Here we go again the “too big to fail” health insurer at it again.  Read some of this and see why even the doctors have trouble knowing they are in network, much less patients trying to figure all of this out.  Insurers make money by making contract complex and this is no exception.  Doctors don’t even have a say here as United and their cost algorithms are calling the shots.  So if you hear you can keep your doctor, well you can’t blame this one on Obamacare, this one is all the work of United this time.  They have this algorithmic scoring system that uses some proprietary formulas and what it is, we don’t know.  Do they tell the doctors, probably not as they would have to go in depth and explain how their algorithms work. 

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

Doctors don’t have an opt out option on the W500 plan, they have to terminate their underlying PPO agreements.  Now who in the heck can keep track of all of this?  United can’t keep track of what doctors they fire sometimes as they went out and bid and won a Medicare Advantage contract in Maryland, only to find out they had to give it back as they had already fired all the doctors in the area who would be seeing patients.  By the way what does the NHS and Medicare now have in common?  They are both run by former United Healthcare Executives who do everything by the algo. 

Howard County School Board in Maryland Rescinds United Healthcare Contract As Retirees Didn’t Want the Medicare Advantage Plan, No Providers Available..

They have balls I must say and when you look at all of this, reflect back on a decision made by the Supreme Court that allows doctors to group to litigate and this example here might be a good reason why the court denied United for years trying to fight that, as in the past it was always one doctor up against the big corporation. 

US supreme court Rules Physicians Can Work As A Group To Fight Unfair Business Practices of Health Insurers–Victory Over United Healthcare (Oxford Subsidiary)–Context Once Again With Contracts

This is what you get when insurers hire Quants to add to the Actuaries when modeling policies.  The Actuaries look for the long term goals, while the Quants come in with models that look for the short term and add the impact on their stock.  BD

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..

Anyway this is what’s going on with insurers and some of their Quants may in fact have been employed by the likes of high frequency trading firms and banks, so see how they want to push humans through a mechanism that resembles a stock exchange with their models?  The only problem is we are human and can’t change that fast and keep up, so something is going to have to give pretty soon.  BD

United Healthcare has advised CMA that its new Core plan, which will be marketed to employer groups seeking lower premiums and used for its potential future exchange product, will access a significantly narrowed network of approximately 45 percent of UHC’s current PPO provider network.

UHC plans to send amendment notices to physicians selected to participate in the Core network sometime in March. UHC also reports that the terms of each physician’s United Healthcare base contract will apply to the new Core plan.

According to United Healthcare, physicians were selected to participate in the Core plan network based on their performance in several cost containment areas, including referrals to out-of-network physicians, average episodic cost of care and overall contractual fee-schedule reimbursement during calendar years 2012-2013. Although the cost criteria for the Core program mirrors that of the United Premium Designation program, UHC stated that the two evaluations are unrelated and that physicians achieving Premium Designation status may not necessarily be included in the narrow Core product network.

The amendment for the W500 product does not allow physicians to opt out of just the new product; rather, physicians would have to terminate their underlying United Healthcare PPO agreements in order to opt out of the new Core plan network. Physicians will have 45 days from the date of receipt of the amendment notice to notify UHC if they wish to terminate their participation prior to the April 20 effective date.


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