Your Money, Your Healthcare, and Artificial Intelligence

INTERVIEW ON THE PRICE OF BUSINESS SHOW, MEDIA PARTNER OF THIS SITE.

Recently Kevin Price, Host of the nationally syndicated Price of Business Show, interviewed Dr. David Wilcox.

Health Transparency: The Real Truth with Dr. David Wilcox 

The use of technology has been a game changer in healthcare. With the introduction of artificial intelligence, we can speed up clinical trials and even recognize when a patient is deteriorating thus intervening early on and providing optimal outcomes. Artificial intelligence or AI can even create the clinician’s notes which gives them more time for patient interaction.

With any use of technology, there are some players in the healthcare arena who are using technology to drive their bottom line. Take for instance the class action suit against the health insurers Humana and United Healthcare.

A class-action lawsuit, filed on December 12, alleges that health insurer Humana used an AI model called nHPredict to wrongfully deny medically necessary care for elderly and disabled patients covered under Medicare Advantage — a Medicare-approved plan run by private insurers. Another lawsuit, filed last month, alleges United Healthcare also used nHPredict to reject claims, despite knowing that roughly 90% of the tool’s denials on coverage were faulty, overriding determinations by patient physicians that the expenses were medically necessary.

NHPredicts is a computer program created by NaviHealth, a subsidiary of United Healthcare, that develops personalized care recommendations for ill or injured patients, based on “real-world experience, data and analytics,” according to their website. Both United Healthcare and Humana are being accused of instituting policies to ensure that coverage determinations are made based on output from nHPredicts algorithmic decision-making instead of medical experts.

Humana “employees who deviate from the nHPredict AI Model projections are disciplined and terminated, regardless of whether a patient requires more care,” one lawsuit states. Similarly, United Healthcare “disciplined and terminated” employees who strayed from nHPredict guidelines, “regardless of whether a patient requires more care,” according to a lawsuit against the insurer.

David Lipschutz, a lawyer who advocates for Medicare patients, said he’s seen “more frequent” and “inappropriate” insurance claim denials in 2023. The changes coincide with the adoption of AI by health insurance companies to determine coverage for Medicare patients, he said. “In our experience, the use of these algorithmic tools has led to more denials or premature terminations of coverage for things that otherwise would be covered,” Lipschutz said.

Cindy Cardinal, a retiree in North Carolina who cares for her octogenarian father, has spent more than a year fighting various claim denials from United Healthcare, the insurance company that offers her father’s Medicare Advantage plan.

The first tussle began when Cardinal’s father broke his hip, forcing him to undergo emergency hip-replacement surgery. After the operation, a doctor recommended he be admitted to an intensive inpatient rehabilitation program to help him regain his mobility. The program would cost $1,800 a day out of pocket — about the same cost as the average mortgage payment in the state of North Carolina. Cardinal said a response to her father’s claim arrived within minutes: United Healthcare wouldn’t foot the bill. The insurer did not provide any information on how it decided it wouldn’t cover the care ordered by her father’s physician, she said.

Health insurers are early adopters of artificial intelligence but for all the wrong reasons. While those of us in the medical community agree the use of AI will impact the way your medical team delivers care in the future, it has to be regulated to avoid situations where large healthcare entities are trying to drive maximum profits to pass on to their shareholders through shady practices such as the denial of care by major health insurers.

Remember if you have a situation where a health insurer is denying you coverage you can always have your physician ask to have a peer review with the health insurer’s medical doctor to state your case. This approach removes layers of bean counters with no medical training that are making decisions about what care you or your loved one will receive.

You can purchase Dr. David Wilcox’s book How to Avoid Being a Victim of the American Healthcare System: A Patient’s Handbook for Survival on Amazon at the following link https://lnkd.in/diZKYC2

Follow me on social media at:

Facebook – https://www.facebook.com/Dr-David-Wilcox-102834559130574

Twitter – https://twitter.com/DrDavidHelps

You Tube – https://www.youtube.com/channel/UCyYHs6ttrJ5l6-kUc-lEP9Q

According to a statement, “Healthcare is complex and that is not an accident. It is complex by the healthcare entities vying for your healthcare dollars. Covid has exacerbated the American Healthcare System, which was fragile, to begin with. Many clinicians are leaving healthcare due to burnout. How does the average layperson navigate the complexities of the American Healthcare System where a prescription could cost you $5 at one pharmacy and $500 at another? What does the average layperson do when their insurance company rejects their claim? Proactive education of the American Healthcare System prior to accessing it is the key to safely navigating the healthcare system. Until now, little information has been available to provide the layperson with the knowledge they need to be a better partner in their health care. Dr. David Wilcox’s book How to Avoid Being a Victim of the American Healthcare System: A Patient’s Handbook for Survival” is a game-changer and will provide you with the skill set you need to navigate the American Healthcare System.

Website: https://drdavidwilcox.com/

Dr. Wilcox is a Doctorate prepared nurse who also holds a Masters in Health Administration and is Board Certified in Nursing Informatics. Dr. Wilcox has 28 years of healthcare experience in which he worked as a bedside nurse, hospital administrator, and in healthcare information technology which has helped him to develop his unique perspective on the American Healthcare System.

Dr. Wilcox is the author of the book “How to Avoid Being a Victim of the American Healthcare System: A Patient’s Handbook for Survival (2021)” available at https://www.amazon.com/dp/0578878364

Dr. Wilcox currently resides in North Carolina with his wife and their three dogs.

Dr Wilcox’s website: Dr. David Wilcox – Healthcare, American Healthcare System (drdavidwilcox.com)

LISTEN TO THE INTERVIEW IN ITS ENTIRETY HERE