General Discussion
Related: Editorials & Other Articles, Issue Forums, Alliance Forums, Region ForumsMurdered 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.
dalton99a
(84,881 posts)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)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 governments 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/
niyad
(120,664 posts)Silent Type
(7,333 posts)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.
niyad
(120,664 posts)Passages
(1,430 posts)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)"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)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 governments 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)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 governments 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)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)Obama compromised and backed down from the beginning.
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?
Silent Type
(7,333 posts)Cirsium
(1,156 posts)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.
Silent Type
(7,333 posts)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)Cirsium
(1,156 posts)What's your take on the whole thing?
Silent Type
(7,333 posts)choie
(4,705 posts)have granted us healthcare coverage. And how long should we wait and hope for one day in the future? What rot.
Silent Type
(7,333 posts)choie
(4,705 posts)waiting for the munificence of our leaders or the billionaire class.
Silent Type
(7,333 posts)Cirsium
(1,156 posts)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)Better get some GOPers too. And get rid of trump.
Sadly, Biden didnt go after universal healthcare and Harris totally ignored it during campaign except to support ACA which uses private insurers.
Cirsium
(1,156 posts)Yes, it has become more and more difficult. Your point? Give up?
Silent Type
(7,333 posts)We have an infinitely better chance of enacting universal healthcare by not automatically excluding private healthcare because of voter sentiment discussed before.
Id like to see a Public Option too. If its as good as we think/hope, people will gravitate to it quickly.
But remain a purist, and Id wonder if you really want universal healthcare or just want to scream at the clouds.
choie
(4,705 posts)But, I know its quaint, naive and old fashioned to think so, theyre supposed to work for and represent us!
Cirsium
(1,156 posts)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)are rejected by you.
Hope you succeed, but not gonna wait 50 years.
Id get enthusiastic if you honestly think you can even get a bill signed by 90% of Democrats in say next 4 years. Of course, well need some GOPers, assuming no Democrats refuse because their constituents arent on board.
So, the beatings will continue until morale improves.
choie
(4,705 posts)Why the hell should we hold what fucking ignorant people say in a poll? You think doctors that dont take Medicare or Medicaid dont cheat? The American public has been brainwashed to believe that the private sector can do a better job managing healthcare. Its bullshit.
lonely bird
(1,972 posts)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 couldnt 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)it actually rips off the US Taxpayer and Medicare.
support-the-private-alternative-to-medicare/
Silent Type
(7,333 posts)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)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)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 Ill 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, Id be fine with removing MA. But thats not going to happen anytime soon.
Enjoy your benefits, but let the 31 million who choose MA because its better for them keep what they want.
AdamGG
(1,524 posts)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)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)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)Do you have some professional expertise in this area?
Silent Type
(7,333 posts)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.
leftstreet
(36,417 posts)Hurt and kill people to make a buck, deal with the concequences
Jit423
(429 posts)They should all be deported back to their coder of origin.
Emile
(30,795 posts)Farmer-Rick
(11,538 posts)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)However, I will name my next bowel movement in his honor as a gesture of goodwill.
InAbLuEsTaTe
(24,668 posts)rpannier
(24,598 posts)No tears were shed for Brian Thompson.
miyazaki
(2,387 posts)Sayonara sucker.
dchill
(40,766 posts)... careening into a FAFO moment.
Karasu
(368 posts)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)People? Pshaw! What matteeds is shareholder value..... and his bonus!
EdmondDantes_
(116 posts)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)You can bet they did their best to make sure they stayed as close to the required numbers as possible.
NotHardly
(1,370 posts)Coventina
(28,013 posts)Maybe CEOs will think twice about their policies.
Maybe CEOs will request sensible gun control?
That's my hope, anyway...
Karasu
(368 posts)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)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)What the CEOs will do is get beefed up personally security (paid for by the company!) and stop being the public face of companies.
NickB79
(19,662 posts)moondust
(20,516 posts)Park 'em on 5th Avenue and get to work! See if you lose any supporters.
johnnyfins
(1,485 posts)With the amount of guns in hands(legally and illegaly) in the US, this won't end well.
onethatcares
(16,598 posts)asking for a friend
Prairie Gates
(3,569 posts)I haven't seen anybody think of that!
Klarkashton
(2,285 posts)Goddamn squeezed and shit on with no relief that it comes a matter of blind revenge against the system.
Liberty Belle
(9,617 posts)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)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)You can easily imagine what happened. As if foster care wasnt already fucked up.
Evolve Dammit
(19,068 posts)SunSeeker
(54,063 posts)InAbLuEsTaTe
(24,668 posts)Attilatheblond
(4,558 posts)Wow, that is a new level of dehumanizing medical care.
soldierant
(8,003 posts)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)OK, you owe me a new keyboard.
AND.......the adult beverage that ruined it.............
soldierant
(8,003 posts)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)But if one of them are doing it you can bet most... If not all... Are doing it. Something to think about.
LetMyPeopleVote
(155,533 posts)LAS14
(14,789 posts)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)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
RedWhiteBlueIsRacist
(292 posts)Until further notice, I will lay the blame of this killing on Trump as he has made America an unsafe place. IMHO.
Blue_Tires
(56,730 posts)cstanleytech
(27,178 posts)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)And AI is another one of the unheralded reasons why Donnie's about to be Emperor for Life
cstanleytech
(27,178 posts)Blue_Tires
(56,730 posts)raising2moredems
(714 posts)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)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.
Cne99999
(13 posts)Sorry to be crass but he did.
I'm a casualty of his work.
czarjak
(12,530 posts)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.
orangecrush
(22,128 posts)None for this.
Martin68
(24,732 posts)Cthulu on call
(37 posts)The CEO was a scum bag. I feel sorry for his children, but that's about it. Karma.