The AI does what the insurers ask. Vendors say that’s the problem.
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Growing demand
The market for provider information automation is growing, driven by the digital acceleration of insurers during the COVID-19 pandemic, an influx of patient claims and the Unsurprising Act, said Meghan Gaffney, CEO de Veda, a data automation of 5 years ago. set up. In the three years since the company launched its first product, Veda now has six of the top 10 health plans as customers, Gaffney said. She declined to specify the names of the insurers.
“If you think about a great health system, they send Excel spreadsheets with thousands of rows and hundreds of columns to health plans,” Gaffney said. “Today, if they’re not using data, there are people on the computers who enter that data by hand. The No Surprises Act says in health plans, must be correct. ‘ It’s really a game changer in the market. It is forcing them to modernize. “
He said he would not be surprised if the upgrade of a claims processing system would take a year, although he noted that a successful implementation would not have delayed payment. She was unsure whether insurers would disclose how their claims processing algorithms would be useful to providers. Instead, he thought it was more important for insurers to be transparent about how AI decisions affected doctors and patients and avoid blaming bad results on the system.
“If you think about AI, it’s like a saw or a hammer, a tool for a carpenter. We can do very good or very bad things with a hammer. You can build a house or break a window, “Gaffney said.” The tool is not the problem. I think what is happening is that the tool has become a good excuse to enact policies that may not be doing good for people. “
As payers’ use of artificial intelligence increases in claims processing, there are also problems with the system, although Anthem’s high-profile issues are the first instance in which a health insurer has been called in this area, said Elena Elkina, partner of Aleada Consulting. which advises healthcare clients on data management and privacy.
As an example, he pointed to a Twitter post last year from property, pet and life insurer Lemonade, in which the AI was presumed to analyze 1,600 data points, including “non-verbal cues” from consumers. , to deny claims more conveniently. The insurer did not specify what information it enters into its algorithm, but said it does not discriminate on the basis of individual appearance, disability, or other personal characteristics. After being heavily criticized for its data collection methods and possible biases, insurtech removed “that terrible thread that caused more confusion than anything else” in an updated Twitter post.
The company said it does not benefit from denying claims and that it gives unearned premiums in customer service to a charity. Elkina said insurers who save money by automating claims rarely pass on cost savings to members.
“It’s like being a member of a gym – you can buy the subscription or you can get it as a gift, but you have to go there to benefit from it,” Elkina said. “It’s the same as AI. You can have a good use case, but to start using it effectively, you have to work hard. And I think companies don’t realize it. They invest money in it and wait. that AI is a magic switch. But it is not. “
Back in Maine, the situation has worsened since the state medical association began hearing complaints from independent doctors and hospitals in September, said President Jeffrey Barkin. He believes Anthem lost staff during the start of the pandemic and implemented Cotiviti as a “defensive measure” to save labor shortages. But he said that when individuals began returning to providers en masse in 2021, to offset deferred attention during the first year of the pandemic, Anthem’s count of claims increased, highlighting the dysfunctional system it had put in place. marching and highlighting its shortage of staff.
“There may be some hope for improvement in sight,” Barkin said. “But if they’re not able to meet their obligations, and they’re billions of dollars, well, that can prove that having a private, publicly traded company like Anthem manages Blue Cross plans isn’t feasible, which it could be really important to know when designing an advancing health plan. “
After Fellers removed Anthem from its network, it obtained one-case, continuity-of-care agreements so that the 63 patients insured through the carrier could continue to see it at low out-of-pocket costs. He was also connected with a representative of Hymn trying to fix their relationship.
Fellers said he is not sure what he would need to go online with Anthem. Repaying the $ 30,000 you say you owe back in coded claims would be helpful, and offering interest on late payments could also help alleviate the situation. But he doesn’t feel hopeful about any of them. And for now, he has no plans to recover.
“I was really looking forward to accepting insurance so that people could use the benefits that have really been earned and be able to see someone,” Fellers said. “Now I understand why providers have really left the network or don’t want to work with them. I think it’s really inconceivable that they should do so at the height of a pandemic.”
