[johnohara]

In December 2021, the American Hospital Association issued the following statement regarding United Healthcare's plans to closely scrutinize medical claims for ER visits. [0]

UHC subsequently reversed itself and delayed the plan for 6 months. That was in 2021-2022. It's now 2024-2025.

Around that time many insurers, not just UHC, began implementing AI-assisted claims adjudication. It was a bumpy ride with a steep learning curve and probably took a couple of years to fine-tune the algorithms and learning models.

Especially as the Covid-19 claims tsunami subsides.

No matter tho', every claim paid is considered a loss by insurers. Every claim denied is considered a small step towards mitigating those losses.

In the U.S., medical reimbursement is a push and shove, shove and push battle fought inch by inch with high-speed data systems. It has been that way for a long time.

[0] https://www.aha.org/special-bulletin/2021-12-29-aha-expresse...

[nradov]

That's simply not how the system works. For the most part, medical insurers no longer provide much real "insurance" in the sense of bearing risk. Instead they mostly act as administrators for employer self-funded health plans. Since insurers are subject to an 85% minimum medical loss ratio, every paid claim is actually a gain because they get to take up to 15% from a larger revenue stream. The majority of the pressure to tighten coverage rules actually comes from those large employers since they're the ones ultimately paying the bills.

https://www.cms.gov/marketplace/private-health-insurance/med...

If anyone wants to see real reform then eliminating employer sponsored health plans is one potential way to get the incentives more properly aligned.