The problem is that what is profitable is marking the case as reviewed. What is needed is skin in the game. Misdiagnosis should have financial penalties like speeding tickets otherwise the optimal most capital-effective solution is a rubber stamp.
The incentivized behavior for insurance companiese right now isn't fast review, it's fast denial (which saves money on both review time and insurance payout). We need to make a coverage denial take an order of magnitude more time and effort than an approval, so insurance companies are forced to think real hard about denying access to care, and are incentivized to only deny care in relatively extreme cases.
Raise the bar for denial reasons, and forbid generic denial templates.
More difficult or more expensive. A random sample of denials being sent to a public board might do the trick, with a mandatory per-review fee charged to the insurer, and the sample size increasing as a function of reversed denials.
It should be a continuous stream of cases being randomly selected and reviewed.
Insurance is fundamentally incentivized to scam its own customers. We need to add more regulation/oversight to reduce situations where management can play tricks to tip the balance in their favor. It's an arms race.
The article was mostly about optimizing medical director "productivity levels", but it also mentioned that they outsourced to nurses in the Philippines who were doing a really bad job. Is there any oversight there? Are the nurses being incentivized to maximize denials? It'd be interesting to see how their productivity measurements are calculated too.
Of course nothing is going to change (because of something to do with "socialism" I bet), but at least now I know to avoid Cigna.
I mean it shouldn't be.
Imagine this; you have the choice between 2 insurance companies. One has a reputation of denying all claims and the other doesn't. Which do you pick for your insurance?
Whichever insurance is provided by my employer.
I'm sure there's a degree of thinly-veiled abstraction there. "Oh, we never specified such incentives for the outsourced nurses" ("... and while we did specify those incentives for their contract agency, we had NO idea that they'd put such incentives on their employees, none at all!")
People with known medical issues aren't really looking for insurance, they aren't pooling risk, they are sick. They need coverage. Businesses can easily handle insurance, but coverage is another matter. You are talking about people you know will cost more than they payout. That's charity, and better left to the state than the private sector.
Paying for health insurance premiums with pre tax dollars is tied to employers, or you can do it if you are self employed.
By and large, you can purchase the same health insurance that an employer offers on healthcare.gov, that meets the minimum ACA coverage standards.
However, there is no reason for employers to be able to compensate employees with pre tax dollars via subsidizing health insurance, but an individual cannot buy health insurance with pre tax dollars. That is just a handout to big businesses to give them an advantage over smaller businesses.
Also, employers compensating employees only in straight pay only also makes it easier for employees to compare compensation offers.
Bad analogy. Speeding tickets carry no penalties to those who issue them wrongly. You can sue and if you win the local government will eventually pay for the damages, meaning the taxpayers, meaning also you. They have no skin in the game.
The point is that these companies should get hit several times a month with a bill till middle management sees it is a cost center and actually worries about "how do we bring down this number?" and it becomes a bigger problem than "how do we reduce our coffee budget?".
So, there should be misdiagnosis tickets.
By this logic, would you say that software engineers should be financially liable for any bugs they cause along with people who misdiagnose those bugs in the process of root cause?
In contrast, how do I even know my medical diagnosis was wrong? How do I know it could have been better given the facts at hand at the time? There also seems to be no market function at all that gives market feedback to the medical institution
Edit: procedures going wrong is of course already highly penalized and insurance for this is a significant cost of our health care.
Yes. Professional engineers are held ethically, professionally, and in some cases financially responsible for the work they sign off on. Personally, I agree with Dijkstra who pointed out in a speech in 1993 that the term "software engineer" is a hollow sham:
> And also the programming manager has found the euphemism with which to lend an air of respectability to what he does: “software engineering”...
> In the mean time, software engineering has become an almost empty term, as was nicely demonstrated by Data General who overnight promoted all its programmers to the exalted rank of “software engineer”! But for the managing community it was a godsend which now covers a brew of management, budgeting, sales, advertising and other forms of applied psychology.
> Ours is the task to remember (and to remind) that, in what is now called “software engineering”, not a single sound engineering principle is involved. (On the contrary: its spokesmen take the trouble of arguing the irrelevance of the engineering principles known.) Software Engineering as it is today is just humbug; from an academic —i.e. scientific and educational— point of view it is a sham, a fraud.
From https://www.cs.utexas.edu/users/EWD/transcriptions/EWD11xx/E...
Now depends what happened, how much you sue for, but losing license and ending in jail are not impossible results. Its up to judge to decide. If that's not skin in the game then I don't know what is. Compared to 99.9% of IT folks who at worst can lose their jobs and move on (not ideal situation of course, but incomparable pressure for relatively similar compensation).
The insurance companies are banking on most people not having the time, energy, or knowledge on how to push back on them. Having a service provider that can do this will cause those insurance companies untold amount of pain.
I suspect the real trick would be to keep insurance company lobbyists from finding a way to shut that down.