Tag: Insurance

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Health Law Highlights

AI in the Health Insurance Industry: An Explainer and Research Roundup

Summary of article from The Journalist’s Response, by Rachel Layne:

As artificial intelligence (AI) becomes increasingly prevalent in health insurance, U.S. states are seeking to regulate its use due to concerns of racial bias and flawed coverage determinations. Major health insurers like Humana, Cigna, and UnitedHealth face lawsuits over alleged improper use of AI in coverage decisions. Various state and federal initiatives aim to increase transparency around AI systems’ creation, data inputs, and decision-making algorithms. The National Conference of State Legislatures reports that at least 40 states have introduced or passed AI-regulating legislation in 2024, with many states modeling their regulations on guidance from the National Association of Insurance Commissioners. However, the varying rules across states could pose challenges for insurers.

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Health Law Highlights

ACA Health Insurance Plans Are Being Switched Without Enrollees’ OK

From National Public Radio, by Julie Appleby:

Some consumers are being switched from one ACA insurance plan to another without their consent, potentially disrupting their medical care and prescription needs. This unauthorized switching can also lead to large IRS bills for back taxes. Agents can access a policyholder’s coverage using only a person’s name, date of birth, and state. This ease of access plays a significant role in the problem.

Consumers may end up in plans they did not choose and may bear tax burdens if they are signed up for coverage that includes premium tax credits for which they are ineligible.

The Centers for Medicare & Medicaid Services (CMS) is aware of the problem and has outlined technical efforts to resolve issues when complaints are lodged. However, it is unclear whether these efforts will be sufficient. CMS is considering further regulatory and technological solutions, including two-factor authentication. States that run their own marketplaces have been more successful in preventing unauthorized switches as they require more information before a policy can be accessed.

The issue is causing an outcry from agents who lose out on commissions when their clients are switched by other agents. It also casts a shadow on a record year for ACA enrollment, with more than 21 million people signing up for 2024 coverage.

Florida, Georgia, and Texas appear to be hotspots for plan-switching. 

Some agents suspect names and lists of potential clients are being circulated to agents willing to bend the rules. Online or social media advertising is a way some outfits troll for prospects, who then end up on lists sold to brokers or are contacted directly by agents.

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Health Law Highlights

UnitedHealth Defends Lucrative Billing Tactic in Appeals Court

From Bloomberg Law, by Jacklyn Wille:

  • “Cross-Plan Offsetting” is the practice by an insurer of clawing back benefits it says were overpaid to a provider under one plan by reducing future payments to the provider under a different plan that it administers.
  • This common insurance billing tactic has invited litigation over its legality and opposition from the Labor Department.
  • In one such case, the Eighth Circuit is being asked to decide whether Smith and Ghanim, who are covered by health plans funded by their employers and administered by United, have been harmed in a way that would give them standing to challenge the practice under ERISA.