AI does what the insurance company asks. The supplier said that was the problem.


growing demand

Driven by insurers’ digital acceleration during the COVID-19 pandemic, a flood of patient claims, and the No Accidents Act, the market for automated provider information is growing, according to Meghan Gaffney, CEO of Veda, a five-year-old data automation company. increase. start up. In the three years since the company launched its first product, Veda now counts six of the 10 largest health plans as customers, Gaffney said. She declined to name the insurance company.

“If you think about a large health system, they send health plans an Excel spreadsheet with thousands of rows and hundreds of columns,” Gaffney said. “Today, if they’re not using the data, someone is in front of a computer manually entering data. The No Accidents Act tells health plans, ‘Hey, you have 48 hours to get this data into your system, by the way. , it has to be right. It’s really a game-changer in the market. It’s forcing them to modernize.”

She said she wouldn’t be surprised if it would take a year to update the claims processing system, although she noted that a successful implementation would not delay payments. She’s not sure it would be useful for providers to disclose how their claims processing algorithms work. Instead, she believes it is more important for insurers to be transparent about how AI decisions affect clinicians and patients and avoid blaming the system for poor outcomes.

“If you think about artificial intelligence, it’s like a saw or a hammer, a carpenter’s tool. 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 isn’t the problem. I think what’s happening is that the tool has become a very good excuse to have policies that may not be good for people.”

Elena Elkina, a partner at Aleada Consulting, said that as payers’ use of AI in claims processing exploded, so did the system, although Anthem’s high-profile problem is where health insurers are being called to. The first example who advises healthcare clients on data management and privacy.???

For example, she pointed to a Twitter article last year by property, pet and life insurer Lemonade that said AI analyzed 1,600 data points — including consumers’ “non-verbal cues” — to more easily deny claims . The insurer did not specify what information it entered into the algorithm, but said it does not discriminate on the basis of a person’s appearance, disability or other personal characteristics. After being widely criticized for its data collection methods and potential bias, the insurtech company removed “this horrible post that caused more confusion than anything else” in an updated Twitter thread.

The company said it does not profit from denying claims and donates any premiums not used for customer service to charity. Insurers that save money through claims automation rarely pass any cost savings on to members, Elkina said.

“It’s like a membership to a gym — you can buy a membership, you can get it as a gift, but you need to be there to benefit from it,” Elgina said. “It’s the same with AI. You can have a great use case, but in order to start using it effectively, you need to put in a lot of effort. I don’t think companies realize that. They put money into it and expect AI to be A magic switch. But it wasn’t.”

Back in Maine, things have gotten worse since the state’s medical association began hearing complaints from independent clinicians and hospitals in September, said President Dr. Jeffrey Barkin. He believes Anthem lost its staff during the start of the pandemic and implemented Cotiviti as a “defense measure” to make up for the lack of manpower. But he said that when individuals began returning to providers in droves in 2021 — to make up for care that was delayed in the first year of the pandemic — Anthem’s surge in claims underscores the capabilities it has built. dysfunctional system and highlighted its staff shortages.

“There may be some hope for improvement,” Barkin said. “But if they can’t meet their obligations, and it’s in the billions, then that might show that it’s not feasible to have a privately-held public company like Anthem do the Blue Cross, which might really be designed to move forward. Important things to know when planning your health.”

After Fellers removed Anthem from his network, he got a single case and a continuum of care agreement, so the 63 patients insured through the carrier could continue to see him at a lower out-of-pocket cost. He also has ties to Anthem representatives who are trying to mend their relationship.

Fellers said he wasn’t sure what he needed to build a network with Anthem. Retroactively compensating him for the $30,000 they say they owe him, and offering interest on late payments would help ease the situation. But he has no hope of any of these happening. Currently, he has no plans to take back the insurance company.

“I’d really like to get insurance so people can use the benefits they’re really getting and be able to meet someone,” Ferrers said. “I understand now why the vendors have really left the network or didn’t want to work with them. I don’t think it would have been unconscionable for them to do so at the height of the pandemic.”



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