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a epidemic at the root of the problem licensing and excise taxing data sellers facial recognition yet one more tool used to secure match data the epidemic billions in profits for banks and us corporations using killer algorithms to further erode consumer privacy ftc reclaim your name campaign not good enough no path for regulation identified all data sellers including banks insurers etc should be required to buy a license data selling game now exploits the non regulated billion dollar epidemic data dealer the attack of the killer algorithms gamified pharma and health insurance companies pairing up humana s analytics subsidiary and lilly to figure out how to save make money and provide better patient care selling research data that competes with fda sentinel initiative insurance company in network complex erroneous algorithms continue to wreak havoc with patients and doctors when it comes to coverage and purchasing insurance time to begin sniffing some data to include labeling and identifying killer algorithms mastercard as well as other financial institutions using big data to get into your online pants as many consumers seem to be accidentally and inadvertently leaving their internet fly open white house office of science and technology policy ostp and mit co hosting public workshop big data privacy not possible unless we license and excise tax the sellers the corporate profit epidemic continues to spread big data in farming back to the data selling business once again with concerns of where the data is sold and who uses it to profit paying for ip with the food we eat today 60 minutes blasts the data sellers ftc admits they have lost control time to license and excise tax all data sellers banks companies etc congress needs to act on this fraud algorithms failing at indiegogo crowd funding site some getting through with physicists claiming the technology claimed is not possible healthcare related apps devices limitations and risks of machine ethics that really don t exist abstract basically substantiating the existence of what i coined as the attacks of the killer algorithms one trick algo world needs to be licensed and indexed spurious correlations for profit are out of control with prediction tools and apps being all the rage today their reliability and accuracy are not always there before the word prediction read more saturday april 29 2017 0 medically related my commentaries other items of interest saturday april 29 2017 doj enters whistleblower law suit against united healthcare risk fiddling for profit a walk back down ingenix memory lane again here we go again back to those ingenix algorithms and business models getting a rerun of sorts of what occurred in 2011 in 2011 there was one main lawsuit from the ama along with many others that were filed some being still settled over using formulas that short changed doctors and patients on out of network chargees in addition all other insurers who licensed and used the formulas were also drug into court for settlements this was a big deal and now we have another lawsuit with again other insurers being named for using the formulas of ingenix once again here s a case that has not settled yet as an example and one that just recently settled cigna legal case with ingenix flawed formulas for out of network payments allowed to proceed under erisa can t avoid the claims ingenix optum united healthcare lawsuits still bouncing around out there one recently settled in new jersey with horizon blue cross blue shield that was still using the flawed and corrupt data base for out of network payment calculations a couple years ago medicare said they were going to rerun the medicare risk assessment scores so there was no secret as to what was going to occur with an audit cms to rerun the medicare advantage risk scores dating back to 2008 to catch the automated risk fiddlers of said insurer fraud amounting to around 70 billion be ready for it there are other lawsuits on the books that have not settled yet in other areas like this one with mental health that could go to a class action suit too class action lawsuit filed against unitedhealthgroup and their various subsidiaries there of relative to mental health claim denials violation of parity laws here s a back link to the big settlement by the ama again this is only one of many and at the time i was writing a series of blog posts called the attack of the killer algorithms and this was chapter 19 ama announces doctors and patients can expect to see the unitedhealthcare ingenixclass action settlement checks in the mail soon out of network short payments attack of the killer algorithms chapter 19 unitedhealthcare erisa class action lawsuit expanded to include dme and ambulatory surgical center providers if you missed this along the way things go so ugly with the ingenix name united healthcare changed it to optum which you see all over the place today as they are buying up broke doctor practices and urgent care centers like they are going out of style there s 2 sides to united healthcare one that does insurance and the other optum side that s buying up and creating software was well as consuming and acquiring companies that have anything to do with doctors unitedhealth group announced re branding of business units focus on optum changes ingenixname to optuminsight so again with this new lawsuit which was created from the efforts of a high ranking former united healthcare executive not just an employee we are seeing the same process again ingenix algorithms and models followed to fiddle with risk scores make patients look sicker and get more money from the government this time instead of doctors express scripts ended up at one point in time a while back buying the old united healthcare pharmacy benefit business and acquired some software and algorithms in the process and in 2010 was bragging how they are going to predict if you will take your medications this flawed scoring still goes on today express scripts new program to contact and predict patients who may not be taking their medicine based on ingenixalgorithms we want the revenue please don t stop medication adherence predictions enter the world of quantitated justifications for things that are just not true members of the proprietary code hosing clubs out there destroying your privacy the entire lawsuit can be read here and there s quite a few pages to the pdf to read benjamin poehling was the former high ranking executive that filed the whistle blower lawsuit it s kind of uncanny that poehling came from arthur andersen where the current ceo of united healthcare worked as anderson s cfo and all the enron issues were on his watch enron lead to the end of the arthur andersen auditing firm due to fraud here s a few quotes from the suit united s senior management push relentlessly to increase united s revenue from risk adjustment tellingly uhmr has assigned risk adjustment to its finance department not one of its clinical departments relator was assigned to his job despite having no clinical background in 2010 and 2011 uhmr has implemented projects referred to as remediation plans focus area projects or affordability agendas to increase ioi uhg engages in an aggressive and extensive effort to find a justification or pretext to submit risk adjustment claims for additional diagnoses regardless of whether the patient had or was actually treated for the diagnosis in the relevant period by a qualifying provider united s program has some components that are broad based and others that target specific high value hccs as an overall goal uhg attempts to reach each of its members at least once every two years through one of its programs designed to find additional risk adjustment claims ingenix conducts chart reviews on behalf of uhmr uhcs and commercial clients in the retrospective chart review process ingenix identifies provider charts to review and arranges for the charts to be collected it uses both internal coders and also contracts with external vendors to review and code the charts 129 these vendors review charts using a blind review in a blind review the reviewer codes every condition he or she identifies from the chart without knowing what codes the provider identified from the chart previously thus the reviewer works from the raw chart material and reaches independent conclusions under the coi program united pays providers approximately 100 for each diabetes patient they assess for diabetes complications submit a supporting diagnosis via a claim and submit a medical record with matching documentation in addition it pays 200 for each doctor that receives training on the coi program and diagnosis coding recently the coi program has expanded to other conditions that united suspects are frequently undercoded such as chronic kidney disease ckd and chronic pulmonary disease copd relator knows that at least the following united executives know about some or all of the problems discussed herein and have participated in the scheme to continue submitting fraudulent claims and to refuse to correct previously submitted false claims stephen hemsley uhg chief executive officer gail boudreaux uhg executive vice president and ceo of united healthcare larry renfro optum ceo tom paul uhmr chief executive officer cindy polich uhmr president lee valenta ingenix s former chief operating officer and current president of ingenix s life sciences division jack larsen former cfo of psmg and current ceo of uhcs scott theisen uhmr senior vice president of finance jeff dumcum senior vice president of ingenix and david orbuch psmg chief compliance officer and this united s refusal to correct errors in its risk adjustment claims is so extreme that it submits risk adjustment claims to cms for diagnoses taken from claims that it itself refuses to pay as being fraudulent and or abusive united developed playbooks containing ideas for increasing its risk scores these playbooks are garnering top level attention at the company while the myriad problems with united s risk adjustment programs and processes go unresolved 195 united conceals the one way nature of its risk adjustment programs from cms and even its investors for example united s remediation plan for 2010 that sought to increase ioi by 800 million allocated 100 million to project 7 project 7 was united s codeword for initiatives to increase risk adjustment payments the company used a codeword as opposed to growth enrollment or claims because it did not want cms or other investigatory government agencies to know it had a campaign to claim an additional 100 million through risk score increases united customizes its kickbacks depending on the nature of its overall reimbursement arrangement with the provider group the providers united chooses to pay additional amounts for increased risk scores are those that do not already have an incentive to upcode diagnoses united uses three basic payment structures for its providers 1 percent of premium capitated providers which receive a percent of united s cms premiums for its patients 2 fixed capitated providers which receive pmpm payments from united that are not tied to united s cms premiums and 3 feefor service providers which are paid based on the claims they submit to united if you made it through those paragraphs you can easily see how complex insurers have made medical billing for sure once again we come back to the business models of ingenix and some of the automation in the irad data base to work these claims here s another billing subsidiary united bought again we re talking coding and billing here ingenix wholly owned technology subsidiary of unitedhealth to acquire a life coding software services tons of money and profit with coding transactions and algorithms subsidiary watch i talk too about the united optum incest at times too with hhs and cms and here s a blast from a few years ago this was the beginning of pushing population health that all know the term and nobody really knows what it does half the time to even include vendors of the algorithmic processes this is where the government bought yet another united healthcare model reach for the top program combines prototype from ingenix a wholly owned subsidiary of united healthcare for public private community health data on hhs gov site simon stevens who is now running the nhs and worked at united healthcare a few years ago had this to say united health care says cheaper efficient doctors and reducing hospital visits by the elderly would help reduce the cost of healthcare former acting director of cms andy slavitt claims simon is a good friend of his and let s not forget that andy slavitt was the ceo of ingenix when a lot of this was going on larry renfro came in later from his executive position at aarp to run the ingenix show united healthcare sure seems to be lining up some big executives as well with last year hiring the former ceo of stanford university healthcare to work for united as a vp and recently in the uk optum hired nick seddon who worked for david cameron as his special healthcare adviser there s a group in the uk that is also bringing attention to the fact that one company united optum has been taking over way too much ground and is not leaving enough competition out there with other countries the entire suit takes a while to read but there s a ton of detailed explanations as to what united and other insurers taking advantage of their consulting and billing services are accused of again do leopards change their spots here s another suit you might want to read about it just does not stop when you have complex built algorithms that can spin around faster than you can take a deep breath to score and stick you with more risks than you ever dreamed of all for the sake of making money from the government cigna united healthcare face class action suits pbm over charging customers for prescriptions optumrx pharmacy benefit management software front running consumers with killer algorithms at the drug store feel free to search this blog there s plenty of information like this written since 2008 on how companies cheat with computer code and algorithms bd united healthcare the largest provider of medicare advantage ma plans services is being sued by the department of justice doj for fraud to give you a sense of united healthcare s size consider that just their third quarter revenue was 46 3 billion up 11 6 per cent from the same period a year earlier and the bulk of the growth was billing services and data analysis for healthcare groups which ws up 34 percent since the beginning of 2016 medical charts the primary source of diagnostic data were reviewed looking for incremental increases but not for errors that would decrease the risk adjustment new diagnostic codes were submitted but an erroneous diagnosis was not deleted on a two way street they do not look both ways and these reviews were profitable a 30 cost for chart review resulted in an average o...