This comes right back around to what I have been saying for 2 years again, it’s those algorithms and the general public does not understand this and this story below goes through those motions. Nobody at Aetna would solve the issue in a way that it could be communicated back to the patient that they were found later to be covering the newborn’s conditions – problem here – those algorithms.
You know we might even be to the point to where internally their own hired 
employees are experiencing difficulties in explaining this to consumers, right? All you have to do is watch the video and see how the patient had to get the news media involved to get resolution here. This is why some of the coding and explanations we see today look kind of stupid as if something on a data table doesn’t match, well who knows what will be shown on the “human” version of an explanation of benefits. I said a while back that we need to certify some of the algorithms used by insurance companies and put the same efforts into accuracy that we do with creating software for medical records!
Rules on EHR Certification Should Take Back Seat to Certifying Insurance Algorithms At Present – We Need This First
Here’s another interesting real life case too where even the utilization folks and peer groups at hospitals can’t understand them either.
Hospitalists, Peer Committees and Utilization Struggle to Comprehend United HealthCare Algorithms
In the video the patient says the customer service folks sound like they are reading from a script and yes there’s a lot of that today all over, I hear it all the time in areas outside of healthcare too, as this is what we design today as business models with recorded conversations to ensure that everything “legal” is covered. This one had a good ending, but look at what the patient had to go through and again its back to those algorithms used by 
Wall Street and Health Insurance companies. I am guessing too the doctor in charge of the patient may be contacted too as well as the hospital on their “coding” issues but this is huge and nobody except a few crooks really do coding that good.
Congress better line up some good “Algo Men” to stay on top of what is occurring here, otherwise laws quickly become useless without dealing and playing on the same level of intelligence with data. BD
She's heartbroken because she has endured what no mother should have to endure. While pregnant with twins, she lost one of them at 30 weeks. The other baby, Ki sleigh, was born with serious heart problems.
But Barnes is angry because her insurance company, Aetna, held up paying thousands of dollars in medical charges. The reason? The insurance company said the newborn might have been suffering from a pre-existing condition.
And this is but one reason we all need to get out and vote. Heaven forfend that the party of anti-change, those who would have us go back to wax tablets or slates because the mere notion of computers is beyond their ken, regains a majority in either the House or Senate.
ReplyDeleteThe Tea Party is driven upon lies, fear, and ignorance, as is much of politics. Their superior marketing, dedicated TV channel, and figurehead spokes-"id-10-t" have helped them spread their reach beyond their wildest dreams.
Although it has its flaws, PPACA is most Americans' only hope of getting some chance of a fair deal with the insurance superpowers.
Unfortunately, far too many have bought into insurance company marketing: "in good hands", "like a good neighbor", and all that tripe. All insurance companies care about your (or your employer's) money. Their objective is to spend as little of it on taking care of you and your family, and as much as possible on paying their executives high salaries and shareholders high dividends. (The only exceptions to this rule are mutual associations such as USAA, New York Life, and a couple of others, none of which AFAIK offer health insurance.).
We do need "algorithm police". Not only in the insurance industry, but also in the banking and financial sector. There are probably unemployed Wall St computer programmers who could be enlisted in this effort, as well as in cyberdefense efforts. How about it, President Obama: CyberCorps?