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WellPoint Ran a Breast Cancer Algorithm to Target Members for Cancellation of Policies - “Fraud Detection” is the Ca

Posted Apr 22 2010 8:32am

 I’m glad to see “algorithms” finally getting some real attention here as this is what I have talked about for the last couple of years here and how the word “fraud” enters the picture to “score” individuals. It’s what has been happening for a long time.  Things don’t change until the results of the algorithm are regulated.   The computer formula, or algorithm is what places that decision making information on computer screens that nobody seems to question, but that means coverage or not coverage.  Another company ran an “HIV” algorithm that ended up in court. image

It’s all about those “algos”, ask any broker on Wall Street, exactly what they use too.  Also mentioned in this article is the use of 3rd party companies and I have covered that too.  Paying fines doesn’t really help the patients who need care and that have been cancelled when time is of the essence.  In addition I posted with healthcare reform to “expect” additional algorithm use as the word “fraud” is the out they need to begin the scoring processes, whether or not it is real fraud being investigated or not, this is the “catch all” that justifies the use of the algorithmic scores.

Not too long ago I did a radio blog talk show where I gave my feelings on how some of this occurs and you can listen in to the archive here.

Payors Algorithms other Dubious Deals with the MedicalQuack - Blog Talk Radio 3-16-2010

Here’s a post I wrote about “scores” last year and how the word “fraud” leads to algorithmic formulas being used for risk management, in other words if you are going to need major healthcare, you are a risk.

Health Fraud Scores Could Be a Contributing Factor to Medical Claims Being Denied

Also, the very same companies who run these algorithms secure big contracts “to fight fraud”.

Little Progress on Fighting Healthcare Fraud – Look At Who’s Getting the Anti-Fraud Contracts

In this post several dermatology offices lost all their insurer coverage within 5 days, a 3rd party investigation from Ingenix is what is slated as the reason.  It pitted doctors against patients and again the word “fraud’ investigation was the grounds for the investigation.

Skins game With Dermatology Offices in California – All Insurance Carriers Quit Paying For Treatment Within a 5 Day Period

Here’s a post about how to try to combat “scored” health claims, get your data and know what is going on with companies using it too, lots of it is being sold for profit too.  It can be a real challenge for consumers as they have the data and patients have to go dig.  The battle here is difficult as you are fighting with a sword and your are lined up against those who have machine guns, in other words they have the data, reports and have done the algorithmic scoring.

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

We need some better laws, including visual algorithms that show how the formulas are run and their “desired” results. 

Are We Ever Going to Get Some Algorithm Centric Laws Passed for Healthcare!

Health insurers don’t hide this and suggest that algorithms are the answer to their solutions.  Granted we are not going away from running business intelligence and algorithms as the world lives on this today, but having a say on the decisions made is something we all need to be pro-active about.  Read up and realize that this is what causes the end results. 

Health Care Insurers Suggest Algorithms and Business Intelligence solutions to provide health insurance solution

Anything that is not paid out is considered a savings and goes to help pay dividends to share holders.  It almost makes health insurance that is traded on the open exchange on Wall Street really look like a less than honest type of business as shareholders by law come first and this is not a comforting thought when you are at your lowest point and need immediate care.  I realize that this makes many uncomfortable to having to come to the realization that it is modern day technology that is creating all this and it makes me uncomfortable to report it, but get with it and realize it’s not going away and until we get some regulation on how algorithms are used in healthcare and on Wall Street, there’s not a lot going to change. The SEC needs algorithmic centric auditing formulas and the infrastructure to support it.

Remember all these folks have invested heavily in software that allows for the decisions made while our government under prior administrations just sat back and didn’t seem to realize the impact it would have by not keeping up.  This is the reality of what we have today and the current administration is working diligently to correct this and upgrade everywhere, and that includes the FDA too.  The FDA is probably one of the worst hit agencies with being the public eye and their area of responsibility today.  Not only do they have infrastructure issues but they are hit every day with a new challenge with rapid emerging technologies in healthcare and have both going on at once, that is a challenge. 

This is the price we are paying today with analytics and with bank corruption.  Insurance companies and Wall Street invested and have had financial hey days while former administrations were on “snooze control” and even convinced the Bush administration and others on how private industry could do things better.  In essence they did do things better, that is for profit, but not for the average citizen in the US and this is where tech denial and ignorance has brought us today, not a good place to be. 

I have quite a few posts and here’s how you can quickly search for archived articles here, there’s many.  BD

None of the women knew about the others. But besides their similar narratives, they had something else in common: Their health insurance carriers were subsidiaries of WellPoint, which has 33.7 million policyholders -- more than any other health insurance company in the United States.

The women all paid their premiums on time. Before they fell ill, none had any problems with their insurance. Initially, they believed their policies had been canceled by mistake.

They had no idea that WellPoint was using a computer algorithm that automatically targeted them and every other policyholder recently diagnosed with breast cancer. The software triggered an immediate fraud investigation, as the company searched for some pretext to drop their policies, according to government regulators and investigators.

But WellPoint also has specifically targeted women with breast cancer for aggressive investigation with the intent to cancel their policies, federal investigators told Reuters. The revelation is especially striking for a company whose CEO and president, Angela Braly, has earned plaudits for how her company improved the medical care and treatment of other policyholders with breast cancer.

Still, Isaacs feels outgunned: "The industry just has these tremendous financial, legal and political resources that others don't," he said. "In my own state, regulators are often afraid or unwilling to go up against them. It is hard to figure out what the future brings."

The investigation last year by the House Energy and Commerce Committee determined that WellPoint and two of the nation's other largest insurance companies -- UnitedHealth Group Inc and Assurant Health, part of Assurant Inc -- made at least $300 million by improperly rescinding more than 19,000 policyholders over one five-year period.

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