DeepSummary
The podcast episode discusses how some insurance companies are using algorithms to determine coverage decisions for seniors on Medicare Advantage plans, which are Medicare plans offered by private insurers. The investigation by Stat News found that an algorithm purchased by UnitedHealth Group in 2021 was predicting how long patients would need care, and coverage was being denied based on that projected length of stay, regardless of the patient's actual condition as assessed by their healthcare providers.
The case of Frances Walter, an elderly woman who broke her shoulder and needed rehabilitation, is highlighted. The algorithm projected that she would need 16.6 days of care, but she required longer due to her complicated condition. Her coverage was cut off based on the algorithm's prediction, forcing her family to enroll her in Medicaid and spend down her life savings to pay for additional care.
While insurers argue that algorithms can help prevent overbilling by facilities, the investigation raises concerns about the lack of transparency, potential biases, and the inability of patients to question or appeal decisions made solely by algorithms. The Centers for Medicare and Medicaid Services has issued new rules requiring transparency and human involvement in such decisions, but enforcement mechanisms are lacking.
Key Episodes Takeaways
- Insurance companies are using algorithms to determine coverage decisions for seniors on Medicare Advantage plans, often denying care based on projected lengths of stay rather than patients' actual conditions.
- The case of Frances Walter highlights the potential consequences of algorithm-driven coverage denials, including being forced to enroll in Medicaid and spend down life savings to pay for additional care.
- Patients are often unaware that algorithms are being used to make coverage decisions and have no ability to question or appeal those decisions.
- Algorithms can perpetuate biases and make flawed decisions on a large scale due to biases inherent in the data used to train them.
- While new regulations aim to improve transparency and require human involvement in such decisions, enforcement mechanisms are lacking.
- Appealing algorithm-driven coverage denials is difficult, with only a small percentage of appeals being successful.
- There are concerns about the lack of transparency, potential biases, and the inability of patients to appeal decisions made solely by algorithms.
- Insurers argue that algorithms can help prevent overbilling by facilities, but the investigation raises questions about the appropriateness of using algorithms to make coverage decisions without considering patients' actual conditions.
Top Episodes Quotes
- “Based on this projected length of stay by an algorithm, patients in the facility were then getting coverage denied in concert with that projected length of stay, regardless of their actual condition, based on the assessment of their in person providers.“ by Casey Ross
- “It can really perpetuate bias and bad decision making on a massive scale. When it's humans doing this on a sort of case by case basis, that's one thing. But when it's an algorithm that sits behind these physicians and it's based on data that's been fed into it, those data can be biased and the decision making gets skewed.“ by Casey Ross
- “And so Francis Walter is then made to enroll in Medicaid, and she has to. She has to pay down her life savings to pay for extra care.“ by Casey Ross
- “And it was about a year and a half later that a judge finally found that, yes, in fact, the Walter family and her providers were right. She was entitled to more care, and she was eventually reimbursed about 0.2% of the people that this happens to appeal and achieve that outcome.“ by Casey Ross
Entities
Company
Person
Organization
Podcast
Product
Book
Episode Information
Marketplace Tech
Marketplace
4/22/24
Artificial intelligence has become a big part of medicine — reading images, formulating treatment plans and developing drugs. But a recent investigation by Stat News found that some insurers overrely on an algorithm to make coverage decisions for seniors on Medicare Advantage, a Medicare plan offered by private insurers. Marketplace’s Meghan McCarty Carino spoke with Casey Ross, who co-reported the story. He said an algorithm predicted how long patients needed care and coverage was curtailed to fit that calculation.