5 ms·

Taking 1.2 seconds to review claims means they are without any question "doing something wrong". "Remaining solvent" doesn't seem to be the goal, rather "maxim

Taking 1.2 seconds to review claims means they are without any question "doing something wrong". "Remaining solvent" doesn't seem to be the goal, rather "maximising quarterly bonuses regardless of lives destroyed" seems a more fit description.

JumpCrisscross 3y ago
> Taking 1.2 seconds to review claims means they are without any question "doing something wrong" Nobody said they aren’t. The point is, given the volume of claims, to do a proper analysis, we’d need a material fraction of doctors doing insurance reviews (instead of seeing patients). So we get a reliance on heuristics. If you’re lenient, you get targeted by fraudsters. So we get a bias towards denial. (Nobody is getting a material quarterly bonus for denying a few more claims. That nonsense occurs at the level of PBMs and other scale operations.)
- justinclift 3y ago
  > If you’re lenient, you get targeted by fraudsters. So in this scenario, it sounds like the fraudsters are the medical insurance companies, and the group being lenient are the regulators. A place taking (on average) 1.2 seconds to review each claim shouldn't be in business.
- OfficialTurkey 3y ago
  We have a system where doctors and nurses review medications and treatment options for patients. It's called _the medical system_. You know, the one where I can go see my doctor, talk to them about what's going on, and work with them to create a treatment plan that suits my problems and my goals. Why do we need to bolt on a secondary system that sucks up an untold wealth of time and money?
  - lotsofpulp 3y ago
    https://www.beckersspine.com/orthopedic/54193-fake-orthopedic-companies-involved-in-48m-billing-fraud-money-laundering-scheme.html https://www.beckersspine.com/orthopedic/54193-fake-orthopedi... https://www.pbs.org/newshour/health/feds-break-up-1-2b-medicare-orthopedic-brace-scam https://www.pbs.org/newshour/health/feds-break-up-1-2b-medic... https://www.fbi.gov/contact-us/field-offices/dallas/news/press-releases/federal-grand-jury-indicts-dallas-anesthesiologist-on-health-care-fraud-offenses https://www.fbi.gov/contact-us/field-offices/dallas/news/pre... https://www.cnn.com/2023/06/28/politics/doj-health-care-fraud-scheme/index.html https://www.cnn.com/2023/06/28/politics/doj-health-care-frau...
    - ceejayoz 3y ago
      Small potatoes. https://www.axios.com/2023/06/14/medicare-advantage-overpayments-estimated-study https://www.axios.com/2023/06/14/medicare-advantage-overpaym... > Overpayments to insurers administering Medicare Advantage plans now exceed $75 billion a year due to aggressive coding of patients' health conditions and easily-achieved bonus payments tied to quality, researchers with the USC Schaeffer Center for Health Policy & Economics found.
      - lotsofpulp 3y ago
        Insurers are not the ones coding, it is the healthcare providers. And the government is the one deciding to pay. If anything, that would mean more claims should be denied. Looking at the study, it seems like the government made some erroneous assumptions about who would be taking advantage of the policies the government created, resulting in the extra costs. (Third paragraph of “policy context” section). https://healthpolicy.usc.edu/research/ma-enrolls-lower-spending-people-leading-to-large-overpayments/ https://healthpolicy.usc.edu/research/ma-enrolls-lower-spend...
        ceejayoz 3y ago
        Nope. https://www.nytimes.com/2022/10/08/upshot/medicare-advantage-fraud-allegations.html https://www.nytimes.com/2022/10/08/upshot/medicare-advantage... > Anthem, a large insurer now called Elevance Health, paid more to doctors who said their patients were sicker. And executives at UnitedHealth Group, the country’s largest insurer, told their workers to mine old medical records for more illnesses — and when they couldn’t find enough, sent them back to try again. > Each of the strategies — which were described by the Justice Department in lawsuits against the companies — led to diagnoses of serious diseases that might have never existed. But the diagnoses had a lucrative side effect: They let the insurers collect more money from the federal government’s Medicare Advantage program. > Eight of the 10 biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to the federal audits. And four of the five largest players — UnitedHealth, Humana, Elevance and Kaiser — have faced federal lawsuits alleging that efforts to overdiagnose their customers crossed the line into fraud.
- iamjackg 3y ago
  If a business can't handle its own scale without negatively affecting its customers, it should probably stop growing. It's the same issue we see with Google accounts being seemingly randomly terminated. Since that probably won't happen, heuristic usage should at least come with penalties attached, otherwise the incentives are lopsided. If an airline's overbooking heuristics fail and get you bumped, you either get put on another flight and/or receive financial compensation. If an insurance company's "heuristics" fail and deny a legitimate claim, there should be a penalty. If Google terminates your account because of a mistake, they should pay a fine. They shouldn't be allowed to have their cake and eat it too.
  - JumpCrisscross 3y ago
    > If a business can't handle its own scale without negatively affecting its customers The scale probably helps. The point is if every billable decision is medically reviewed for more than a few seconds, a material fraction of the healthcare workforce needs to be diverted from patients to review. There is simply no solution, given the current industrial structure, to avoid some combination of non-expert, high-speed review without making even stupider trade-offs.
    - NoraCodes 3y ago
      Sounds like we need to replace the structure, given that it's not fit for purpose.
      - JumpCrisscross 3y ago
        > Sounds like we need to replace the structure, given that it's not fit for purpose We soundly agree. Health insurance, where risk is pooled, makes sense. Health "insurance," where payments are pooled with a bunch of needless intermediation, is unnecessary.
        ethbr1 3y ago
        *(catastrophic) risk pooling
trogdor 3y ago
That is not necessarily true. As another commenter pointed out, average review time is likely a misleading figure, since the overwhelming majority of decisions are made automatically, using predetermined rules engines. So nearly all decisions take zero seconds, and a small minority take much longer, leading to an average of 1.2 seconds, when in reality, those claims that are reviewed manually take far more than 1.2 seconds to review. As the other commenter put it: “(most cases take 0 time) + (a low number of cases take non-zero time) = 1.2 seconds on average.”

JumpCrisscross 3y ago

> Taking 1.2 seconds to review claims means they are without any question "doing something wrong" Nobody said they aren’t. The point is, given the volume of claims, to do a proper analysis, we’d need a material fraction of doctors doing insurance reviews (instead of seeing patients). So we get a reliance on heuristics. If you’re lenient, you get targeted by fraudsters. So we get a bias towards denial. (Nobody is getting a material quarterly bonus for denying a few more claims. That nonsense occurs at the level of PBMs and other scale operations.)

justinclift 3y ago
> If you’re lenient, you get targeted by fraudsters. So in this scenario, it sounds like the fraudsters are the medical insurance companies, and the group being lenient are the regulators. A place taking (on average) 1.2 seconds to review each claim shouldn't be in business.
OfficialTurkey 3y ago
We have a system where doctors and nurses review medications and treatment options for patients. It's called _the medical system_. You know, the one where I can go see my doctor, talk to them about what's going on, and work with them to create a treatment plan that suits my problems and my goals. Why do we need to bolt on a secondary system that sucks up an untold wealth of time and money?
- lotsofpulp 3y ago
  https://www.beckersspine.com/orthopedic/54193-fake-orthopedic-companies-involved-in-48m-billing-fraud-money-laundering-scheme.html https://www.beckersspine.com/orthopedic/54193-fake-orthopedi... https://www.pbs.org/newshour/health/feds-break-up-1-2b-medicare-orthopedic-brace-scam https://www.pbs.org/newshour/health/feds-break-up-1-2b-medic... https://www.fbi.gov/contact-us/field-offices/dallas/news/press-releases/federal-grand-jury-indicts-dallas-anesthesiologist-on-health-care-fraud-offenses https://www.fbi.gov/contact-us/field-offices/dallas/news/pre... https://www.cnn.com/2023/06/28/politics/doj-health-care-fraud-scheme/index.html https://www.cnn.com/2023/06/28/politics/doj-health-care-frau...
  - ceejayoz 3y ago
    Small potatoes. https://www.axios.com/2023/06/14/medicare-advantage-overpayments-estimated-study https://www.axios.com/2023/06/14/medicare-advantage-overpaym... > Overpayments to insurers administering Medicare Advantage plans now exceed $75 billion a year due to aggressive coding of patients' health conditions and easily-achieved bonus payments tied to quality, researchers with the USC Schaeffer Center for Health Policy & Economics found.
    - lotsofpulp 3y ago
      Insurers are not the ones coding, it is the healthcare providers. And the government is the one deciding to pay. If anything, that would mean more claims should be denied. Looking at the study, it seems like the government made some erroneous assumptions about who would be taking advantage of the policies the government created, resulting in the extra costs. (Third paragraph of “policy context” section). https://healthpolicy.usc.edu/research/ma-enrolls-lower-spending-people-leading-to-large-overpayments/ https://healthpolicy.usc.edu/research/ma-enrolls-lower-spend...
      - ceejayoz 3y ago
        Nope. https://www.nytimes.com/2022/10/08/upshot/medicare-advantage-fraud-allegations.html https://www.nytimes.com/2022/10/08/upshot/medicare-advantage... > Anthem, a large insurer now called Elevance Health, paid more to doctors who said their patients were sicker. And executives at UnitedHealth Group, the country’s largest insurer, told their workers to mine old medical records for more illnesses — and when they couldn’t find enough, sent them back to try again. > Each of the strategies — which were described by the Justice Department in lawsuits against the companies — led to diagnoses of serious diseases that might have never existed. But the diagnoses had a lucrative side effect: They let the insurers collect more money from the federal government’s Medicare Advantage program. > Eight of the 10 biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to the federal audits. And four of the five largest players — UnitedHealth, Humana, Elevance and Kaiser — have faced federal lawsuits alleging that efforts to overdiagnose their customers crossed the line into fraud.
iamjackg 3y ago
If a business can't handle its own scale without negatively affecting its customers, it should probably stop growing. It's the same issue we see with Google accounts being seemingly randomly terminated. Since that probably won't happen, heuristic usage should at least come with penalties attached, otherwise the incentives are lopsided. If an airline's overbooking heuristics fail and get you bumped, you either get put on another flight and/or receive financial compensation. If an insurance company's "heuristics" fail and deny a legitimate claim, there should be a penalty. If Google terminates your account because of a mistake, they should pay a fine. They shouldn't be allowed to have their cake and eat it too.
- JumpCrisscross 3y ago
  > If a business can't handle its own scale without negatively affecting its customers The scale probably helps. The point is if every billable decision is medically reviewed for more than a few seconds, a material fraction of the healthcare workforce needs to be diverted from patients to review. There is simply no solution, given the current industrial structure, to avoid some combination of non-expert, high-speed review without making even stupider trade-offs.
  - NoraCodes 3y ago
    Sounds like we need to replace the structure, given that it's not fit for purpose.
    - JumpCrisscross 3y ago
      > Sounds like we need to replace the structure, given that it's not fit for purpose We soundly agree. Health insurance, where risk is pooled, makes sense. Health "insurance," where payments are pooled with a bunch of needless intermediation, is unnecessary.
      - ethbr1 3y ago
        *(catastrophic) risk pooling

trogdor 3y ago

That is not necessarily true. As another commenter pointed out, average review time is likely a misleading figure, since the overwhelming majority of decisions are made automatically, using predetermined rules engines. So nearly all decisions take zero seconds, and a small minority take much longer, leading to an average of 1.2 seconds, when in reality, those claims that are reviewed manually take far more than 1.2 seconds to review. As the other commenter put it: “(most cases take 0 time) + (a low number of cases take non-zero time) = 1.2 seconds on average.”