It's like "using dice to deny claims". Yeah... I guess? But they are the ones performing the actions. What they base those actions on is besides the point.
The point is that denying claims, particularly denying >90% of claims as the first generation of "AI" did (a D20 model), or denying claims requested by doctors without a Very Good Reason, is tantamount to refusing medical treatment to people who have already paid to be covered for medical treatment, and may stand to die if their medical conditions are not treated, as a result of second-guessing the doctor.
It also dramatically reduces the productivity of doctors, who are being filibustered by a system that forces ever-increasing amounts of pre-approvals, charting requirements and appeals on them. If the median doctor can suddenly only perform half as much work... people also die as a result.
It's not behavior that _deserves social protection_, is the point. Allowing companies to participate in social murder & fraud if they claim an AI told them to internally is morally, politically, bureaucratically, and economically abhorrent. Tear it all down and salt the earth with the bankrupt remains of these companies that had the _audacity_ to shift to second-guessing a majority of medical claims.
> Before health insurers reject claims for medical reasons, company doctors must review them, according to insurance laws and regulations in many states. Medical directors are expected to examine patient records, review coverage policies and use their expertise to decide whether to approve or deny claims, regulators said. This process helps avoid unfair denials.
> But the Cigna review system that blocked van Terheyden’s claim bypasses those steps. Medical directors do not see any patient records or put their medical judgment to use, said former company employees familiar with the system. Instead, a computer does the work. A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments. Company doctors then sign off on the denials in batches, according to interviews with former employees who spoke on condition of anonymity.
> “We literally click and submit,” one former Cigna doctor said. “It takes all of 10 seconds to do 50 at a time.”
The problem is not the dice. It's the denials.
RealPage is a service used by landlords to fix prices and reduce competition. It doesn't actually matter that it uses AI to achieve this, they may as well have used in person conversations or a weekly newsletter, what matters is that it's all price collusion. They aren't "using AI to...", they are knowingly and proudly fixing prices to reduce price competition, and AI (or some kind of algorithm at least) may be used somewhere in the data analysis tools.
If online posts and discussion over the last few days, it most definitely does not have social protection.
Though they aren't claiming that it's okay because AI does it. It's that it's profitable and makes it even more so because now they can fire the people whose jobs it was to deny claims.
You can get away with most things in business so long as a pension or retirement fund gets to wet its beak. And that's what private insurance with no public alternative does.
What forces the insurance company to give sound rejections? There are numerous categories of care where you would not expect the individual to survive long enough to bring a lawsuit, or the individuals in question would not have the financial means.
Even if a lawsuit is brought, what obliges the insurance company to be reasonable? The ability to deny medication that I am hearing about certainly are not in my insurance contract.
The contract does say things like "standard of care", which is why they need an actual MD to reject a claim. The AI (or whatever) can help but in the end there is a doctor claiming to read the file and say you didn't need whatever it is.
You can bring a suit, and often the threat alone will work. They're counting on you to give up rather than fight. Or be unable to afford it because most lawyers won't take something like that on contingency.
They're content to just reject the bill or refuse to pay.
They'd love it if you sued the doctor for malpractice on the grounds of recommending something that the insurer's doctor rejected.
I don't think you can use the insurer's doctor who rejected your claim. You can try to get their board certification revoked, and in the wake of the murder people are talking about doing that more. But it's not in itself going to get you your meds.
I don’t follow how the insurance companies doctor escapes liability in this case. If they are interfering with a patients treatment plan, doesn’t that qualify as practicing medicine?
Otherwise the insurance company could easily staff itself with less scrupulous poorly qualified doctors and say “your job is to reject claims”. Why would that doctor have any motivation or requirement to fulfill the duties of a “doctor”?
It pays pretty well and you don't have to see any patients. And as they say, do you know what they call the one who graduates last in med school? "Doctor"
The problem with suing the doctor is that you need a fairly high standard of evidence to prove malpractice. If they have any way to say "this is not utterly unreasonable", they can claim it was your doctor's opinion versus theirs.
And the insurance company has many lawyers looking for ways to let them say that. It's why they have AI rather than just rejecting claims at random.
Though it appears they often do that as well. But the burden is still on you to prove it.
