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Showing posts with label Insurance Companies. Show all posts
Showing posts with label Insurance Companies. Show all posts

Wednesday, November 15, 2023

Private UK health data donated for medical research shared with insurance companies

Shanti Das
The Guardian
Originally poste 12 Nov 23

Sensitive health information donated for medical research by half a million UK citizens has been shared with insurance companies despite a pledge that it would not be.

An Observer investigation has found that UK Biobank opened up its vast biomedical database to insurance sector firms several times between 2020 and 2023. The data was provided to insurance consultancy and tech firms for projects to create digital tools that help insurers predict a person’s risk of getting a chronic disease. The findings have raised concerns among geneticists, data privacy experts and campaigners over vetting and ethical checks at Biobank.

Set up in 2006 to help researchers investigating diseases, the database contains millions of blood, saliva and urine samples, collected regularly from about 500,000 adult volunteers – along with medical records, scans, wearable device data and lifestyle information.

Approved researchers around the world can pay £3,000 to £9,000 to access records ranging from medical history and lifestyle information to whole genome sequencing data. The resulting research has yielded major medical discoveries and led to Biobank being considered a “jewel in the crown” of British science.

Biobank said it strictly guarded access to its data, only allowing access by bona fide researchers for health-related projects in the public interest. It said this included researchers of all stripes, whether employed by academic, charitable or commercial organisations – including insurance companies – and that “information about data sharing was clearly set out to participants at the point of recruitment and the initial assessment”.


Here is my summary:

Private health data donated by over half a million UK citizens for medical research has been shared with insurance companies, despite a pledge that it would not be used for this purpose. The data, which includes genetic information, medical diagnoses, and lifestyle factors, has been used to develop digital tools that help insurers predict a person's risk of getting a chronic disease. This raises concerns about the privacy and security of sensitive health data, as well as the potential for insurance companies to use the data to discriminate against people with certain health conditions.

Monday, August 21, 2023

Cigna Accused of Using AI, Not Doctors, to Deny Claims: Lawsuit

Steph Weber
Medscape.com
Originally posted 4 August 23

A new lawsuit alleges that Cigna uses artificial intelligence (AI) algorithms to inappropriately deny "hundreds or thousands" of claims at a time, bypassing legal requirements to complete individual claim reviews and forcing providers to bill patients in full.

In a complaint filed last week in California's eastern district court, plaintiffs and Cigna health plan members Suzanne Kisting-Leung and Ayesha Smiley and their attorneys say that Cigna violates state insurance regulations by failing to conduct a "thorough, fair, and objective" review of their and other members' claims.

The lawsuit says that instead, Cigna relies on an algorithm, PxDx, to review and frequently deny medically necessary claims. According to court records, the system allows Cigna's doctors to "instantly reject claims on medical grounds without ever opening patient files." With use of the system, the average claims processing time is 1.2 seconds.

Cigna says it uses technology to verify coding on standard, low-cost procedures and to expedite physician reimbursement. In a statement to CBS News, the company called the lawsuit "highly questionable."

The case highlights growing concerns about AI and its ability to replace humans for tasks and interactions in healthcare, business, and beyond. Public advocacy law firm Clarkson, which is representing the plaintiffs, has previously sued tech giants Google and ChatGPT creator OpenAI for harvesting internet users' personal and professional data to train their AI systems.

According to the complaint, Cigna denied the plaintiffs medically necessary tests, including bloodwork to screen for vitamin D deficiency and ultrasounds for patients suspected of having ovarian cancer. The plaintiffs' attempts to appeal were unfruitful, and they were forced to pay out of pocket.

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Last year, the American Medical Association and two state physician groups joined another class action against Cigna stemming from allegations that the insurer's intermediary, Multiplan, intentionally underpaid medical claims. And in March, Cigna's pharmacy benefit manager (PBM), Express Scripts, was accused of conspiring with other PBMs to drive up prescription drug prices for Ohio consumers, violating state antitrust laws.

Cohen says he expects Cigna to push back in court about the California class size, which the plaintiff's attorneys hope will encompass all Cigna health plan members in the state.

Wednesday, November 6, 2019

Insurance companies aren’t doctors. So why do we keep letting them practice medicine?

(iStock) (Minerva Studio/iStock)William E. Bennett Jr.
The Washington Post
Originally posted October 22, 2019

Here are two excerpts:

Here’s the thing: After a few minutes of pleasant chat with a doctor or pharmacist working for the insurance company, they almost always approve coverage and give me an approval number. There’s almost never a back-and-forth discussion; it’s just me saying a few key words to make sure the denial is reversed.

Because it ends up with the desired outcome, you might think this is reasonable. It’s not. On most occasions the “peer” reviewer is unqualified to make an assessment about the specific services.

They usually have minimal or incorrect information about the patient.

Not one has examined or spoken with the patient, as I have.

None of them have a long-term relationship with the patient and family, as I have.

The insurance company will say this system makes sure patients get the right medications. It doesn’t. It exists so that many patients will fail to get the medications they need.

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This is a system that saves insurance companies money by reflexively denying medical care that has been determined necessary by a physician.

And it should come as no surprise that denials have a disproportionate effect on vulnerable patient populations, such as sexual-minority youths and cancer patients.

We can do better. If physicians order too many expensive tests or drugs, there are better ways to improve their performance and practice, such as quality-improvement initiatives through electronic medical records.

When an insurance company reflexively denies care and then makes it difficult to appeal that denial, it is making health-care decisions for patients.

The info is here.

Thursday, June 20, 2019

Legal Promise Of Equal Mental Health Treatment Often Falls Short

Graison Dangor
Kaiser Health News
Originally pubished June 7, 2019

Here is an excerpt:

The laws have been partially successful. Insurers can no longer write policies that charge higher copays and deductibles for mental health care, nor can they set annual or lifetime limits on how much they will pay for it. But patient advocates say insurance companies still interpret mental health claims more stringently.

“Insurance companies can easily circumvent mental health parity mandates by imposing restrictive standards of medical necessity,” said Meiram Bendat, a lawyer leading a class-action lawsuit against a mental health subsidiary of UnitedHealthcare.

In a closely watched ruling, a federal court in March sided with Bendat and patients alleging the insurer was deliberately shortchanging mental health claims. Chief Magistrate Judge Joseph Spero of the U.S. District Court for the Northern District of California ruled that United Behavioral Health wrote its guidelines for treatment much more narrowly than common medical standards, covering only enough to stabilize patients “while ignoring the effective treatment of members’ underlying conditions.”

UnitedHealthcare works to “ensure our products meet the needs of our members and comply with state and federal law,” said spokeswoman Tracey Lempner.

Several studies, though, have found evidence of disparities in insurers’ decisions.

The info is here.

Friday, March 3, 2017

California Regulator Slams Health Insurers Over Faulty Doctor Lists

Chad Terhune
Kaiser Health News
Originally published February 13, 2017

California’s biggest health insurers reported inaccurate information to the state on which doctors are in their networks, offering conflicting lists that differed by several thousand physicians, according to a new state report.

Shelley Rouillard, director of the California Department of Managed Health Care, said 36 of 40 health insurers she reviewed — including industry giants like Aetna and UnitedHealthcare — could face fines for failing to submit accurate data or comply with state rules.

Rouillard said she told health plan executives in a meeting last week that such widespread errors made it impossible for regulators to tell whether patients have timely access to care in accordance with state law.

“I told the CEOs it looks to me like nobody cared. We will be holding their feet to the fire on this,” Rouillard said in an interview with California Healthline. “I am frustrated with the health plans because the data we got was unacceptable. It was a mess.”

The article is here.

Wednesday, January 21, 2015

Getting mental health services can be hard, despite law requiring parity

By Lisa Gillespie
The Washington Post
Originally published January 5, 2015

Even though more Americans than before have access to health insurance because of the Affordable Care Act, getting mental health services can still be challenging.

A report released in November concludes that despite a 2008 mental health parity law, some state exchange health plans may have a way to go to even the playing field between mental and physical benefits. The report, released by the advocacy group Mental Health America, was paid for by Takeda Pharmaceuticals U.S.A. and Lundbeck U.S.A., a pharmaceutical company that specializes in neurology and psychiatric treatments.

The report listed the states with the lowest prevalence of mental illness and the highest rates of access to care as Massachusetts, Vermont, Maine, North Dakota and Delaware. Those with the highest prevalence of mental illness and most limited access are Arizona, Mississippi, Nevada, Washington and Louisiana.

The entire article is here.

Tuesday, January 6, 2015

Denied

When insurance companies deny the mentally ill the treatment their doctors prescribe, seriously ill people are often discharged, and can be a danger to themselves or others

By Scott Pelley
CBS - 60 Minutes
Originally aired on December 14, 2014

Here is an excerpt:

Two years ago tonight, we were reeling from the shock of the murders of 20 first graders and six educators at Sandy Hook Elementary School. Since then, we've learned that the killer suffered profound mental illness. His parents sought treatment but, at least once, their health insurance provider denied payment.

Because of recurring tragedies and an epidemic of suicides, we've been investigating the battles that parents fight for psychiatric care. We found that the vast majority of claims are routine but the insurance industry aggressively reviews the cost of chronic cases. Long-term care is often denied by insurance company doctors who never see the patient. As a result, some seriously ill patients are discharged from hospitals over the objections of psychiatrists who warn that someone may die.



The entire story is here.

Monday, November 10, 2014

More Insurers Put Spending Limits On Medical Treatments

By Michelle Andrews
NPR
Originally published October 21, 2014

To clamp down on health care costs, a growing number of employers and insurers are putting limits on how much they'll pay for certain medical services such as knee replacements, lab tests and complex imaging.

A recent study found that savings from such moves may be modest, however, and some analysts question whether "reference pricing," as it's called, is good for consumers.

The California Public Employees' Retirement System (CalPERS), which administers the health insurance benefits for 1.4 million state workers, retirees and their families, has one of the more established reference pricing systems.

The entire article is here.

Monday, July 29, 2013

Connecticut Mental Health Lawsuit Takes Insurers To Task

High Co-pays and issue in High Profile Case

By JAY STAPLETON
Connecticut Law Tribune
Originally published July 12, 2013

A Connecticut law firm has taken the lead in a high-profile federal lawsuit that accuses a group of insurance companies of overcharging for mental health services, prompting thousands of vulnerable patients to avoid treatment.

In the American Psychiatric Association v. Anthem Health Plans lawsuit, the firm of Murtha Cullina was hired as chief legal counsel for the plaintiffs. Attorney Marie Pepe VanDerLaan of the firm's Hartford office, the lead lawyer in the case, filed the complaint on the APA's behalf in U.S. District Court in New Haven.

At the heart of the claim is that the insurance company manipulated billing statements in order to charge higher co-pays for patients being treated for mental disorders than those required for patients with physical ailments. The APA is a lead plaintiff in the case, joined by psychologist Susan Savulak of Newington and several of her patients.

The entire article is here.

Saturday, May 5, 2012

Conflicts Arise As Health Insurers Diversify

By Jay Hancock
Kaiser Health News
Originally published April 29, 2012

Like hospitals and doctorseverywhere, Banner Health fights a daily battle to get paid by insurance companies and government agencies for the care it delivers.

So the hospital system hired a company called Executive Health Resources to fight back against the likes of Medicare and UnitedHealthcare when they deny claims or pay bills for less than what Banner thinks it is owed.

But Banner executives began to worry about EHR's independence when the firm was acquired in 2010 by UnitedHealth Group, UnitedHealthcare's parent.

"It does seem as though there is reason for concern because they can use our own information against us," said Dennis Dahlen, CFO of the Phoenix-based Banner.

Critics call United's ownership of EHR a troubling conflict of interest that could give it confidential information about rivals as well as patients and limit EHR's power to demand payment from its much larger corporate sister. "How is that ownership going to affect the mission of a company whose business is to extract more money from payers?" said Scot Silverstein, a physician and specialist in medical software and patient records at Drexel University. "Imagine going to a plaintiff's lawyer to take your malpractice case and not knowing that plaintiff's lawyer actually works for the hospital that you're suing."

The entire story is here.

Sunday, July 10, 2011

Managed Care Enters The Exam Room As Insurers Buy Doctor Groups


Now, that touch could get a lot more personal.  United's health services wing is quietly taking control of doctors who treat patients covered by United plans in several areas of the country -- buying medical groups and launching physician management companies, for example.
It's the latest sign that the barrier between companies that provide health coverage and those that actually provide care to patients is crumbling.
Other large insurers, including Humana and WellPoint, have announced deals involving doctors in recent months, part of a strategy to curb rising health costs that could cut into profits and to weather new challenges to their business arising from the federal health law. But United is the biggest insurer by revenue, making the trend much more significant.
Many patients insured by these companies are going to see much tighter management of their care.
"Health care costs are still going to rise," said Wayne DeVeydt, chief financial officer of WellPoint, which entered the business of running clinics in June with the announcement that it would acquire CareMore, a health plan operator based near Los Angeles that owns 26 clinics. "But the only way to stem those costs in the long term is to manage care on the front end."
That means enlisting doctors. Their orders drive most health care spending, including the wasteful share: treating heart patients with expensive stents when cheaper drugs might work, or overusing high-tech imaging devices, for example. By managing doctors directly, insurers believe they can reshape the practice of medicine - and protect their profits.
Read the rest of the story from Kaiser Health News.