Congress Grills the Health Insurance Executives Today – They Didn’t Know Their Algorithms

The video starts out with talking about a case of “claimed denied” with a HMO, Regal. That hit a bit close to home as I used to help MDs and that was one of the HMO carriers. Not Regal, but other carriers had a few years back this “floating patient” syndrome with EOBs and the capitation lists. Patients were still eligible, no change with insurance, but were floaters, appeared some months and disappeared on other months, and would make some monthly statements pay the doctors short. Fixed that one with some SQL queries and had the MDs start getting their statements on spreadsheets instead of huge paper files so the data could be imported and analyzed into a small custom data base to figure out who was short that month and the dollar amounts as well as create individual listings to review each month and compare and the “floating patient” syndrome seemed to disappear in time once confronted.

From what I could see in this video, none of them knew how to explain their “algorithms”, which brings me back around to a suggestion, we certify software for EMRs to make sure they are correct and integrate properly, why not certify Insurance Carriers and their algorithmic software? I have said this in “jest” to quite a few people, even a couple who work in the insurance business and surprisingly everyone agrees with a distinct array of enthusiasm that it is a missing link and why not, the other side gets certified so why do half the job. BD

(CBS) It was a rare sight - leaders from the nation's largest insurers sitting down to get grilled.
Members of Congress pushed the top brass from Cigna, Humana, Aetna and more to explain why premiums have shot up 131 percent in the past 10 years - more than triple the average wage increase, reports CBS News correspondent Nancy Cordes.
Lawmakers accused insurers of putting profits before customers - customers like 2-year-old Sidney Gendernalik from Los Angeles, who suffers from a rare syndrome known as infant spasms. Her father, Mark Gendernalik, said that Sidney can have up to 50 seizures a day.

Congress Questions Insurance Executives - CBS Evening News - CBS News