Tag: claims

Fixing Medicare Starts With Cracking Down On A Multibillion-Dollar Catheter Scam

Mary Pat Campbell

Link: https://thefederalist.com/2024/02/20/fixing-medicare-starts-with-cracking-down-on-a-multibillion-dollar-catheter-scam/?utm_source=feedly&utm_medium=rss&utm_campaign=fixing-medicare-starts-with-cracking-down-on-a-multibillion-dollar-catheter-scam

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The New York Times reported recently about a sharp spike in Medicare spending on catheters, amid numerous signs that scammers have targeted that benefit to bilk the government out of taxpayer funds. With Medicare rapidly approaching insolvency, the problem is twofold: Criminals still consider the program such an easy source of cash — because the feds do such a poor job at finding and catching the crooks. 

Times reporters interviewed several seniors explaining how they had been billed for catheters they never received and do not need or use. It also noted that the number of Medicare beneficiary accounts billed for catheters rose roughly nine-fold last year, from 50,000 to 450,000. 

The pattern of Medicare spending on catheters echoes the increase in beneficiaries billed. Based on this graph from the Times story, it doesn’t take a doctorate in economics to realize that something fishy has happened regarding payments for catheters — and that, assuming most or all of the increase is due to fraud, Medicare has already given the scammers billions of dollars.

Over and above whether and when the feds can catch the scammers, the real question is: How did this happen? Or, given the federal government’s history of permitting fraud in federal health care programs, how does this keep happening?

Author(s): Christopher Jacobs

Publication Date: 16 Feb 2024

Publication Site: The Federalist

The Impact of COVID-19 on Life & Disability Claims Departments – Results of a Gen Re Survey in the UK Market

Mary Pat Campbell

Link: https://www.genre.com/knowledge/publications/2022/october/rm22-3-en

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The main concern of managers was that their assessors were, like the rest of the population, limited in terms of what they could do to unwind or use to escape due to lockdown restrictions and limited freedom. This contrasted with usual routines.

We asked about the impact of these concerns on the health of claims professionals. Absenteeism within claims teams varied across the companies and while sick leave increased slightly there did not appear to be any significant or concerning trends (Figure 6).

Author(s): Grace Cairns

Publication Date: 9 Oct 2022

Publication Site: Gen Re

5 insurance use cases for machine learning

Mary Pat Campbell

Link: https://www.dig-in.com/opinion/5-use-cases-for-machine-learning-in-the-insurance-industry

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4. Fraud detection

Unfortunately, fraud is rampant in the insurance industry. Property and casualty insurance alone loses about $30 billion to fraud every year, and fraud occurs in nearly 10% of all P&C losses. ML can mitigate this issue by identifying potential claim situations early in the process. Flagging early allows insurers to investigate and correctly identify a fraudulent claim. 

5. Claims processing

Claims processing is notoriously arduous and time-consuming. ML technology is a tool to reduce processing costs and time, from the initial claim submission to reviewing coverages. Moreover, ML supports a great customer experience because it allows the insured to check the status of their claim without having to reach out to their broker/adjuster.

Author(s): Lisa Rosenblate

Publication Date: 9 Sept 2022

Publication Site: Digital Insurance

Net Interest: Lemonade

Mary Pat Campbell

Link: https://www.netinterest.co/p/my-adventures-in-cryptoland

Excerpt:

Insurance is a peculiar business because customers don’t really want it, hence the adage, “insurance is sold, not bought.” As much as she’s a customer, she’s also a counterparty: what’s good for her (a claim) is not good for the company. There’s a zero-sum dynamic to the relationship, which means that the classic Amazon flywheel around customer experience and lower pricing doesn’t work. 

This concept got Lemonade tied up in knots this week. In a series of tweets, the company told of how its platform is getting better at “delighting customers”. One way it does this is, “when a user files a claim, they record a video on their phone and explain what happened. Our AI carefully analyses these videos for signs of fraud. It can pick up non-verbal cues that traditional insurers can’t, since they don’t use a digital claims process.”

It seems a strange way to “delight” customers by allowing AI to auto-reject their claims based on how their face looks or their accent sounds. The company realized its (PR) error, deleted the tweets and issued a denial. But this is what happens when your customers and your shareholders start mixing in an industry that doesn’t lend itself very well to that.

Author(s): Marc Rubinstein

Publication Date: 28 May 2021

Publication Site: Net Interest at substack