I think you're on the right track but not quite there.
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.
> need to make a coverage denial take an order of magnitude more time and effort than an approval
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.
CMS does do random inspections, but they are far too infrequent (on the order of years between inspections) and the penalties far too low to correctly align incentives.
It should be a continuous stream of cases being randomly selected and reviewed.
That doesn't make sense to me. Why wouldn't maximizing denials always be the priority for an insurance company? If you make denials slower, it will just slow down all cases.
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.
> 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.
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!")
> Why wouldn't maximizing denials always be the priority for an insurance company?
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?
> 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?
And as some of the pre-ACA "catastrophic" plans often showed, those who do often go with "whichever is cheaper", and only find out when they get sick how dismal they are.
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.