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Health Insurers Spending Millions to Update IT Infrastructure to Comply With Federal Laws–New Software, Algorithms and Oth

Posted Sep 24 2010 11:32am

This is an expense where there’s no getting around the need as new algorithms will be needed in order to assist customer service individuals and agents to give you the correct answers and information.  After all we all know that any information you image received today via a question that is asked comes right off the computer screen.  The algorithms for enrollment, for example on children need to be changed so when an agent is taking information to qualify an individuals, those updated decision making algorithms will appear correctly on the computer screens and calculate additional information as needed. 

Companies like United Health Group I’m sure are maybe ahead of the game here as they own a technology company that built it’s business on the algorithms and software they provide as with subsidiaries too they are also able to mine and combine data from other available sources.  This article even confirms this as it sates United did their work in advance.  Algorithms will also need to be adjusted to allow claims to go through on office visits that are preventive to where there is no longer a co-pay.  This is all an automated process today and there are not big rooms of people looking at paper for the most part.  In addition, Ingenix is preparing to also sell you more software on how to code better if you are a healthcare provider.

Also don’t forget to get your claims in for the under payment legal suit settlement that was based around the Ingenix algorithms used for customary fees for a number of years.  It’s all about those “algorithms” or formulas used to calculate accurate or “desired” results that we have to deal with. 

Blue Cross had some challenging times too with getting their algorithms in line to comply and their issue in California was the amount of an increase they were going to provide to consumers.

HHS to California Blue Cross – Bring Your Algorithms to Washington And Explain

The connecting of data too goes beyond just the commercial end as some Medicare contractors are owned by insurance companies too, so we have more data to bring together here too.  At the link below a reader of the Medical Quack took a lot of time to provide some history and information on how some of this works so check out the comments too. image

In summary as you can see, once new laws go into place, it is a lot of work to make sure all the data flows correctly and consumers are given accurate information.  We of course don’t see how the processes are done since this is all outsourced if you will and not housed internally with government software, so how they do all of this to remain compliant is that we need to somewhat take their word and do audits to make sure everything is correct. 

One other note that was kind of disheartening too was the fact that the Senate cut “cloud computing” from the budget, so what you have here is basically the idea that you are going to get your Cheerios with web services but without the cloud, you have no milk to pour on so laws like this make it even harder at times for our government to move quicker in many areas of IT, and Health IT in particular.  image

Senate Cuts Cloud Services From Budget That Would Allow for Data Center and IT Infrastructure Consolidation–Back to the 8 Track Tapes Next?

Anyway, just be prepared and know that it’s the mathematical processes with computers that need to be in place for all of this to happen and the information you are given depends on it.  BD 

Sept. 24--Health insurers are spending tens of millions, are overhauling health plans they offer and are reconfiguring the technology used to assist customers to comply with federal health reform laws passed in March.

Thursday was a major deadline, ushering in new mandated benefits for consumers. Insurers now pay for the full cost of preventive services such as mammograms and colonoscopies. They also must accept children regardless of their medical conditions, as well as waive the cash spending limits they had on customers for each year and for each person's lifetime.

"The removal of cost share on preventive services was a major change that impacted a lot of plans," said ConnectiCare spokesman Stephen Jewett. "That's a broad one. ... I suspect it impacted a lot of different plans at a lot of different insurance companies."

The public's first glimpse of changes related to reform was a batch of proposed rates announced in recent weeks -- increases of much more than 20 percent in some cases -- for health plans sold directly to individuals and families. Those rates take effect Oct. 1, and primarily affect new customers to the individual market. Rates for 2011 are expected in October and November.

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