Once again we’re back to no accountability from our govt.
Corporations wilfully break the law,
Snipped
UnitedHealthcare (UNH) is facing increasing scrutiny for its allegedly high claim denial rate. However, since insurers try to keep these numbers hidden, the true extent of its denials remains uncertain, especially when it comes to private plans.
At the same time, posts on social media have been claiming that UnitedHealthcare’s claim denial rate is the highest in the industry at 32%. This figure comes from the personal finance website Value Penguin, which said it calculated that rate from available in-network data from plans sold on the marketplace.
UnitedHealthcare is a division of UnitedHealth Group and the largest private health insurer in the U.S. with a market cap north of $500 billion. Its biggest business, UnitedHealthcare Employer and Individual, serves more than 29 million Americans through health benefit plans.
Although the Affordable Care Act permits regulators to require insurers to share information on claim denials, the federal government has so far not collected much of this data and has shared even less with the public, according to a 2023 report from ProPublica.
Still, some recent reports show that denials have been on the rise.
In October, a report from the U.S. Senate Permanent Subcommittee on Investigations showed that the nation’s insurers have been using AI-powered tools to deny some claims from holders of Medicare Advantage plans.
Article in its entirety
https://www.yahoo.com/news/no-one-knows-often-health-202056665.html
Inside the shady world of health insurers — and the 1.2 seconds it takes them to deny claims
Key takeaways
Megan Rothbauer faced a $52,531.92 bill for her heart attack treatment due to being taken to an out-of-network hospital by ambulance.
Insurance companies are increasingly using artificial intelligence to deny coverage for medical treatments, leading to widespread coverage denials and lawsuits.
Insurers like UnitedHealthcare and Cigna have faced criticism and legal action for denying claims based on AI algorithms, with allegations of systematic denial of necessary medical procedures.
When Megan Rothbauer suffered a heart attack at work in Wisconsin, she was rushed to hospital in an ambulance.
Given the medical emergency — 30-year-old Ms Rothbauer would end up spending 10 days in a medically induced coma — she was whisked to the nearest available facility.
It proved to be an expensive decision.
The nearest hospital was “not in network”, which left Ms Rothbauer with a $52,531.92 bill for her care.
Had the ambulance driven a further three blocks to Meriter Hospital in Madison, the bill would have been a more modest $1,500.
“I was in a coma. I couldn’t very well wake up and say, ‘Hey, take me to the next hospital’,” she told WISC TV.
“It was the closest hospital to where I had my event, so naturally the ambulance took me there. No fault to them.”
Although the hospital reduced the bill by 90 per cent, the incident laid bare the expensive complexity of the American healthcare system with patients finding that they are uncovered, despite paying hefty premiums, because of their policy’s small print.
In many cases the grounds for refusal hinge on whether the insurer accepts that the treatment is necessary and that decision is increasingly being made by artificial intelligence rather than a physician.
It is leading to coverage being denied on an industrial scale. Much of the work is outsourced, with the biggest operator being EviCore, which is used by insurance companies serving about 100 million people.
According to ProPublica, a non-profit investigative organisation, it uses AI to review — and in many cases turn down — doctors’ requests for prior authorisation, guaranteeing to pay for treatment.
Cynics call it the “dollars for denial” business, with some contracts providing incentives for cutting spending.
The controversy over coverage denials was brought into sharp focus by the gunning down of UnitedHealthcare’s chief executive Brian Thompson in Manhattan.
While no official explanation has been given for the killing, the casings apparently left on the ammunition — “deny”, “defend” and “depose” — are thought to refer to the tactics the insurance industry is accused of using to avoid paying out.
Figures compiled by ValuePenguin, a consumer research site, found that UnitedHealthcare rejected one in three claims last year, about twice the industry average.
‘Illegal scheme’
Cigna, the fourth largest health insurance company in the US, rejected 18 per cent of its claims. It is being sued in a California class action over its mass denials of coverage.
According to the writ, Cigna operated an “illegal scheme to systematically, wrongfully and automatically deny its insureds the thorough, individualised physician review of claims guaranteed to them by California law and, ultimately, the payments for necessary medical procedures owed to them under Cigna’s health insurance policies”.
In response to the writ, Cigna said the lawsuit “appears highly questionable and seems to be based entirely on a poorly reported article that skewed the facts”.
It added: “Cigna uses technology to verify that the codes on some of the most common, low-cost procedures are submitted correctly based on our publicly available coverage policies, and this is done to help expedite physician reimbursement.
“The review takes place after patients have received treatment, so it does not result in any denials of care. If codes are submitted incorrectly, we provide clear guidance on resubmission and how to appeal.”
Frequently, the insurers will deny claims on the basis that the treatment is unnecessary — despite the view of the patient’s own doctor.
According to the California claim, medical reviews were done by computer rather than another physician.
Algorithm used to deny claims
At the heart of the operation was PXDX, an algorithm developed by Cigna that enabled the company’s doctors to “automatically deny payments in batches of hundreds or thousands at a time”.
The system meant claims were rejected without opening files, “leaving thousands of patients effectively without coverage and unexpected bills”.
In just two months in 2022, it is alleged, Cigna’s doctors denied more than 300,000 requests for payment, spending 1.2 seconds “reviewing” each request.
https://www.yahoo.com/news/inside-shady-world-health-insurers-231118443.html
h/t Phennommennonn