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Health Insurance Underwriting procedures – Data Mining to Cherry Pick and some are listed on the Web

Posted Mar 29 2009 3:49pm

With the Ingenix story in the news the last few weeks, there are a couple of other data sources out there that are used to mine your medication and health records data. Part of the reason that is is all coming to light is due to the fact the data is now trying to be used in a constructive basis, for good healthcare and with all of this comes out what’s being going on somewhat behind the scenes for years.  The data bases have been sold for years for risk management purposes and do not fall under HIPAA.

Milliman's Intelliscript or Ingenix Medpoint are the 2 big data miners that find out when you apply for health insurance what your medication rap sheet has been for the last 5 years.  By applying for insurance, you sign a release to allow the companies to mine the information, no signature and permission, then probably no insurance will be written for you; however, the release you sign is HIPAA compliant, whatever that constitutes at this point.  

It was not until recently when the FTC investigated and stated that both companies need to provide a copy of the analysis they provided to the insurer so you could see how your medications were analyzed and if you were in the “red”, “yellow’ or “green” zone, just like a stoplight.  Of course anyone taking cancer drugs sticks out like a sore thumb, so anyone taking some of the drugs will be scrutinized.  In today’s economy, work for a company that went bankrupt, no cobra available and you happened to either have breast or prostate cancer in the last 5 years, WellPoint says you are out of luck.   This one statement below says everything that is wrong with the health care business, no focus on wellness, just cold hard calculations that say “we don’t care”.

“From a business standpoint, it makes no sense for an insurer to sell a plan with a $200 monthly premium if the company knows that the consumer is taking medications that cost $400 every six months, industry experts said.”

Nearly 1 in 6 Online Health Insurance Shoppers Are Uninsurable

What if you are taking a medication for an off label diagnosis and treatment plan, try and explain that one!  It may be helping your condition, but by the standards set up, there’s no room for that in the analysis process, you are still grouped in the “labeled” section, which may be much worse than your condition really is.

In the real world today we are finding additional uses for drugs that we didn’t know about before, and there’s information almost weekly coming out on this topic, but in the risk management world it doesn’t appear to do you any good.  Now there’s a new one on the street that wants to do the same with labs, Realtime Solutions and begin aggregating this data as well.  Shoot, could one abnormal pap smear knock you out of the race here?   

“HIPAA does not give the Department of Health and Human Services the ability to directly investigate or hold accountable entities, such as pharmacy benefit managers or companies such as Ingenix and Milliman, who are not covered by HIPAA.”

So now that we have found a good and healthy resource that can be used for medical records, can we stop the business intelligence data mining of pharmacy benefit managers used behind the scenes to deny?  De-identification is not good enough today either in many areas as that has also been in the news of late about how simple matches are being made with queries too.  Pay cash, buy $4.00 generics and don’t use any of the retail store discount cards is about the only way you can avoid getting in the books.   Your doctor will get hit up on why you are not taking your meds, but that’s ok, most of them are used to it by now anyway, they don’t like it, but it’s something they hear on their evaluations relative to pay for performance when those statistics come in, from the same data bases no less.    

The search for John Doe – Who’s running the queries (Algorithms) and wants to know

There is the MIB that is also another resource used and if there are errors, they need to be corrected in files as well.  I have talked a couple of individuals that have fought for years to get items corrected that are causing them to not be eligible for insurance, one an off label drug use and another from erroneous records submitted years ago and the doctor is now dead, so no chance of getting things rectified there.

What is the MIB - Medical Insurance Bureau - and how does it affect qualifying for insurance?
How can insurance companies find out if you have a pre-existing condition - The MIB
Health Insurers Show 14 Percent Increase in Use of MIB Data

The video below shows one woman’s plight on trying to get her file at the MIB corrected to no avail.  There are errors everywhere and if we don’t have the opportunity to correct them, the errors are shared in thousands of other data bases too. 

Well this is the summary for today relative to business intelligence and privacy.   Business intelligence here sure seems to have the upper hand and relates to cost only and hopefully we can get some better business intelligence awareness in Congress soon.  Perhaps it’s about time we quit putting price tags on illness and focus more with the responsibility of finding cures.  I think we have about hit bottom here with passing the buck on who’s going to pay and what.  Time for some new business models that don't’ dissect each individual on their current health at all points, education instead of greed would go along way.  BD  

Trying to buy health insurance on your own and have gallstones? You'll automatically be denied coverage. Rheumatoid arthritis? Automatic denial. Severe acne? Probably denied. Do you take metformin, a popular drug for diabetes? Denied. Use the anti-clotting drug Plavix or Seroquel, prescribed for anti-psychotic or sleep problems? Forget about it.

This confidential information on some insurers' practices is available on the Web — if you know where to look. image

What's more, you can discover that if you lie to an insurer about your medical history and drug use, you will be rejected because data-mining companies sell information to insurers about your health, including detailed usage of prescription drugs.

For cancer, the key is how patients have been doing in remission. Wellpoint, a national insurer, rejects applicants who have had breast or prostate cancer within the past five years. With other types of cancer, 10 years must have passed. Assurant Health, based in Milwaukee, rejects most patients whose cancer has not been in remission for at least eight years.  If one were taking  the highest dose of the cholesterol-reducing drug Zocor for 18 months, they sell this as a plus for not needing a blood test, well those are pretty much standard today. 

Other reasons for automatic denial by various companies: alcohol-related problems of people who have not been abstinent for at least six years, chronic bronchitis, severe migraines, and a cardiac pacemaker installed within the last two years.

Some insurers will automatically reject applicants who are using certain prescription drugs. Wellpoint denies anyone who within the past year has taken Abilify and Zyprexa for mental disorders as well as Neupogen, which is used to treat the side effects of chemotherapy. Vista lists the anticoagulant Warfarin and the pain medication Oxycontin. Both companies list insulin.

Intelliscript and Medpoint do computerized searches of a person's drug use, gleaned from pharmacy benefits managers and other databases. The two companies say they comply with privacy laws. ''Ingenix requires each Medpoint client to obtain the authorization of the individual applicant or insured person,'' said Ingenix spokeswoman Karin Olson.

Last year, the Federal Trade Commission accused both companies of violating the Fair Credit Reporting Act by not offering to provide consumers with information about them. The companies agreed to settlements in which they promised to let people see their personal information.

Insurers shun those taking certain meds

Related Reading:

The AMA and the California Medical Association file legal suit – WellPoint and Ingenix
Ingenix Publishes Episode Treatment Groups Methodology – Recreating themselves?
The search for John Doe – Who’s running the queries (Algorithms) and wants to know
Andrew Cuomo – You Have to Like This Guy – Healthcare Reform
Prescriptions risk score used to deny health insurance
Cigna and Aetna face lawsuit – AMA joining the the cause on payment issues
Prescription Data Used To Assess Consumers - No Privacy Unless You Pay Cash...
Americans with Cancer and Insurance Still not able to afford treatments
What is the MIB - Medical Insurance Bureau - and how does it affect qualifying for insurance?
Health Insurance Reserves – How much is in the till, could it be 1 or 2 trillion nationwide?
Health Care Insurers Suggest Algorithms and Business Intelligence solutions to provide health insurance solution
Health insurer accused of overcharging millions – United Health Care/Oxford Insurance 50 Million Fine
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