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Healthcare Reform Bill – Expect “Fraud Algorithm” Use to Increase With “Scoring” the Insured With

Posted Mar 22 2010 9:27am

History was made yesterday with the House passing the Healthcare Reform bill and a lot of the language and what can and can’t be done is changing.  There’s still the one big “loop hole” here called “fraud”.  We need business intelligence software to find and eliminate fraud by all means, but there’s a lot of gray in this area.  What does and will constitute a “fraud” investigation?  You can read more at the link below where one company was brought to terms with finding an individual who had HIV and was cancelled, and this is an old case filed back a number of years ago. image

We also have some of the very same “for profit” companies securing more contracts to prevent “fraud” and when in fact some have been the recipients of fines and court cases for using data bases that were corrupt and calculated the wrong amounts paid to doctors and coverage for patients with out of network customer charges.  This is something to perhaps give some thought to.

The bill does a lot to make qualifying easier and adds some rules that will help individuals get on board, but what about the payout?  Insurers state they do not use these algorithms to deny claims, but rather bring it to the attention of someone to review, and well we all know what that means, delay and whatever else comes down the tubes there to prove that the claim is legitimate, regardless of what type of “score” the algorithms produced.  This is known as a “false positive” where you may have to somewhat prove your authenticity and innocence and the fact that you need care!

Also discussed is the losing proposal of “co-ops”.   We learned that lesson a long time ago in California.  I watched “co-ops” become useless in another industry, logistics, a number of years ago as marketing and sales strategies changed, the participating companies just would come in and cut the rates of the “co-op” to a lesser amount, so there went the pricing benefit.  Also, the way the “co=ops” were formulated in logistics and worth a mention is that they were a “non profit” organization and all members were also responsible for any legal actions and debt too.  Insurers will still have the ability to negotiate rates with those that perhaps are deemed “profitable” and thus some of the companies who participate could become non participants with striking their own deal. 

I did some reading on the web and many small businesses feel it will be cheaper to pay the fines rather than take on the administration of health insurance, as well all know is a huge headache in its present format. When you stop and think about it, this is somewhat the facts that we read in the news with insurers, pay out some money and keep moving on and make changes as they are visible on the surface, key word here “visible”.  Algorithms run 24/7 and provide the information we use to make decisions, as humans, we sleep several hours of the day so we need a Department of Algorithms not only for health insurance but also to give the SEC some real teeth and information abilities to audit. 

“Department of Algorithms – Do We Need One of These to Regulate Upcoming Laws?

Again, I see some big steps in the right direction here, but will it work?  What will insurance companies look like in their business practices in the year 2014?  Will some of these laws be outdated by then, good guess would be “yes” on my part as technology will drive and create loop holes to where they are no longer effective and resolve little. 

How to Fight Algorithmically “Scored” Health Care Claim Denials – Line Up and Deliver Your Own Data

One more small item you will see is the 10% tax on indoor tanning services that is slated for July 1st to kick in, that is if you use one of these facilities.  Raising taxes on Medicare is almost a “no brainer” as additional funds need to come from somewhere in some type of tax in order to keep it alive.  There’s not a lot of room for dispute in that budget.  What I find too that is almost obsolete is the proposed excise tax on high cost insurance plans slated to begin in 2018 and I wonder if the plans will even exist by that time or if perhaps that will just the norm.  Again, something to think about as things are changing rapidly. 

With requiring 85% of premium money to be spent on healthcare by insurers, all I can say to that is “get those audit algorithms in place” as both government image insurance agencies and the SEC will need them as there’s no use in doing battle with swords when the other folks have machine guns, a reality that so many are slow to admit and grasp, it is what it is. Tech denial and acknowledging the existence of the business tools used in today’s world is one of the biggest hurdles we have and it goes back to lack of education and leaders who are pretty much “non-participants” who continue to embellish the old paradigms of how the world used to be. 

It is beyond me how we can even think that these 2 worlds of healthcare and “for profit” insurance organizations can truly work together for a common goal as it just simply does not exist, and keep in mind we live in a world of change so technology is going to continue to evolve at both ends of the stick here and I predict even within a year there will be monumental changes required and outdated laws requiring major updates, but we might still be stuck on this bill as the technology clock continues to tick and waits for no one with a result of  little or nothing getting accomplished, tech denial and non participation will do us in while the “fat cats” get fatter.  BD   

Millions of Californians who don't have health insurance or can't afford their current coverage will feel the impact of the historic health care overhaul almost immediately.

From uninsured 20-somethings to seniors struggling to pay for prescriptions, the changes that kick in this year will touch a broad swath of people.

Small businesses that offer insurance to employees will get tax credits. Insurers no longer will be able to place lifetime dollar limits on benefits or rescind coverage, except in cases of fraud. Parents will be able to keep children on their health plans up to age 26. And people with existing health conditions can purchase coverage from a federally subsidized pool.

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