31–40 of 75 posts
If patients and doctors start using LLMs to strategize how to maximize claim approval rate, I wonder how would the insurance companies react to it. Would it start getting more strict and start requesting for more evidence?
>The popular image of a denial is an insurer overruling a doctor on whether a treatment is needed. That is the exception. Only about 5% of denied in-network claims were turned down because the care was deemed not medically necessary. The rest were administrative, for an excluded service, for a missing referral or prior authorization, or for a reason the insurer never specified. When an insurance company denies a heal…
There is absolutely a middle ground? The healthcare system, like any system, has an incentive structure. Doctors are incentivized to prescribe treatments, because that's how they make money for themselves and their practice. Doctors are not angels sent from heaven, they're people like you and me, and they respond to incentives like you and me. It's also well known that people strongly prefer receiving treatment over…
This is literally illegal! Physicians cannot refer patients to entities they own or have an interest in.
What is perverse is that, while we have the Stark Law to constrain physician behavior, we've decided that it's okay if a diffuse group like a non-physician-owned hospital chain enforces rules to this effect.
Before everyone wants to throw a rock at another CEO... > Only about 5% of denied in-network claims were turned down because the care was deemed not medically necessary. The rest were administrative, for an excluded service, for a missing referral or prior authorization, or for a reason the insurer never specified. I worked in health tech for a while, and I can tell you the muck around a lot with ICD/CPT codes to max…
I think this perspective makes sense from someone who works on the insurance side of things.
On the other side, there is no way for the insurance company to acknowledge the clinical severity of a patient except via abstruse ICD code choices that only billing clerks know. So this is a perfect case for an LLM - map normal human words onto ICD claim codes to accurately convey patient severity.
If patients and doctors start using LLMs to strategize how to maximize claim approval rate, I wonder how would the insurance companies react to it. Would it start getting more strict and start requesting for more evidence?
Hospitals and some doctors already do - it isn’t a one-sided problem with insurance as the only group optimizing for their desired outcome.
Not supporting nor opposing the insurance industry, just something I think the public should watch out for and understand.
Earlier quoted context omitted.
> I like the US healthcare system as much as anyone I can't tell if you're being serious. I'm not American but all of my American friends tell me the US healthcare system is an absolute nightmare
People like to complain about things and have very unrealistic perceptions of what other systems are like. It's also really unpopular online to say good things about the US healthcare system. It definitely has some issues, but it also does some things really, really well. These are, of course, anecdotes, but here some things from my life: - Next day MRI for my wife after she injured her back at the gym. Had it been m…
Earlier quoted context omitted.
Hospitals and some doctors already do - it isn’t a one-sided problem with insurance as the only group optimizing for their desired outcome.
I would watch out for insurance as an industry having to increase rates because successful claims rate are increasing much faster than the industry can handle. Not supporting nor opposing the insurance industry, just something I think the public should watch out for and understand.
The ACA tried to make health outcomes a part of the calculation for everyone involved but it is hard to compete with the all mighty dollar.
>The popular image of a denial is an insurer overruling a doctor on whether a treatment is needed. That is the exception. Only about 5% of denied in-network claims were turned down because the care was deemed not medically necessary. The rest were administrative, for an excluded service, for a missing referral or prior authorization, or for a reason the insurer never specified. When an insurance company denies a heal…
4. It's something that might help a bit, but the patient would still be fine without. Ie, a disagreement over what "necessary" means.
Earlier quoted context omitted.
There is absolutely a middle ground? The healthcare system, like any system, has an incentive structure. Doctors are incentivized to prescribe treatments, because that's how they make money for themselves and their practice. Doctors are not angels sent from heaven, they're people like you and me, and they respond to incentives like you and me. It's also well known that people strongly prefer receiving treatment over…
> Doctors are incentivized to prescribe treatments, because that's how they make money for themselves and their practice. This is literally illegal! Physicians cannot refer patients to entities they own or have an interest in. What is perverse is that, while we have the Stark Law to constrain physician behavior, we've decided that it's okay if a diffuse group like a non-physician-owned hospital chain enforces rules t…
There has to be a done of exceptions to this.
You see a cardiologist and they recommend a stent. They aren’t going to recommend a different cardiologist does it.
You see a doctor, and they refer you for a test. They have a share portfolio that contains shares in the facility they referred to.
Medicine is riddled with potential conflicts of interest. Managing them is what professionals are supposed to do and what regulators are supposed to enforce.
I don’t live in the US, I’m a n Mew Zealand. Sadly, I am aware of behaviour that looks like corruption in our system.
When I went to an in-network ENT (that I found on my insurer's website) they were billed $850 for my 10-minute exam. The insurance said they'd pay $550. So I got to pay the rest. And this is gold coverage with an already-met deductible. You just never know what the roulette wheel is going to hand out. Makes me think of that study a few years ago that found most Americans couldn't afford an unexpected $400 medical bil…
>The popular image of a denial is an insurer overruling a doctor on whether a treatment is needed. That is the exception. Only about 5% of denied in-network claims were turned down because the care was deemed not medically necessary. The rest were administrative, for an excluded service, for a missing referral or prior authorization, or for a reason the insurer never specified. When an insurance company denies a heal…
In this case, two things:
The system decides on the initial denial at most insurers. And when a claims adjuster reviews, the system is presumed to be accurate, and the adjuster has to provide reasoning to overturn the system's denial (this is before the denial has been returned to the provider). It's not "assume the provider was correct", but "we've decided to deny it, give the system reasons why we shouldn't". And that person reviewing it is often an LPN (no shade thrown at LPNs, but they shouldn't be overriding physician decisions, doubly so given an absent history).
How this has affected me personally: I had, for most of my life, a severely deviated septum. I spent most of my life mouth breathing because I could barely pull enough air through my nostrils to make breathing that way not an active effort. I finally went to an ENT who confirmed, sure enough, an approximately ninety per cent deviation. "Great, so lets schedule surgery". ENT: "Slow down. First I have to prescribe you these two nasal sprays so that when you come back in four weeks and report no change, because to both our disappointment, the sprays didn't realign and open up the cartilage in your nose, then I can submit the pre-auth to your insurer and they won't immediately reject it." What a fucking joke.
> "we detected your doctor is wrong"
It's not even that your doctor is wrong, it's "our nurses/expert systems disagree with your doctor so we're not paying".