This has been a long case and just goes to show you how far back insurers have been using sophisticated and non sophisticated algorithms to cut payment to doctors.  I saw this in the early HMO days in California with what we called the “floating patients” on their capitation payments as doctors were always getting ripped on their payments way back.  I have been there and seen that one as it’s been goingimage on for years.  All you have to do is write a little code to run or not run and bingo the parameters are set to allow and disallow in less than a second. 

I had to chuckle a little bit about the lead in line to this story as we have this great discovery statement “it could be a computer modifying your health insurance claim”..well it’s being going on for years and is nothing new.  Why do people still picture health care claims all manually being handled by people?  I don’t know, has not been that way for years. 

This case is a physicians group who sued and what’s funny is you hear United bragging all the time about their web services and software and here doctors had to sue to get it improved so we do indeed have “selective” software interest and those that make money for the company come first, such as a lot of the apps that mine and record your data so United Behavioral, a big subsidiary of the company in northern California can score and sell you all over the place and create a “behavioral profile” on you.  As a matter of fact, I don’t know if they combine the scoring from the voice algorithms that record and analyze your current state on the phone or not, but could be.  As you see business trends it appears the company will do these sort of analytics to sell much faster than fixing a website that doctors use for their work with the company.  The claims were settled based on stats and not on patient care the article states. 

“This Call May Be Recorded for Quality Purposes”..Heck Not, Millions of Algorithms Have Been Turned Loose to Listen To and Analyze Your Voice When You Talk To Your Insurance Company As Algorithms Continue To Take Over the World…

Doesn’t this remind you of the Ingenix lawsuits from a few yeas back where current Medicare Chief Andy Slavitt was the CEO has his infamous Ingenix (sub of United Healthcare) algorithms short paying MDs for 15 years?  It’s also kind of scary that this person too who knows how to rip with algos is running Medicare and he’s lined his pocket very well with all of it on top of being a former Goldman Sachs banker.  It is very ironic and very much like the bank business that those who ripped the public and doctors with algorithms people didn’t even know existed, rise to the top with government.  I know many MDs in southern California tell me with the use of complex contracts, they get paid from United at rates less than Medicare today. 

Ingenix Gets Contract from State of Alabama To Review For Fraud – Same Company Underpaid Doctors for 15 Years Settled Recently with the AMA– Algorithmically Incorrect Calculations

It is a bit bizarre as what the doctors groups were suing for was the absence of what United and Optum brag about providing for clinicians all the time..and to me this kind of says we have some Astro Turfing going on out there as why would the MDs being suing for this if what we read in the news is true?  This contradicts some of what is put out there today.  You can read more on News Rigging at this below and watch a video to see what that’s all about. 

News Rigging Has Arrived! Astroturf and Manipulation of Media Messages-TED Video About “The Fake Grass Roots” Of Big Pharma and Other Campaigns That Fool and Fool Again…

The doctors do have reason to be concerned as when you look at secrecy of what United and Optum are doing with buying up clinics in the US, they will again reduce payments and control what doctors will be able to earn and those algorithms will literally just be shoved down their throats at some point.  If you read any of what Zeke Emanuel writes at the HHS think tank that writes most of US Healthcare policy anymore and where Jonathon Gruber works as a fellow, Zeke tells you over and over how great Optum is so be aware and be alert as they grow in plain site that everyone misses with adding new subsidiaries all the time. 

Optum Clinics Holdings, New Subsidiary Incorporated In 2015 Raises Over 36 Million (Exchange of Shares) From Investors Unknown-Form D Used to Maintain Secrecy Of Who They Are For Now…

So here we have a small victor with United/Optum adding the services they brag to all that they provide, but seems all of it may not be true at all.  United runs algorithms and uses Quants to model insurance polices and other items to make money first before focusing on provider services that don’t provide an immediate ROI as does all their data selling activity as well.  BD 

If you’re wondering who denied or modified your health insurance claims, the answer may be it was a computer.

Minnetonka, Minn.-based UnitedHealthcare has reached an $11.5 million settlement with four physician organizations regarding charges that the firm uses software to automatically adjudicate medical claims.

UnitedHealthcare on April 27 settled a nearly 15-year-old case with the Medical Society of the State of New York, the Connecticut State Medical Society, the North Carolina Medical Society and the Tennessee Medical Association.

The physician groups charged that UnitedHealthcare’s payment practices for in-network physicians were unfair, including allegations that the insurer used automated software that sometimes improperly adjudicated claims submitted by participating physicians.

The suit said that UnitedHealthcare used software that automatically “downcoded” procedures or denied payments to physicians identified as “high utilizers.”

Downcoding is a practice through which an insurer changes coding to a new category that leads to lower reimbursement.

UnitedHealthcare also routinely refused to pay at least part of a claim for healthcare services rendered on a given day in what’s known as “bundling,” according to the suit.

As part of the settlement, UnitedHealthcare promised to spend at least $9 million in extensive enhancements to their provider self-service website by the end of this year, increasing efficiency and reducing delays in managing and resolving claims. The agreement also calls for $2.5 million in attorney fees.


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