Health knowledge made personal
Join this community!
› Share page:
Search posts:

Baby Denied Medical Coverage–The Pre-Existing Condition Algorithm Complicated by So Called Insufficient Coding - Aetna

Posted Oct 17 2010 12:00pm

This comes right back around to what I have been saying for 2 years again, it’s those algorithms and the general public does not understand this and this story below goes through those motions.  Nobody at Aetna would solve the issue in a way that it could be communicated back to the patient that they were found later to be covering the newborn’s conditions – problem here – those algorithms.

You know we might even be to the point to where internally their own hired employees are experiencing difficulties in explaining this to consumers, right?  All you have to do is watch the video and see how the patient had to get the news media involved to get resolution here.  This is why some of the coding and explanations we see today look kind of stupid as if something on a data table doesn’t match, well who knows what will be shown on the “human” version of an explanation of benefits.  I said a while back that we need to certify some of the algorithms used by insurance companies and put the same efforts into accuracy that we do with creating software for medical records! 

Rules on EHR Certification Should Take Back Seat to Certifying Insurance Algorithms At Present – We Need This First

Here’s another interesting real life case too where even the utilization folks and peer groups at hospitals can’t understand them either. 

Hospitalists, Peer Committees and Utilization Struggle to Comprehend United HealthCare Algorithms

In the video the patient says the customer service folks sound like they are reading from a script and yes there’s a lot of that today all over, I hear it all the time in areas outside of healthcare too, as this is what we design today as business models with recorded conversations to ensure that everything “legal” is covered.  This one had a good ending, but look at what the patient had to go through and again its back to those algorithms used by Wall Street and Health Insurance companies.  I am guessing too the doctor in charge of the patient may be contacted too as well as the hospital on their “coding” issues but this is huge and nobody except a few crooks really do coding that good. 

Congress better line up some good “Algo Men” to stay on top of what is occurring here, otherwise laws quickly become useless without dealing and playing on the same level of intelligence with data.  BD

She's heartbroken because she has endured what no mother should have to endure. While pregnant with twins, she lost one of them at 30 weeks. The other baby, Ki sleigh, was born with serious heart problems.

But Barnes is angry because her insurance company, Aetna, held up paying thousands of dollars in medical charges. The reason? The insurance company said the newborn might have been suffering from a pre-existing condition.

Post a comment
Write a comment: