THIS TIME ON CODE WACK!
How are corporate health insurers using artificial intelligence to step up their claims’ denials? And what’s being done to out some of the bad actors in Medicare Advantage?
To find out, we spoke to Diane Archer, founder and president of Just Care USA, an independent digital media hub covering health and financial issues facing boomers and their families. Miss Archer is the past chair of the Board of Consumer Reports, currently serves as a senior advisor at Social Security Works and as a member of the board of the Center for Health and Democracy.
SHOW NOTES
WE DISCUSS
We have Medicare Advantage insurance companies dictating what treatments and medicines we can have. Is it legal for them to overrule a doctor’s order?
“It is legal for them to overrule the doctor if the doctor is prescribing a treatment that is actually not reasonable and necessary.
“But the question is, are they overruling doctors when the treatment is reasonable and necessary? And the answer seems to be that in a large number of instances, that’s exactly what they’re doing. ” – Diane Archer
Who is making the decision to overrule physician-recommended treatment? Is it an algorithm?
“The insurers say no, but recent reports out of Stat News and other media outlets is that in fact that there are these sweeping denials that the insurers are making with no review by a doctor.
“And so that is cause for terrific concern because again, it is in the insurance company’s interest to make these sweeping denials and then maybe to approve care if somebody appeals.
“But since most people don’t appeal, [the insurers] end up able to keep a ton of money… ” – Diane Archer
What policies do you believe are needed to rein in corporate health insurance companies?
“I think we have to overhaul the entire way that these insurance companies operate in Medicare. They have to be fully transparent, they have to be paid differently….
“Medicare for All is the ultimate solution here. Medicare for All would be based on a fee-for-service model where insurers were out of the picture altogether except to process claims and then people would not have out-of-pocket costs to get care.
So it would be a much more equitable system than we have now where copays and deductibles present huge barriers to care for people. And more so in Medicare Advantage, I should add, than in traditional Medicare.” – Diane Archer
Helpful Links
Senators probing largest Medicare Advantage plans over how algorithms factor in care denials, STAT
Over 35 Million Prior Authorization Requests Were Submitted to Medicare Advantage Plans in 2021, Kaiser Family Foundation
1 in 3 doctors has seen prior auth lead to serious adverse event, American Medical Association
Letter to CMS on Prior Authorization and more, American Medical Association
My Insurance Overruled Doctor’s Orders. It’s Not the First Time, Sarcoidosis News
Episode Transcript
Read the full episode transcript.
Biography: Diane Archer
Diane Archer is founder and president of Just Care USA, an independent digital media hub covering health and financial issues facing boomers and their families.
Ms. Archer is the past chair of the Board of Consumer Reports. She began her career in health advocacy in 1989 as founder and president of the Medicare Rights Center, a national consumer service organization dedicated to ensuring that older and disabled Americans get the health care they need.
She served as director of the Health Care for All project for the Institute for America’s Future and currently serves as a senior advisor at Social Security Works. She is a member of the Board of the Center for Health and Democracy.
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