Current Events:  Another Example of the US Healthcare System Torturing Its Users and Wasting $$

So, I’m reading an article about Medicare Advantage plans in a credible magazine.  (Why in the world am I reading this?  The article caught my eye because I have a Medicare Supplement plan, but my ex-employer has been pushing their Medicare Advantage plan to their retirees.  Some of my former colleagues have switched to it; some not.  I haven’t switched but wonder if I’m doing the smart thing.)

The article says Medicare Advantage plans require more prior authorizations than original Medicare.  Further, of the 46 million prior authorization requests, “only” 7.4% are denied, in whole or in part.  “Only” 7.4% … geez, that’s 3.4 million denials.

Here’s the really, really bad part.  Some of those 3.4 million denials are appealed.  Well, upon appeal, 83% of those denials are overturned fully or partially. 

That is an incredibly high defect rate in the decision to deny or approve a prior authorization.  They get it wrong 8 out of 10 times.

That’s 2.8 million requests for prior approval that were needlessly denied, fully or partially.  Imagine the wasted time and cost associated with those defects … by the patient, the healthcare provider, and the insurance company.

That’s 2.8 million requests from real people who are dealing with a health issue.  Imagine the emotional toll.  Note that these are people are my fellow retirees and senior citizens.

Anybody with even a modest understanding of managing quality and efficiency / productivity would be all over this and fix it in quick time.  Why haven’t they?  I don’t have a clue.  Management malpractice?

Oh, and AI could probably do a lot better than the people making these decisions to approve or deny prior authorizations.  God forbid they’re already using AI and the algorithms are fouled up … and they haven’t noticed.