In reading other discussions, I came across this recent gem from a different company:
November 14, 2024 - In an unprecedented move, Anthem Blue Cross Blue Shield plans representing Connecticut, New York and Missouri have unilaterally declared it will no longer pay for anesthesia care if the surgery or procedure goes beyond an arbitrary time limit, regardless of how long the surgical procedure takes. The American Society of Anesthesiologists calls on Anthem to reverse this proposal immediately.
I worked for a company that used ML to fight health insurance fraud ("mistakes") in the German market - where doctors/administrators would require payment for extra procedures that they never actually performed. So "denial rate" or even "profit margin" would go up with better AI that discovers more fraud!
Maybe a good metric would be something like "expected lifespan"? But even that can be misleading (e.g. maybe different insurers serve different populations...)
How can you say that doesn't mean anything? It means that if you have united, your twice as likely to be denied necessary, prescribed care! That's what it literally means. I don't care if occasional doctor over prescribe a thing and make extra money, does that happen in 1/3rd of all prescriptions given by all doctors in the network? This man's company was increasing profits by denying necessary care to people, including dying people who would have been saved. He made the decision to keep the company doing that and his purview built the system that automated denials so they could deny even more, all without letting an actual fucking doctor see any of it. That's monstrous! That's disgusting! He's literally killing people with his policies, while taking home the highest salary in the business! How much human suffering, how many hours of terror and pain, how many dead bodies did that man let happen, did he _make_ happen, all so he could take home millions and millions of dollars. I'd bet he never had to fight for a prescription, he never got taken off a necessary medication, he never spent months of his life fighting on the phone to save his mother's life, or to get the necessary medication so that she could at least die in peace.
I have. We have. So many more people than apparently you think. He deserved a lot worse that a gunshot.
When the systems are so kafkaesque, so labyrinthine, the processes are intentionally gordian knots of unknown requirements, silently attacking your very need to survive as a human being. When the systems can't be fixed by the people most drastically effected, what recourse do we have? Nothing. So I'll cheer his death, at least someone did something for once.
He gets the blame as a "representative" of the industry, and certainly deserves all the blame for what his own company did. The fattest check in the company and all the executive power come with all the blame.
But let's not dilute the issue, politicians didn't create the circles of hell of getting a claim assessed and denied in milliseconds by some algorithm. That was CEOs' chase for the profit.
Politicians however are responsible for allowing insurance companies to reject claims at all for FDA approved indications. Insurance companies should not have the power to deny any medically prescribed claim for an FDA approved use.
His innovation was to deploy AI models to automate claim denials. The system didn't make him to do that. He's responsible for the deaths of thousands and is rightly receiving 0 sympathy for his demise.
I don't mean to make light of real AI like well-trained large deep models, but clearly the use here of "AI" by these insurance firms isn't reflective of any intelligence.
Someone will get blame so there is pressure and change happens, life isn’t fair for regular people so there is no reason it should be fair for these people
as if any other insurance company can do any better, in a broken system
but the system, those that created it (politicians) and those that exploit it (non-medical hospital staff) get off