Here we go again with contracts and just like your insurance claims, these contract are getting down to details, and wouldn’t surprise me to see this go down to Q-tips one day as the capability is there, just depends on who and how they decide to use imagetheir queries, algorithms and business intelligence.  Humana did luck out and was able to keep their Tri-Care contract with protesting the process it was originally awarded to United Healthcare.  Guess what, it takes a ton more algorithms to figure out if rules were followed and if any procedures were not followed….last I read we have a counter appeal of the appeal from United, and I’m guessing they will come armed with algorithms from their Ingenix (algorithm) subsidiary. 

Humana Keeps Tricare In The South And Back in May of 2010 HealthNet Was Able to Keep the Northeast-Both Companies Filed Appeals

Back to this story it seems we have cost issues here with Blue Cross involved and it looks like they have different rates for different regions, so you don’t like one, well in the world of technology create yourself a “virtual location” so can pay those rates over there <grin>.  I say that in jest but some may just very well write an algorithm to do just that as cost is in the limelight.  In California this week relative to Blue Cross it got even more confusing with 2 regulatory agencies monitoring premium increases, is this a bad deal, 2 regulatory departments for the price of one?  No, being silly here and it doesn’t work that way as the HMO folks are getting steep increases while the other group is not.  image

Blue Cross Rate Increases Spread Between 2 Regulatory Agencies in California-Consumer Watchdog Calls on Governor to Merge Insurance Commissioner & Managed Care Office As HMO Side Rates Go up 16%

The Department of Healthcare and Family Services has decided to go with Blue Cross/Blue Shield of Illinois HMO, a decision Urbana-based Health Alliance is formally protesting. State workers will have to change doctors and hospital affiliations but the laid the amount to be saved at $101 million, fact or fallacy we don’t know really know as other items will pop up tomorrow to affect the dollar studies someone did.  That’s the way the world works today.  The workers say that Blue Cross does not have enough in network facilities. 

Let’s make those members drive…and drive some more…that’s what happens here in California with admissions sometimes too if a patient needs to be re-admitted within 30 days, they drive to another hospital and they get admitted but we have good weather here in California and in the Midwest with nasty winter weather, this makes a big difference, but I don’t think the geeks that count the beans thoughts about this much, that is until they need care.  Perhaps bus tokens were included in compensation <grin>.  In this case the people living in the Illinois area would not see much change, but the increases come in with the folks outside the area, so we shall see how this contract goes.  On top of all of this, the State of Illinois is broke and has difficulty paying their own bills and that has been all over the news, even on 60 minutes in the last few months. 

Smarter use of business intelligence by the folks making this decision could have simulated this scenario ahead of time too, so bean counters maybe not using enough resources here and it’s time for an all out war on algorithms!  Some create accurate results and some create “desired” results and when what you pay for health insurance and the care you get, well more are taking time out to learn about algorithms <grin>.  BD

URBANA -- Humana has joined Health Alliance Medical Plans in filing protests with the state of Illinois on plans to award new insurance contracts for state employees and retirees.

Insurance vendors have until noon today to file protests, according to the state's Chief Procurement Officer Matt Brown.

State employees and retirees are set to begin enrolling in new health plans May 1, but whether an evaluation of the protests and a decision from the Executive Ethics Commission will be done in time for final contracts to be awarded before then is hard to tell. The process can take days or weeks, Brown said

Health Alliance expands protest; Humana joins in |


Post a Comment

Google Analytics Alternative