Posted on 11/19/2023 7:37:12 PM PST by anthropocene_x
Although artificial intelligence is in its early stages in the health-care industry, it already has triggered legal action. A class-action lawsuit filed on Tuesday alleges that UnitedHealthcare used an artificial intelligence algorithm to wrongfully deny coverage under Medicare Advantage health policies.
The insurer made health-care determinations using its nH Predict algorithm, overrode physician recommendations, and denied elderly patients’ claims for stays in extended-care facilities, according to the lawsuit in the U.S. District Court for the District of Minnesota. The plaintiffs also alleged the technology lets the company “aggressively deny coverage, because they know they will not be held accountable for wrongful denials.”
When these coverage denials are appealed to federal administrative law judges, about 90% are reversed, demonstrating the “blatant inaccuracy” of the nH Predict algorithm and attesting to the AI’s ”90% error rate,” the complaint said.
UnitedHealthcare was “effectively using AI to throw the elderly — our parents or grandparents — out onto the street,” said Ryan Clarkson, managing partner of Clarkson Law Firm. “Defendants bank on the patients’ impaired conditions, lack of knowledge and lack of resources to appeal the erroneous AI-powered decisions,” the complaint said.
(Excerpt) Read more at benefitspro.com ...
UnitedHealthcare was denying 90% of initial claims before AI, All they did was take the human out of the loop.
The whole thing is a crap shoot. I have regular Medicare and can’t get them to cover blood work. Friends of ours with similar medical conditions, never have a problem getting blood work covered.
AI means no one is responsible, move on, perfect for the rats and all those in control
Doctors don’t advocate for patients AT ALL anymore— if pre certification is denied. It’s up to patient who often does not have enough knowledge to challenge, is too sick old or infirm, or doesn’t have the time or energy to keep fighting the system. Health insurance for many is a joke- it is working when few people are able to fight for their rights and most requests are denied. I would love to see no health insurance and true pay as you go at real life competitive pricing with tax deferred health savings accounts to use to pay. I refuse to engage system unless absolutely have to because I simply don’t have the mental energy to keep fighting the system that wants me sick. So if I absolutely need something I pay for it. I dread upcoming medicare bullshit that penalizes you for not using it
Another reason to avoid Medicare Advantage plans.
AND United Healthcare.
I believe the payment problems are fewer with a traditional medicare and a supplemental because medicare pays first.
What should I have instead? I had United Health Medicare Advantage last year and it worked fine. What do you recommend?
United has been using AI for years to not pay or delay payments to providers
Robit: “Destroy all humans, destroy all humans.”
“ I believe the payment problems are fewer with a traditional medicare and a supplemental because medicare pays first.”
True. I had few problems with BC/BS medicare advantage plans, but Dr’s had trouble getting some procedures approved. When I moved to Texas, my Cardiologist recommended a supplement plan. If medicare pays anything, the plan pays 100% of the difference. No referrals, and coverage anywhere in the US. More expensive, and doesn’t cover dental, but well worth it. We are insured by Aetna, and have had zero problems for 5 years, and too many expensive procedures and hospital stays to mention. Just the copays with an advantage plan would be more than the premiums I pay.
The U.S. health care system is broken and needs fixing. In the U.S., we spend on average $12,914 per person per year on health care, whereas that figure in the other comparable countries is $6,125. That comes to $6,800 more per person—and if you multiply that by 334 million Americans, we are spending an excess $2.3 trillion a year on health care—and getting poorer results. The U.S. spends 96% of the biomedical research money on medical drugs and devices, and only four percent on how to make the population healthier and how to deliver health care more efficiently and effectively. In 1991, 80% of pharmaceutical research was taking place in university medical centers, by 2004 it was only 26%, thus 74% is being done at for-profit research companies. They own the data and control the publishing of it. In 2008, the average annual price of a new drug in the U.S. was $2,115; by 2021, this annual average price of a new drug had risen to $180,000. Think about that. The greatest bipartisan agreement among our political leaders in Congress is that it is fine for them to accept large contributions from drug companies. Huge amounts of money flow about equally to Democrats and Republicans (https://imprimis.hillsdale.edu/americas-broken-health-care-diagnosis-and-prescription/ Assessed 11 Nov 2023).
There is no difference between Big Medicine, Big Pharma, Big Tech, Big Military and Big Corporations. All of them create levers of power, which they help design, and then control, to coerce people to do what is far too often not in their best interests. Today they have melded with governments to procure more power to destroy competition and alternative thinking.
• Patients whose medical claims are denied by insurers have the right to appeal the decision. However, despite a clean-up of the rules by the Affordable Care Act (ACA) aimed at making appeals easier, a decade on only about 0.2% of denials are appealed by consumers (Appeals Against Medical Insurance Denials Underused, Says Lawyer - Medscape - Mar 28, 2022). Advocates say that approximately 50% of appeals are successful, so patients are missing out. The most common route to winning the appeal is for the healthcare team to provide evidence of “medical necessity.” Healthcare software company Change Healthcare estimated that US hospitals spent $8.6 billion in administrative costs to appeal denied claims.
entropy12 is a rather surprising screen name for someone doing everything he can to stay healthy.
My main gripe with Advantage, aside from them pushing people out of therapy early, is in many states if you want to switch back to original Medicare you need underwriting, which you many not pass...so you are locked out.
It was the one thing I never understood how to compute during my thermodynamics courses in engineering college.
The state of medicine is truly amazing, many diagnoses can be very confusing though so fortunately we have the insurance companies to help us understand what we really need.
My physician had prescribed something for me. He was convinced that the problem would be chronic and require daily intervention.
The insurance company decided that it should only be a real problem and be fully covered under the plan in January, April, July, and October. They also explained that it shouldnt be a real problem requiring only partial coverage in February, May, August, or November. Though my physician had been right for some of those months, I shouldnt need it full time and therefor wouldnt be covered at all March, June, September, or December.
Now that all may be obvious to you, me, and the insurance company, the trick is just finding the physician that can convince the condition to follow the right schedule.
Yes. Go with a Medicare Supplement instead.
With Medicare plus a Supplement: You and your doctor choose your care.
With Advantage: your plan chooses you care. Not you and your doctor.
With Medicare plus a Supplement: No referrals needed
With Advantage: Highly restrictive referrals
With Medicare plus a Supplement: Many doctors to choose from
With Advantage: Limites specialists available
With Medicare plus a Supplement: No lab fees
With Advantage: High MRI & Outpatient Fees.
With Advantage: Upfront Copay for ER Visits
With Medicare plus a Supplement: No pre-authorizations.
With Medicare plus a Supplement: No hidden costs.
With Advantage: High out-of-pocket costs. 56,700 a year for most plans for infusion costs - those used for cancer, rheumatology, gastroenterology, neurology, dermatology.
With Medicare plus a Supplement: Many supplements to choose from to help with costs.
With Advantage: You cannot have a supplement.
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I recommend regular Medicare augmented with one of the regular Medicare Supplement Insurance (Medigap) policies. My Medigap is Plan F, which is now grandfathered. Plan G is still available in California and is almost as good as Plan F. I don't know what Medigap plans are available in Kansas.
Yes...the dirty little secret of infusion costs & the cancer costs not covered under Advantage are frightening.
Oh, I am glad I read the rest of your post before responding.
In my defense I had a encounter with a poster, who, in all seriousness, was arguing for the insurance companies being the guardians of our health because they held doctors accountable.
Hope you managed to get the insurance company to see reason.
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