As the Affordable Care Act keeps rolling out new surprises and unexpected changes for all this has been one that is becoming yet more controversial.  What is even more bothersome is the lack of communication that really is bringing this to the forefront.  Perhaps United is trying to figure out a line of human conversation to let the doctors and patients know that theirimage math models tell them this loses money for them I guess.  You do have to realize in the world we live in today that real time analytics are used by all insurers and the government doesn’t seem to embrace this fact that math models and subsequent executing algorithms are doing the work.  That’s what you have here as executives look at the numbers and then it goes to the IT department to create a model to execute the task and get the letters out and out they roll.  Sometimes even internally models are not accurate and mistakes get made and I have blogged about a few of those with instances with other insurance companies as well.  Letters in the past with models created have gone out in error telling doctors and patients that they are no longer in network, link below.  Be sure and read all the link in this post if you can, it will help make a lot more sense of this post.

Insurance Company “In-Network” Complex Erroneous Algorithms Continue to Wreak Havoc With Patients and Doctors When It Comes To Coverage and Purchasing Insurance–Time to Begin “Sniffing Some Data”, To Include Labeling And Identifying Killer Algorithms

This is what I call “Attacks of the Killer Algorithms” and they happen around us everyday and now with the data selling epidemic present (United also sells a lot of data with subsidiaries)  in the US, the amount of flawed data is on the rise as well, not all is flawed but enough of it is and this is normally where “access” is becoming a big issue and problem…the Algo Duping page videos will bring you up to speed on how this works not only with insurance but also in the financial areas as nobody is holding anyone accountable for their models and thus this is a good time to become a skeptic when you need to be as modelers play a greater role today than ever.  Pay particular attention to the Quants documentary on the Algo Duping page as insurance companies use Quants too and just look at the classifieds, they are looking to add tons of them all across the US.   In the post below I wrote about United stating that CMS has known for months about the changes upcoming, but I wonder did they understand how the math models would play out once executed?  How many at CMS are aware and how have they been notified, just general questions one might inquire about.  I am guessing this is the path to be taken by the Connecticut Attorney General.

United Healthcare Medicare Advantage Doctor Firing Moves On Into Ohio, New York, And Maybe More? CMS Has Known For Months About the Changes And Is Monitoring….United’s Cost Algorithm Says…You’re Out the Door

What we are ending up with for all of Obamacare is the constant rise and fall of the machines, up one day and down the next as business intelligence models used by insurers change the rules all the time but at the same time comply with verbiage in the law..it’s a mess and I might add it could be a time for true digital laws that include IT Infrastructure rules to be followed in the law as with the ACA it was up to Nancy DeParle and her group after the law was passed to translate all of this to the tech side. 

Obamacare: The Continuous Rise and Fall Of The Machines With Complex Insurance Math Models Resulting In Spasmodic, Executing “Killer Algorithms”–And Gov Can’t Model…

So we shall see how this goes and what the next step is and if this is the way it’s going to work with the math models and algorithms and the machines making such decisions without any human conversations or explanations offered.  Again business math models are what allows all of this to take place and sometimes they go on for years, like the AMA lawsuit to where doctors and patients were paid short for 15 years until someone catches the numbers and the formulas not being correctimage and it impacted other insurers using the same model with lawsuits.  With all the recent acquisitions and mergers in the last couple of years, the number of insurance company owned subsidiaries has grown a lot and there’s more to health insurance today than just premiums and claims and a lot of action takes place with company  subsidiaries.

So what is HHS going to do?  Right now they are very wrapped up in the Healthcare.Gov website for sure and the CIO of CMS is quitting.  Of course we have all read about the involvement of United with their QSSI subsidiary there being the head contractor now with using the same technology CMS is using to look for fraud with payments, a big data cruncher from Cray Computers.  This is the same technology being used with the Federal Hub to facilitate “in memory” technologies to send the 834 data formats to insurers.  You can read more on that at the link below as there are tons of engineers working on both the Hub and the entire Healthcare.Gov site now, writing a ton of code for apps and trying to make an XML schema work where java is the rule right now with the enterprise, so engineering questions galore one might say.  This is a hard hat area so just a little warning on the link below.

Fixing the HIPAA Compliant “834” Insurance Transaction Format Still Work In Progress for Healthcare.Gov With Contractor QSSI–This Is The Format that Sends Application Data to Health Insurers…

If you were not aware, CMS turned the tables and gave the Medicareimage Advantage insurers a raise next year of 3.3 instead of a planned cut so there’s lots of room there for discussion s this number gets churned into the math models used by insurers to forecast and examine profitability in all their affected business sectors and you do have to remember the corporation sells a lot of software services and consulting too besides just health insurance with their Optum business unit

It will be interesting to follow this along and see if we get any “humans” to come to table here or to see if the “machines” with math models and executing algorithms that send letters are going to be the future here with decision making for sure.  Again take a look at the Algo Duping page when you have time to watch some videos and you will get an education on how IT Infrastructures control and rule everything today, but as you are seeing the models don’t always play in the real world as anticipated when humans being get hurt.  The Quant documentary said that well with the quote from Mike Osinski who wrote the sub prime software abused by banks, “you can do anything with software”, so keep that thought and be a skeptic when you need to be.  BD


HARTFORD, Conn. — Connecticut Attorney General George Jepsen asked federal regulators Wednesday to "aggressively scrutinize" what he calls UnitedHealthcare's decision to drop a large number of doctors from its Medicare Advantage Plan network in the state.

Jepsen sent a letter to the federal Department of Health and Human Services asking for the review, saying he is concerned about the potential harm to patients. He said the insurer also is dumping doctors in Medicare Advantage networks in other states.

He said UnitedHealthcare is refusing to release information about the doctor terminations, including the number of physicians and patients who will be affected. Some doctors in Connecticut have already received termination notices, Jepsen said.

Jepsen said the insurer has yet to notify affected patients so they can take action before open enrollment in insurance plans closes Dec. 7. He asked federal regulators to consider extending the enrollment period.

http://www.startribune.com/politics/national/230880651.html

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