctors order knee replacement when the don't even meet original Medicare coverage requirements.

So, yes, at a minimum you are misunderstanding.

Passages

(1,430 posts)
82. The fraud has been documented and addressed to some degree. Not as well as it should/could be.
Fri Dec 6, 2024, 11:34 AM
Dec 6

2015
But when it comes taking on big and well-connected insurance companies that have been ripping off the Medicare program for years, the administration has been far less aggressive in catching, much less punishing, the abusers.

As the Center for Public Integrity reported last week, officials in the Obama administration were advised as long ago as 2009 that a formula the government uses to pay private insurers that participate in the Medicare Advantage program “triggered widespread billing errors and overcharges” that waste billions of tax dollars every year.

There was no press release issued by the administration about that 2009 report; in fact, the administration buried it. The report probably never would have surfaced at all had the Center for Public Integrity not filed a Freedom of Information request seeking records going back several years regarding payments to Medicare Advantage plans.

https://www.middletownpress.com/opinion/article/Wendell-Potter-Fed-war-on-health-care-spending-11797618.php

Cirsium

(1,156 posts)
25. There is it
Thu Dec 5, 2024, 05:49 PM
Dec 5

"There is no way to enact health care reform that doesn't include private insurers."

Why in the world would that be?

Silent Type

(7,333 posts)
26. Well try voter preferences for one.
Thu Dec 5, 2024, 05:56 PM
Dec 5

Gallop Poll 2023

WASHINGTON, D.C. -- A 57% majority of U.S. adults believe that the federal government should ensure all Americans have healthcare coverage. Yet nearly as many, 53%, prefer that the U.S. healthcare system be based on private insurance rather than run by the government. These findings are in line with recent attitudes about the government’s involvement in the healthcare system, which have been relatively steady since 2015.

https://news.gallup.com/poll/468401/majority-say-gov-ensure-healthcare.aspx

Every major change to our so-called healthcare system in last 30 years has involved private insurers-- Part C under Clinton, ACA/Obamacare, Part D drug plans, Medicaid is now delivered primarily through private insurers. Don't think we'll get anywhere bucking private health insurers involvement.

Cirsium

(1,156 posts)
32. Easily resolved
Thu Dec 5, 2024, 06:30 PM
Dec 5

Give people the option. I am not aware of any proposal that would outlaw private health insurance.

Polls heavily influenced by industry fear mongering tell us exactly nothing. Those signs people carry that say "government keep your hands off my Medicare" tell us all we need to know regarding "attitudes about the government’s involvement in the healthcare system."

In any case, the politicians don't care about public opinion, they are worried about campaign donations.

Silent Type

(7,333 posts)
33. I agree, but it didn't work under Obama and it's even less likely to work now. If Obama had insisted ACA not use
Thu Dec 5, 2024, 06:37 PM
Dec 5

private insurers, it would not have passed then and definitely not now.

I will say, you need to read up on how many people don't trust "gubmint" insurance.

Cirsium

(1,156 posts)
35. Obama did not try
Thu Dec 5, 2024, 06:52 PM
Dec 5

Obama compromised and backed down from the beginning.

"Its impact shouldn't be exaggerated -- by the left or the right or the media," he said. "It is only one part of my plan, and shouldn't be used as a handy excuse for the usual Washington ideological battles. To my progressive friends, I would remind you that for decades, the driving idea behind reform has been to end insurance company abuses and make coverage available for those without it… the public option is only a means to that end, and we should remain open to other ideas that accomplish our ultimate goal. And to my Republican friends, I say that rather than making wild claims about a government takeover of health care, we should work together to address any legitimate concerns you may have."

And here's what he said about the alternatives to the public option being discussed in Congress: "For example, some have suggested that the public option go into effect only in those markets where insurance companies are not providing affordable policies. Others have proposed a co-op or another non-profit entity to administer the plan. These are all constructive ideas worth exploring."

Mr. Obama closed with what could be seen as the takeaway line from the section of the speech: "But I will not back down on the basic principle that if Americans can't find affordable coverage, we will provide you with a choice. And I will make sure that no government bureaucrat or insurance company bureaucrat gets between you and the care that you need."

https://www.cbsnews.com/news/was-obama-clear-on-the-public-option/


Open to other ideas? Whose ideas were those? He equates government bureaucrats with insurance company bureaucrats? Say what?

Cirsium

(1,156 posts)
42. That's the story
Thu Dec 5, 2024, 07:54 PM
Dec 5

That excuse always works. "Well it ever would have passed anyway because..." and "we would have done the right thing if only..."

There is no doubt that universal heath care advocates were completely left out of the discussion and industry lobbyists were brought to write the bill. Maybe the public option - which was itself a fall back compromise position - ever would have passed even if Obama had fought for it. But for sure nothing will happen if you don't fight for it.

Cirsium

(1,156 posts)
44. Yep
Thu Dec 5, 2024, 08:13 PM
Dec 5

We are lucky they even let us live at all, I guess. We will just have to settle for whatever crumbs fall off the table.



Silent Type

(7,333 posts)
48. We got the best we could get and should be thankful for it and hope that some day in the future it's improved.
Thu Dec 5, 2024, 08:43 PM
Dec 5

choie

(4,705 posts)
52. Yes we should be so glad that our betters
Thu Dec 5, 2024, 09:26 PM
Dec 5

have granted us healthcare coverage. And how long should we wait and hope for “one day in the future”? What rot.

choie

(4,705 posts)
54. I don't know, but certainly not sitting in our duffs
Thu Dec 5, 2024, 10:01 PM
Dec 5

waiting for the munificence of our leaders or the billionaire class.

Silent Type

(7,333 posts)
55. So, you think we can totally reform the healthcare system without leaders and the votes. Good luck.
Thu Dec 5, 2024, 10:03 PM
Dec 5

Cirsium

(1,156 posts)
65. Do you realize what you are saying?
Thu Dec 5, 2024, 11:53 PM
Dec 5

It is not even logical. It is certainly reactionary and anti-democratic. We are talking abiut pressuring the leaders to address the desperate needs of the people. You say that we are stuck with the leaders who oppose that and we can't do anything about it.

"I must confess that over the past few years I have been gravely disappointed with the white moderate. I have almost reached the regrettable conclusion that the Negro's great stumbling block in his stride toward freedom is not the White Citizen's Counciler or the Ku Klux Klanner, but the white moderate, who is more devoted to 'order' than to justice; who prefers a negative peace which is the absence of tension to a positive peace which is the presence of justice."

- Dr. Martin Luther King, Jr.

Silent Type

(7,333 posts)
67. Call up Democrats and get a bunch on board if you think you can, I'll support that.
Fri Dec 6, 2024, 12:06 AM
Dec 6

Better get some GOPers too. And get rid of trump.

Sadly, Biden didn’t go after universal healthcare and Harris totally ignored it during campaign except to support ACA which uses private insurers.

Silent Type

(7,333 posts)
69. My point is that it's unlikely to happen nowadays, but if you figure out a viable way I will support it.
Fri Dec 6, 2024, 12:38 AM
Dec 6

We have an infinitely better chance of enacting universal healthcare by not automatically excluding private healthcare because of voter sentiment discussed before.

I’d like to see a Public Option too. If it’s as good as we think/hope, people will gravitate to it quickly.

But remain a purist, and I’d wonder if you really want universal healthcare or just want to scream at the clouds.

choie

(4,705 posts)
66. I don't believe I said that.
Thu Dec 5, 2024, 11:57 PM
Dec 5

But, I know it’s quaint, naive and old fashioned to think so, they’re supposed to work for and represent us!

Cirsium

(1,156 posts)
61. It has been there
Thu Dec 5, 2024, 11:47 PM
Dec 5

The opportunity has been there and there is broad public support. Of course the industry has run a well financed campaign to mislead the public, but we look to Democrats - the leadership especially, but all of us, including you - to fight back ffs.

Silent Type

(7,333 posts)
64. So Gallop poll that show 53% do not want private insurers, even if under universal healthcare
Thu Dec 5, 2024, 11:51 PM
Dec 5

are rejected by you.

Hope you succeed, but not gonna wait 50 years.

I’d get enthusiastic if you honestly think you can even get a bill signed by 90% of Democrats in say next 4 years. Of course, we’ll need some GOPers, assuming no Democrats refuse because their constituents aren’t on board.

choie

(4,705 posts)
51. Voter preference elected trump
Thu Dec 5, 2024, 09:23 PM
Dec 5

Why the hell should we hold what fucking ignorant people say in a poll? You think doctors that don’t take Medicare or Medicaid don’t cheat? The American public has been brainwashed to believe that the private sector can do a better job managing healthcare. It’s bullshit.

lonely bird

(1,972 posts)
79. The American public has been brainwashed, period
Fri Dec 6, 2024, 10:08 AM
Dec 6

There was a time when government was generally not reviled.

Of course, that time was when women had to be in the kitchen keeping their mouths shut, gays had to be so far back in the closet that they couldn’t see the light when the door opened and Blacks had to be happy with whatever crumbs they got. Disapproval of government started with FDR, imo, and accelerated with Brown v Bd. Of Ed. When people started seeing social change reactionary forces generally backed by wealth started fighting back albeit quietly. The election of the piece of human garbage named Ronald Reagan gave those forces the courage to show themselves. The agitprop has been going full bore for over 60 years.

This country will not survive the oligarchy. But most of us will not be around to try and pick up any pieces.

Historic NY

(38,045 posts)
89. Like Medicare Advantage which is not Medicare but a privately owned insurance compay..
Fri Dec 6, 2024, 03:11 PM
Dec 6

it actually rips off the US Taxpayer and Medicare.

support-the-private-alternative-to-medicare/

Silent Type

(7,333 posts)
90. IMO, until Congress decides to provide similar "extra benefits" for original Medicare beneficiaries, we should not
Fri Dec 6, 2024, 03:39 PM
Dec 6

Last edited Fri Dec 6, 2024, 04:20 PM - Edit history (1)

try to take away what 32 Million (51% of Medicare eligble beneficiaries) believe is best for them.

If Congress does that, then sure get rid of MA.

When do you think that might happen?

Historic NY

(38,045 posts)
94. Why are they shooting the company ex .that sells Medicare Advantage if its so good.
Fri Dec 6, 2024, 07:25 PM
Dec 6

Just saying . I have Medicare and its back up by my former employers insurance coverage. They pay for my Medicare that come out of SS. I just had an 800k medical issue in Florida not my home state . Minimum co-pays not even 500.
all the drugs via CVS 54 day hospital stay and rehab. Plus another month in home rehab. No expense was spared or questioned.

https://www.medicare.gov/basics/get-started-with-medicare/get-more-coverage/your-coverage-options/compare-original-medicare-medicare-advantage]

Silent Type

(7,333 posts)
95. First off, the shooter looks too young for Medicare. Second, MA is the only potential
Fri Dec 6, 2024, 07:39 PM
Dec 6

way for poorer people to save a little money on premiums and get a little bit of extra benefits.

Original Medicare works well for you and me (except I’ll probably have to go on MA at some point).

My point is why should wealthier Medicare beneficiaries try to take a few bucks away from poorer people.

If Congress got off its ass and bumped up original Medicare, I’d be fine with removing MA. But that’s not going to happen anytime soon.

Enjoy your benefits, but let the 31 million who choose MA because it’s better for them keep what they want.

AdamGG

(1,524 posts)
34. I worked in a doctor's office, the insurance companies puts up all kinds of crazy hurdles
Thu Dec 5, 2024, 06:50 PM
Dec 5

I worked at a movement disorders clinic (Parkinson's, Tourette's, etc.) at a hospital in Boston. If an expensive drug is prescribed (often levodopa where I was), the insurance companies require the doctor to fax paperwork giving a detailed explanation of why the patient needs it.

Then, the approval is only for 6 months and they will discontinue coverage if they don't get faxed an explanation all over again. These were high level doctors who were very busy - seeing patients one day a week, running research labs, lecturing overseas.

The burden of the paperwork fell entirely on clerical staff, who were already busy and things fell through the cracks. That's what the insurance companies count on, that if they make people repeatedly jump through hurdles, that some of them won't follow up and the company won't have to pay.

Silent Type

(7,333 posts)
40. I'm assuming you also dealt with Medicare coverage policies with crazy hurdles, especially
Thu Dec 5, 2024, 07:16 PM
Dec 5

if you are a high user. Ever go on prepayment review or been audited for alleged billing abuse?

And I bet you taught your doc how to document those cases where all you had to do was send in their documentation without having to beef it up. Bet you had traditional Medicare claims denied too.

AdamGG

(1,524 posts)
41. I didn't work in billing
Thu Dec 5, 2024, 07:31 PM
Dec 5

It was a busy office and I was doing scheduling 20 hours a week for a few doctors; someone else did the billing. I attended the meetings of the editors of a research journal and heard conversations about how Medicare pays the hospital much less than private insurance does. They count on making more money from the private insurance patients to compensate for the Medicare ones.

The Editor in Chief of the journal wrote an Editorial about how "Medicare for All" wouldn't work (when Bernie was talking about it during the 2020 primaries) because of that. He meant that a single payer plan couldn't use the same formula to pay the hospitals that Medicare does, not that they were opposed to some kind of single payer.

In terms of the scheduling that I did, there were way more hurdles with private insurance.

MadameButterfly

(1,951 posts)
71. I'm finding this pretty hard to understand
Fri Dec 6, 2024, 02:21 AM
Dec 6

Do you have some professional expertise in this area?

Silent Type

(7,333 posts)
91. Some. Started out working for a state's Medicaid agency in 1970s and have done similar work since, but not for
Fri Dec 6, 2024, 04:25 PM
Dec 6

insurance companies. I really liked working for the state Medicaid agency because people were getting help that was previously out of reach. But the bureaucratic BS got too me.

I even wrote a paper recommending universal Medicare/caid coverage for all in 1981 for a government committee exploring options in a rube red state. You can imagine how little they wanted to hear a recommendation for "socialized medicine." So, I gave up on that aspect.

It is much more complicated than it should be for a lot of reasons.

Jit423

(429 posts)
4. Those damn immigrant AIs taking all those jobs from Americans.
Thu Dec 5, 2024, 03:27 PM
Dec 5

They should all be deported back to their coder of origin.

Farmer-Rick

(11,538 posts)
78. You have to control capitalism
Fri Dec 6, 2024, 09:50 AM
Dec 6

With regulations and heavy taxation of the filthy-rich or it will control you. I think we are at the stage where it has conplete control.

BannonsLiver

(18,217 posts)
6. No tears here either.
Thu Dec 5, 2024, 03:34 PM
Dec 5

However, I will name my next bowel movement in his honor as a gesture of goodwill.

InAbLuEsTaTe

(24,668 posts)
28. I hear ya... I have more sympathy for all the insurees who got screwed, sick, or died under that prick's authority.
Thu Dec 5, 2024, 06:06 PM
Dec 5

Karasu

(368 posts)
11. Why am I not surprised? We need national AI regulation and we need it fucking yesterday.
Thu Dec 5, 2024, 04:19 PM
Dec 5

Some of us have been dealing with the impact of this shit for years. But we're sure as hell not going to get it under a fascist dictatorship of unqualified kakistocrats.

And fuck insurance, especially "health insurance."

Happy Hoosier

(8,558 posts)
12. Every claim denied, was another buck in his pocket.
Thu Dec 5, 2024, 04:21 PM
Dec 5

People? Pshaw! What matteeds is shareholder value..... and his bonus!

EdmondDantes_

(116 posts)
60. Not really true after the ACA
Thu Dec 5, 2024, 11:42 PM
Dec 5

It introduced requirements that any for profit insurance company had to spend 80 cents on the dollar on medical expenses and the remaining 20 cents for costs. Doesn't really serve as inducement to keep premiums down, but it means denying claims only means you have to refund members.

Happy Hoosier

(8,558 posts)
62. All kinds of ways to cook the books
Thu Dec 5, 2024, 11:48 PM
Dec 5

You can bet they did their best to make sure they stayed as close to the required numbers as possible.

Coventina

(28,013 posts)
14. I certainly hope not. That was a shitshow.
Thu Dec 5, 2024, 04:24 PM
Dec 5

Maybe CEOs will think twice about their policies.

Maybe CEOs will request sensible gun control?

That's my hope, anyway...

Karasu

(368 posts)
18. It was indeed a shitshow, but when the alternative is marching quietly into the night for unmitigated fascism...
Thu Dec 5, 2024, 04:30 PM
Dec 5

Last edited Thu Dec 5, 2024, 06:18 PM - Edit history (1)

...that particular shitshow might be preferable to the one we're about to get. History will be the judge there. Personally, I doubt it will be kind.

womanofthehills

(9,332 posts)
57. Blue Cross Blue Shield reversed policy fast
Thu Dec 5, 2024, 10:11 PM
Dec 5

Blue Cross Blue Shield posted a few days ago that if an operation went too long they would not cover extra anesthesia. People posted a photo on social media of their top executive - today they said they would not go thru with that policy.


“Anthem Blue Cross Blue Shield halts anesthesia payment policy after backlash
The health insurer planned to cap the length of time anesthesia can be covered during medical procedures in three states, prompting outrage.“

https://www.nbcnews.com/health/health-care/anthem-blue-cross-blue-shield-time-limits-anesthesia-surgery-rcna183035

HappyLarge

(22 posts)
73. It's a hopeless hope.
Fri Dec 6, 2024, 03:30 AM
Dec 6

What the CEO‘s will do is get beefed up personally security (paid for by the company!) and stop being the public face of companies.

moondust

(20,516 posts)
56. Roll out the guillotines!!!
Thu Dec 5, 2024, 10:05 PM
Dec 5

Park 'em on 5th Avenue and get to work! See if you lose any supporters.

johnnyfins

(1,485 posts)
15. This is just BAD
Thu Dec 5, 2024, 04:28 PM
Dec 5

With the amount of guns in hands(legally and illegaly) in the US, this won't end well.



Klarkashton

(2,285 posts)
19. We might be at the point where people are so
Thu Dec 5, 2024, 05:03 PM
Dec 5

Goddamn squeezed and shit on with no relief that it comes a matter of blind revenge against the system.

Liberty Belle

(9,617 posts)
20. That explains the words written on the bullet that killed him: "deny," "defend" and "depose"
Thu Dec 5, 2024, 05:18 PM
Dec 5

similar to the industry phrase "delay, deny, defend" of how to avoid paying claims:

https://people.com/bullet-casings-words-echo-scathing-phrase-insurance-industry-delay-deny-defend-8756658

 

theplayer

(27 posts)
21. For profit healthcare?
Thu Dec 5, 2024, 05:20 PM
Dec 5

Are you kidding me? Next we'll have for profit prisons. Oh this s*** country already has those? I'm sure the prisoners are housed fed and cared for really well. I don't know how to make that little sarcasm thing show up but no I'm being extremely sarcastic. Too bad there's no help for pieces of s*** like that

HappyLarge

(22 posts)
74. Kansas decided the turn over their Foster Care to a for profit company, a while back...
Fri Dec 6, 2024, 03:38 AM
Dec 6

You can easily imagine what happened. As if foster care wasn‘t already fucked up.

Attilatheblond

(4,558 posts)
30. So, he didn't even want to pay for quack doctors who couldn't make it practicing medicine to rubber stamp denied on case
Thu Dec 5, 2024, 06:11 PM
Dec 5

Wow, that is a new level of dehumanizing medical care.

soldierant

(8,003 posts)
31. Social media is collect gems of responses
Thu Dec 5, 2024, 06:20 PM
Dec 5

Off the top of my head I can only remember "Sorry, my thoughts and prayers are out of network." But there are a lot.

AZ8theist

(6,555 posts)
63. BWAHAHAHAHAHAHAHA!!!!
Thu Dec 5, 2024, 11:51 PM
Dec 5

OK, you owe me a new keyboard.


AND.......the adult beverage that ruined it.............

soldierant

(8,003 posts)
70. Glad you liked it.
Fri Dec 6, 2024, 12:59 AM
Dec 6

You know, you can actually wash keyboards in the top rack of a dishwasher. You just have to be careful - remove batteries if they're cordless, and be sure they are fully dry before putting them in contact with electricity. I live in a very dry climate - if yours is humid you might want to have a spare while waiting for it to fully dry.

slightlv

(4,441 posts)
36. I'm not shedding any tears for this evil fatcat
Thu Dec 5, 2024, 06:54 PM
Dec 5

But if one of them are doing it you can bet most... If not all... Are doing it. Something to think about.

LAS14

(14,789 posts)
84. Two questions about these stats.
Fri Dec 6, 2024, 12:59 PM
Dec 6

Up thread were two interesting posts.

1) Insurance companies don't make more money by denying claims because the ACA mandates that they have to spend 80cents on the dollar for medical care. I can't say I understand how this works, but it gave me pause.

2) Initial denials don't usually result in permanent denials. What is this chart measuring?

ultralite001

(1,183 posts)
38. Humana was also found to be using nH Predict...
Thu Dec 5, 2024, 07:00 PM
Dec 5
According to a lawsuit filed Tuesday, Humana's use of the AI model constitutes a "fraudulent scheme" that leaves elderly beneficiaries with either overwhelming medical debt or without needed care that is covered by their plans. Meanwhile, the insurance behemoth reaps a "financial windfall."


https://arstechnica.com/science/2023/12/humana-also-using-ai-tool-with-90-error-rate-to-deny-care-lawsuit-claims/

Link to the Humana lawsuit:

https://storage.courtlistener.com/recap/gov.uscourts.kywd.128636/gov.uscourts.kywd.128636.736.0.pdf

Link to the United Healthcare lawsuit:

https://cdn.arstechnica.net/wp-content/uploads/2023/11/class-action-v-unitedhealth-and-navihealth-1.pdf
47. Dude got AI'd right back:Assassinated Intently
Thu Dec 5, 2024, 08:42 PM
Dec 5

Until further notice, I will lay the blame of this killing on Trump as he has made America an unsafe place. IMHO.

cstanleytech

(27,178 posts)
86. Only if it's abused, otherwise the potential benefits outweigh the potential cons.
Fri Dec 6, 2024, 02:04 PM
Dec 6

For example an AI probably has a better chance than a human at spotting an unforseen complication with a new drugs interactions when paired with a combination of other medications than a human.
Further an AI probably has a better chance at spotting an actual improved drug combination than a human might.

Blue_Tires

(56,730 posts)
87. I've only ever seen evil and abusive applications of AI
Fri Dec 6, 2024, 02:12 PM
Dec 6

And AI is another one of the unheralded reasons why Donnie's about to be Emperor for Life

cstanleytech

(27,178 posts)
88. That's probably because AI is still in its infancy and it really has a long way to go before its true AI.
Fri Dec 6, 2024, 02:54 PM
Dec 6

raising2moredems

(714 posts)
58. Don't forget the insider trading probe..
Thu Dec 5, 2024, 11:11 PM
Dec 5

Nor the fact that once a person is convicted but has filed an appeal bites the dust, the conviction is vacated. Nor the fact that the CEO's wife might have figured out her comfy lifestyle (kids or no kids) might cease if he got convicted. Reports of her telling of threats that afternoon turned into LE have found no threats against the CEO on the nightly news. I'm not a conspiracy person but too many moving parts at this juncture for me.

John1956PA

(3,432 posts)
76. Thanks for pointing out the bogus claim of threats.
Fri Dec 6, 2024, 06:42 AM
Dec 6

It seemed suspicious to me that he was said to have received threats, but no details about such threats were revealed. As I understand your comment, LE is now stating that it knows of no such threats having been made.

czarjak

(12,530 posts)
75. Two years ago,
Fri Dec 6, 2024, 05:14 AM
Dec 6

They tried to deny my wife's urgent care during a double transplant lifesaving experience. Said she was too healthy for rehab while recovering. Fortunately we prevailed and she is fine now. It was harrowing though. Cold-blooded. Period.

Cthulu on call

(37 posts)
83. Well the 90% error rate was the feature
Fri Dec 6, 2024, 12:49 PM
Dec 6

The CEO was a scum bag. I feel sorry for his children, but that's about it. Karma.

Latest Discussions»General Discussion»Murdered Insurance CEO Ha...