Stop and think a minute, if this was not such a big issue, don’t you think you would have better directories?  This not only impacts Medicare but all polices anymore as constant changes made with quantitative analytics says “one minute you’re in and next minute you’re out”.  We have been watching this for quite a while now and with connected data the metrics chosen and utilized for such listings get more complex all the time.  As matter of fact, insurers have banked on complexities for profit and perhaps now some of their own methodologies are coming back toimage haunt as they might be so complex that they are having issues in house themselves. 

Here Come the Dead Doctors Again Located In Flawed Directories–Now It’s From Insurance Companies Who Can’t Produce Semi Accurate Listings And They Pay These People…

I wrote a year or so back about insurance companies driving themselves off a cliff with “data lakes” and it’s partly an addition process or what I have called “Stat Rat Fever” with sometimes over working risk factors to where everything almost comes to a stand still if you will, until a human steps in for some of the decision processes.  I sit there and watch some of the same in other processes to where the “I wants” with writing code, queries, etc. can’t match up as there’s money and time involved here. 

Health Insurance Business Is Driving Itself Off a cliff & Doesn’t Know When to Stop With Collecting, Analyzing and Processing Non Relevant Data With Little Or No Impact On Giving Good Care..

This is also worth repeating about the design of models and policies with insurers and again it relates to math so it’s really hard to find any healthcare news that tells you what’s going on.  Insurers are using armies of quants, just like the banks have used for years for their business plans, and yes, this is business models in healthcare by the algorithm.  All you have to do is look at the job listings for health insurers and you’ll have tons of listings in your face for quantitative analysts..aka quants.  You can’t wish and hope when you have an coded executed algorithm making decisions.  It’s good to have faith but don’t be stupid and bet on “faith” outdoing an algorithmic process, as it won’t happen.  They do as they are programmed to do, seek out other algorithms and interact with them and so on, just look at the stock market, that’s all that goes on there for big money of course.  Same thing happens with healthcare.  Watch the 4 videos in the footer for a good start on how this works if you like.

Data Scientists/Quants in the Health Insurance Business–Modeling Beyond the Speed and Capabilities of Humans To Keep Up With The Affordable Care Act–Turning Into A World of Killer Algorithms That We All Hate..

With the introduction of quants in areas of healthcare they can get their projections down to how each policy, network, etc. impacts stock price and there’s a bunch of that going on.  I know it’s not really ethical but you can choose the “Algo Fairy” world, which I call the Sebelius Syndrome or reality.  This brings me back around to another recent post and it fits perfectly here, as operation perception deception with tossing fines will fix this problem, not going to happen until the models get changed that insurers are currently using.  Being they can see the impact on stock prices, changes for consumers are on the back burner as we all know stock prices and investors come first.  It’s not supposed to be that way, but it is.  imageRemember Healthcare.Gov and all the changes and coding?  It’s same deal here, models and math needed to make systems work.

Operation “Perception-Deception” Into Full Swing in the US, With Killer Algorithms, Algo Fairies, Algo Duping, The Grays, and Of Course, Flags As Consumers Confuse Virtual World Values With the Real World…

So anyway keep on reading, maybe fines will be levied but don’t look for a real fix any time soon as complexities are here with time and computer code.  Actually too back in 2009 when Sebelius was just nominated I pretty much said such that insurance math models and use of computer code would run her over and she would be duped, no clue on what was waiting.     Here we are today as you know the rest was history with the whacked out perceptions we all have to live through over and over while she was at the helm.  So again, fines..good luck as that can’t push models and code to be written any faster as when you look at this from a business standpoint, insurers would have had it done by now but again stock prices and investor relations top consumer needs and desires here once again. 

CMS might want to entertain something else besides fines to govern as this doesn’t work anymore.  Complexities are there and working both for and against you.  Some of the predictive analytics used today need a complete hosing over as well, as we have a lot of “flawed data” and proof of concepts that don’t work the way people do creating a bit of havoc, so when it comes to technology being able to instantly meet the demands we all have today, sometimes it’s just not there.  Enter the world of Secret Scoring of Doctors, this is what impacts the listings.   BD

“The Secret scoring of America’s Physicians” - Algorithmic Math Models For Insurance Network Contractual Exclusions, Relating to MDs Who See Medicare Advantage Patients..

The CMS plans to more closely monitor Medicare Advantage insurers' provider networks and may fine or otherwise sanction plans that don't accurately show which doctors are available at in-network prices.
New provisions related to provider networks and directories were included in the agency's proposed 2016 rate notice (PDF), released last Friday. Medicare Advantage payments will drop 0.95% on average, but when accounting for higher risk scores based on coding patterns, health plans on average will receive a 1.05% increase.

The CMS said in the notice that it “has become aware of a range of issues with online provider directories.” Medicare beneficiaries have complained of directories in which providers no longer contract with an Advantage plan, or directories still include in-network doctors who have retired, moved locations or died. Other online provider lists do not indicate if doctors refuse to take new patients.


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