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And health insurers are using it to deny claims.

by huttyoop 2y ago

lenerdenator 2y ago
Any health insurers in particular?
- tiew9Vii 2y ago
  Allegedly a insurer "CEO Had Deployed an AI to Automatically Deny Benefits for Sick People" got assassinated very recently.
dataflow 2y ago
Correctly or incorrectly? (Not expecting the former, but it needs to be explicit as the distinction is kinda important...)
- zihotki 2y ago
  Define correctly. From insurance companies' point of view it's rather correct, I'd say
  - dataflow 2y ago
    I'm happy with whatever definition the parent feels is reasonable. There just needs to be some assessment of the merits made, is all I'm saying.
- jfengel 2y ago
  In general do we expect our doctors to be making mistakes 10% to 40% of the time? Those are the rejection rates. Either the insurers are getting it dangerously wrong, or we've got problems even worse than that.
  - lumost 2y ago
    What forces the insurance company to give sound rejections? There are numerous categories of care where you would not expect the individual to survive long enough to bring a lawsuit, or the individuals in question would not have the financial means. Even if a lawsuit is brought, what obliges the insurance company to be reasonable? The ability to deny medication that I am hearing about certainly are not in my insurance contract.
    - jfengel 2y ago
      The contract does say things like "standard of care", which is why they need an actual MD to reject a claim. The AI (or whatever) can help but in the end there is a doctor claiming to read the file and say you didn't need whatever it is. You can bring a suit, and often the threat alone will work. They're counting on you to give up rather than fight. Or be unable to afford it because most lawyers won't take something like that on contingency.
      - lumost 2y ago
        Can I sue the insurance companies doctor for malpractice? In standard care the doctor is liable, not the hospital.
        jfengel 2y ago
        They're content to just reject the bill or refuse to pay. They'd love it if you sued the doctor for malpractice on the grounds of recommending something that the insurer's doctor rejected. I don't think you can use the insurer's doctor who rejected your claim. You can try to get their board certification revoked, and in the wake of the murder people are talking about doing that more. But it's not in itself going to get you your meds.
        lumost 2y ago
        I don’t follow how the insurance companies doctor escapes liability in this case. If they are interfering with a patients treatment plan, doesn’t that qualify as practicing medicine? Otherwise the insurance company could easily staff itself with less scrupulous poorly qualified doctors and say “your job is to reject claims”. Why would that doctor have any motivation or requirement to fulfill the duties of a “doctor”?
mapt 2y ago
"Using it to". Problematic phrasing. I'm sure they also use paperwork to deny claims. Would you make that into a headline? It's like "using dice to deny claims". Yeah... I guess? But they are the ones performing the actions. What they base those actions on is besides the point. The point is that denying claims, particularly denying >90% of claims as the first generation of "AI" did (a D20 model), or denying claims requested by doctors without a Very Good Reason, is tantamount to refusing medical treatment to people who have already paid to be covered for medical treatment, and may stand to die if their medical conditions are not treated, as a result of second-guessing the doctor. It also dramatically reduces the productivity of doctors, who are being filibustered by a system that forces ever-increasing amounts of pre-approvals, charting requirements and appeals on them. If the median doctor can suddenly only perform half as much work... people also die as a result. It's not behavior that _deserves social protection_, is the point. Allowing companies to participate in social murder & fraud if they claim an AI told them to internally is morally, politically, bureaucratically, and economically abhorrent. Tear it all down and salt the earth with the bankrupt remains of these companies that had the _audacity_ to shift to second-guessing a majority of medical claims. > Before health insurers reject claims for medical reasons, company doctors must review them, according to insurance laws and regulations in many states. Medical directors are expected to examine patient records, review coverage policies and use their expertise to decide whether to approve or deny claims, regulators said. This process helps avoid unfair denials. > But the Cigna review system that blocked van Terheyden’s claim bypasses those steps. Medical directors do not see any patient records or put their medical judgment to use, said former company employees familiar with the system. Instead, a computer does the work. A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments. Company doctors then sign off on the denials in batches, according to interviews with former employees who spoke on condition of anonymity. > “We literally click and submit,” one former Cigna doctor said. “It takes all of 10 seconds to do 50 at a time.” The problem is not the dice. It's the denials. RealPage is a service used by landlords to fix prices and reduce competition. It doesn't actually matter that it uses AI to achieve this, they may as well have used in person conversations or a weekly newsletter, what matters is that it's all price collusion. They aren't "using AI to...", they are knowingly and proudly fixing prices to reduce price competition, and AI (or some kind of algorithm at least) may be used somewhere in the data analysis tools.

And health insurers are using it to deny claims.

lenerdenator 2y ago

Any health insurers in particular?

tiew9Vii 2y ago
Allegedly a insurer "CEO Had Deployed an AI to Automatically Deny Benefits for Sick People" got assassinated very recently.

dataflow 2y ago

Correctly or incorrectly? (Not expecting the former, but it needs to be explicit as the distinction is kinda important...)

zihotki 2y ago
Define correctly. From insurance companies' point of view it's rather correct, I'd say
- dataflow 2y ago
  I'm happy with whatever definition the parent feels is reasonable. There just needs to be some assessment of the merits made, is all I'm saying.
jfengel 2y ago
In general do we expect our doctors to be making mistakes 10% to 40% of the time? Those are the rejection rates. Either the insurers are getting it dangerously wrong, or we've got problems even worse than that.
- lumost 2y ago
  What forces the insurance company to give sound rejections? There are numerous categories of care where you would not expect the individual to survive long enough to bring a lawsuit, or the individuals in question would not have the financial means. Even if a lawsuit is brought, what obliges the insurance company to be reasonable? The ability to deny medication that I am hearing about certainly are not in my insurance contract.
  - jfengel 2y ago
    The contract does say things like "standard of care", which is why they need an actual MD to reject a claim. The AI (or whatever) can help but in the end there is a doctor claiming to read the file and say you didn't need whatever it is. You can bring a suit, and often the threat alone will work. They're counting on you to give up rather than fight. Or be unable to afford it because most lawyers won't take something like that on contingency.
    - lumost 2y ago
      Can I sue the insurance companies doctor for malpractice? In standard care the doctor is liable, not the hospital.
      - jfengel 2y ago
        They're content to just reject the bill or refuse to pay. They'd love it if you sued the doctor for malpractice on the grounds of recommending something that the insurer's doctor rejected. I don't think you can use the insurer's doctor who rejected your claim. You can try to get their board certification revoked, and in the wake of the murder people are talking about doing that more. But it's not in itself going to get you your meds.
        lumost 2y ago
        I don’t follow how the insurance companies doctor escapes liability in this case. If they are interfering with a patients treatment plan, doesn’t that qualify as practicing medicine? Otherwise the insurance company could easily staff itself with less scrupulous poorly qualified doctors and say “your job is to reject claims”. Why would that doctor have any motivation or requirement to fulfill the duties of a “doctor”?

mapt 2y ago

"Using it to". Problematic phrasing. I'm sure they also use paperwork to deny claims. Would you make that into a headline? It's like "using dice to deny claims". Yeah... I guess? But they are the ones performing the actions. What they base those actions on is besides the point. The point is that denying claims, particularly denying >90% of claims as the first generation of "AI" did (a D20 model), or denying claims requested by doctors without a Very Good Reason, is tantamount to refusing medical treatment to people who have already paid to be covered for medical treatment, and may stand to die if their medical conditions are not treated, as a result of second-guessing the doctor. It also dramatically reduces the productivity of doctors, who are being filibustered by a system that forces ever-increasing amounts of pre-approvals, charting requirements and appeals on them. If the median doctor can suddenly only perform half as much work... people also die as a result. It's not behavior that _deserves social protection_, is the point. Allowing companies to participate in social murder & fraud if they claim an AI told them to internally is morally, politically, bureaucratically, and economically abhorrent. Tear it all down and salt the earth with the bankrupt remains of these companies that had the _audacity_ to shift to second-guessing a majority of medical claims. > Before health insurers reject claims for medical reasons, company doctors must review them, according to insurance laws and regulations in many states. Medical directors are expected to examine patient records, review coverage policies and use their expertise to decide whether to approve or deny claims, regulators said. This process helps avoid unfair denials. > But the Cigna review system that blocked van Terheyden’s claim bypasses those steps. Medical directors do not see any patient records or put their medical judgment to use, said former company employees familiar with the system. Instead, a computer does the work. A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments. Company doctors then sign off on the denials in batches, according to interviews with former employees who spoke on condition of anonymity. > “We literally click and submit,” one former Cigna doctor said. “It takes all of 10 seconds to do 50 at a time.” The problem is not the dice. It's the denials. RealPage is a service used by landlords to fix prices and reduce competition. It doesn't actually matter that it uses AI to achieve this, they may as well have used in person conversations or a weekly newsletter, what matters is that it's all price collusion. They aren't "using AI to...", they are knowingly and proudly fixing prices to reduce price competition, and AI (or some kind of algorithm at least) may be used somewhere in the data analysis tools.