$400 Million Algorithmic System Illegally Denied Thousands of Medicaid Benefits (gizmodo.com) 64
An anonymous reader quotes a report from Gizmodo: Thousands of Tennesseans were illegally denied Medicaid and other benefits due to programming and data errors in an algorithmic system the state uses to determine eligibility for low-income residents and people with disabilities, a U.S. District Court judge ruled this week. The TennCare Connect system -- built by Deloitte and other contractors for more than $400 million -- is supposed to analyze income and health information to automatically determine eligibility for benefits program applicants. But in practice, the system often doesn't load the appropriate data, assigns beneficiaries to the wrong households, and makes incorrect eligibility determinations, according to the decision (PDF) from Middle District of Tennessee Judge Waverly Crenshaw Jr.
"When an enrollee is entitled to state-administered Medicaid, it should not require luck, perseverance, and zealous lawyering for him or her to receive that healthcare coverage," Crenshaw wrote in his opinion. The decision was a result of a class action lawsuit filed in 2020 on behalf of 35 adults and children who were denied benefits. [...] ]Crenshaw found that TennCare Connect did not consider whether applicants were eligible for all available programs before it terminated their coverage. Deloitte was a major beneficiary of the nationwide modernization effort, winning contracts to build automated eligibility systems in more than 20 states, including Tennessee and Texas. Advocacy groups have asked (PDF) the Federal Trade Commission to investigate Deloitte's practices in Texas, where they say thousands of residents are similarly being inappropriately denied life-saving benefits by the company's faulty systems.
"When an enrollee is entitled to state-administered Medicaid, it should not require luck, perseverance, and zealous lawyering for him or her to receive that healthcare coverage," Crenshaw wrote in his opinion. The decision was a result of a class action lawsuit filed in 2020 on behalf of 35 adults and children who were denied benefits. [...] ]Crenshaw found that TennCare Connect did not consider whether applicants were eligible for all available programs before it terminated their coverage. Deloitte was a major beneficiary of the nationwide modernization effort, winning contracts to build automated eligibility systems in more than 20 states, including Tennessee and Texas. Advocacy groups have asked (PDF) the Federal Trade Commission to investigate Deloitte's practices in Texas, where they say thousands of residents are similarly being inappropriately denied life-saving benefits by the company's faulty systems.
Denying beneifts (Score:5, Insightful)
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But just because the computer system denied the benefits, doesn't mean they don't get them. This leads to a human having to manually fix it. Deloitte should have to pay for that extra work.
Re:Denying beneifts (Score:5, Insightful)
Re:Denying beneifts (Score:5, Insightful)
But just because the computer system denied the benefits, doesn't mean they don't get them. This leads to a human having to manually fix it.
They get the healthcare benefits only if they have "luck, perseverance, and zealous lawyering" (quoting the words of the judge).
That's not the way it's supposed to work. And I'll say, from personal experience, that it is sometimes hard to navigate the runaround from insurance companies to pharmacies to healthcare providers and back to insurance companies when you are sick.
Deloitte should have to pay for that extra work.
Including paying the people who had to benefits denied for their time, persistence, and lawyers.
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We already lost the narrative battle (Score:2, Insightful)
and yes, I have a right to your time if you're a doctor. Who's taxpayer dollars did you think paid for the medical advancements that make your jobs something more useful than leaches and tonics? Don't like it? Tough. This is civilization. You don't get to opt out of it.
Re:We already lost the narrative battle (Score:4, Informative)
I'm extremely liberal, and in favor of "socialized" healthcare ... and even I think that is a brain-dead take.
Your position is effectively that anyone who becomes a doctor is now a slave to society.
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Why so eager to resort to slavery? For all the other rights people get paid for their time (eg cops, judges, etc).
Re: We already lost the narrative battle (Score:1)
You donâ(TM)t have the right to a cop or judge either, you have the right to self defense and the right to a trial in case you are accused by the government or other citizens, but you donâ(TM)t just show up and get a cop or a judge to take home whenever you want some legal advice.
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And somehow judges aren't slaves to society just because we have a right to a trial? But doctors would be?
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You don't have a right to a trial is my point, you can't just show up at court and start a trial, only the government has the right to compel you to trial. You have the right to defend yourself in a trial and pick an attorney, just like you should have the right to go to a hospital and pick your own doctor instead of having one chosen for you at a time that is convenient and not too expensive for the government.
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Rights are things inherent in yourself. Benefits come from an outside source.
Healthcare is something we, as a society, should ensure that everyone has. But it is not a right. It is something that someone else provides for/to you. It is a benefit of living in a functional society...
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Your daily reminder that left side of the political spectrum has always been the party of slavery. From Communist megafactories in Soviet Union that even Hitler with his slave labor camps considered atrocious, to modern day "the worst among the society should be slave masters, entitled to be able to force their betters to slave for them for free".
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Mod parent Funny. That was the joke I was searching for, though in a short form.
However it also has to be moderated as "too obvious". (Current moderations are all Insightful, but I don't think it really rises to that level.)
and if numerous people are found to have died due (Score:2)
Is the problem confined to Texas and Tennessee? (Score:2)
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It takes regular doctors visits and staying on top of your own healthcare to survive. If you have a disability, you better have someone to take care of you or else you are screwed. Even if that disability is severe anxiety or depression, b
we need SINGLE-PAYER HEALTH CARE! (Score:5, Insightful)
we need SINGLE-PAYER HEALTH CARE!
and cut out most of the middle men in the system driving up costs.
Re:we need SINGLE-PAYER HEALTH CARE! (Score:4, Insightful)
A million times this. It would save our country a shit ton of money too as we spend far more per patient than any country with single-payer and yet basically get the same quality of service.
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we spend far more per patient than any country with single-payer and yet basically get the same quality of service.
Worse, actually.
Infant mortality: USA is #49 vs. #40 in Cuba.
Life expectancy: USA is #43 (78.88 years) vs. #21 in UK (80.97). Lebanon is ranked #42.
Certainly healthcare in the USA is among the best in the world, for those that can afford it. The problem is that so few people can afford it.
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We absolutely need it ... but who is going to go convince all the ignorant (note I did NOT say "stupid") people who believe the exact opposite of reality, and think their health care will suffer if socialized?
Before anything else, we need to fix our system of governance to give moneyed interest less of a say. Nothing else significant (or at least, nothing which clashes with moneyed interests ... so 95% of things?) will ever be accomplished until that happens.
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Reality is that you want a mixed system with correct incentives and very strict anti-competition clauses. US has problems because so many service providers were allowed to monopolize certain areas, and because person with a bad medical conditions isn't in a position to shop around. Just like he's not in a position to wait in a queue.
Since payer tends to encourage extreme queues due to chronic under investment over the long run. This is what you're seeing in many nations across Europe right now. To the point
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"We" meaning you. Apparently you've never lived in Canada or elsewhere that has socialized medicine. No one living in the US goes to Canada or the UK for major things like a hip replacement or hand surgery. Instead people from those places come here because you can get the surgery immediately. The wait is over 3 months in the UK for hand surgery. When I lived in Canada the wait was 2-1/2 years for hip replacement. Your little paradise of free medical care comes at two costs--high taxes and rationed res
Medicade applications denied by an Al Gore-ithm? (Score:2)
Say it ain't so, Al. Say it ain't so.
Sorry, couldn't resist.
This was by design. (Score:2)
Health insurance companies are totally corrupt. They make good money by denying claims.
LOL, "Errors" (Score:5, Informative)
I had a friend who did Oracle development; he worked for Blue Cross adding these exact "claim denial" features back in the 1980s. They even talked about "plausible deniability" if/when the "features" were found.
It was a complex algorithm but the end result is that many claims were flat-out denied for literally no reason at all, then contesting the claims also usually got denied, and it was all according to a "scale".
The more aggressive you were in fighting the judgement the more likely you were to (eventually) win. Sometimes. Not always.
But most people gave up after one or two tries, and so Blue Cross got to keep every penny of those claims- claims that they definitely should have paid, no question about it.
These aren't software errors, trust me. These are design features.
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Way back in the late 1970s when I first encountered Blue Cross in my youth I naively assumed that when you made a claim they would evaluate your submission and it it met the guidelines, approve it. I did not know then (it was much, much harder to discover stuff like this before the Internet) that at that time Blue Cross automatically denied all claims on first submission. You had to make an appeal before they would actually evaluate what you submitted.
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And you can probably thank my friend (now deceased) for that, or a dozen other guys like him that 'enhanced' the Blue Cross 'billing system' to the point where it wouldn't pay claims.
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Be quiet, pussyfart.
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400 Million, why? (Score:5, Insightful)
Effectively this is just a DB frontend, with some correlating logic. I'm not suggesting its easy to standup, but it's not that hard to stand up either. Lets assume 20 developers worked on the system, each making $100k / year. Lets assume 10 in the IT, DevOps, DevSecOps, 10 QA, and another 20 people for other stuff, all making $100k. That's 60 people at $100k / year or $6 million / year. Even if you paid them $200k, and factor in $50k / month of infrastructure for two years, that's only $25 200 000.
There is no way you can possibly get to $400 Million, hell, you can't get to $100 Million, someone committed major fraud, and in the process hurt people. Stop awarding contract to con-artists, any one who approved this project should be in jail.
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Effectively this is just a DB frontend, with some correlating logic.
I won't defend the number. I agree it is truly, mind-boggling obscene. But this is an oversimplification. It is very likely this needs to interact with a bunch of other byzantine federal systems like the IRS and Social Security. This means the security governance and interagency agreements of the whole project will be unbelievably difficult and full of bureaucracy.
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In fairness, the Oracle licenses were probably $395m so $5m for the rest of the system was quite a deal actually.
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Nah. You'd hope so, honestly, because at least there would be a good, solid reason behind it. One that nicely made sense.
But it's not. It's a mush of incompetence, more incompetence, hubris, stupidity, penny pinching, yet more incompetence, another dose of hubris, politics (see also stupidity, incompetence and hubris) and of course plenty of good, old fashioned incompetence.
Honestly part of me would love to think that there is a Blofeldt, Gruber or hell even Ming the Merciless somewhere behind there pulling
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We'll spend any amount of money (Score:3)
Thing is the ghouls who support that vote. They won't show up to this thread. They'll keep their heads down in shame on threads like this. But they vote.
You can't reason with them. All you can do is wait for them to die and hope their bad ideas die with them.
If they were denied, they didn't deserve benefits. (Score:2)
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Similar to "law and order" and policing.
Many people would rather spend ten times the amount on the police and prisons than fund social care, tackle poverty and reduce the root causes of crime.
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to prevent anyone from getting anything they don't "deserve". So much so that we've been caught spending more denying healthcare and taking food from children than it costs to just let them have it.
Thing is the ghouls who support that vote. They won't show up to this thread. They'll keep their heads down in shame on threads like this. But they vote.
You can't reason with them. All you can do is wait for them to die and hope their bad ideas die with them.
The scary thing is, the ghouls who vote for the people that permit this kind of thing are the ones who are most often the victims of it, but just don't want to acknowledge it.
It's the same kind of people who spout "own the libs" and "end wokeness and DEI" that also think "the government shouldn't be giving out free food and healthcare"... however they're also the people who generate the greatest welfare burden. As long as it isn't going to the wrong poor people... They'll happily vote for the candidate w
uhmmm (Score:1)
I used to work for insurance companies (Score:5, Interesting)
Turns out, many of them were doing extremely shady things. In one egrigious case, the claim had have been denied three times before it got a review by an actual human claims processor. They were just trying to fuck the insured folks out of coverage. I then pointed this out and complained to my CIO who was my direct boss. She told me to put a lid on it. I told her that the only way I was going to do that is if myself and 20 people who worked for me were not going to work on the account ever again. That was the only thing I'd accept short of firing the customer or firing me. In the end, I guess I must have been valuable because they actually agreed. This was a big name insurance company but only a small branch in a small state. So, that's probably why. Had I picked on United or BCBS, they'd have probably shitcanned me. I quit shortly thereafter anyway for another ethical conflict.
Continental Can case (Score:4, Interesting)
A million years ago in the then-required Engineering Ethics class we studied the Big Company Can case. As Big Company gradually spiraled down from a literal continental-scale manufacturing powerhouse to a small specialty supplier its workforce naturally shrank and its pension liabilities increased - jeopardizing the existence of the company (perhaps) or the salaries of the top executives (certainly). The executives responded by commissioning a small and secret group of mathematicians and programmers (data processing coders in the jargon of the day) to develop algorithms to find the employees that would have the most cost effect on the pension system and then schedule them for re-assignment, transfer, demotion, "promotion" with a move, isolation at remote plants, etc until they either quit or were in a position to be "downsized" - that is, fired - just before they reached age 55 or 30 years of service [1]. Thus improving the financial position of the pension system, the company, and the executive salaries.
Big Company Can eventually lost a large lawsuit over this, but not before it destroyed thousands of people's lives and many of them died. There was also some criminal investigation by various justice agencies but IIRC prosecution was not pursued.
At the time this was taught as unethical behavior to be avoided, if necessary by resignation and whistle-blowing. Today I guess it is viewed as behavior and technical skill worthy of a merit bonus.
[1] the algorithm of course knew which plants were scheduled for closure in 6, 12, and 24 months, which the employees did not know when agreeing to accept a transfer
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It needs to be said (Score:2)
"In practice, the system [in Tennessee] often doesn't load the appropriate data, assigns beneficiaries to the wrong households, and makes incorrect eligibility determinations, [and in Texas] thousands of residents are similarly being inappropriately denied life-saving benefits by the company's faulty systems."
Of course, there's nothing faulty about the algorithmic system whatsoever. The people being targeted are poor and disabled, and unlikely to fight back. It is saving the states money by working precis
$400M for less than $40M annual savings (Score:4, Insightful)
Embrace. Extend. Extinguish. (Score:2)
Automation not always a great thing (Score:2)
Medicaid is insane (Score:2)
Medicaid is actually a huge bundle of different programs, some of which are federal and some of which are operated by states. And there is substantial leeway in the law in terms of how it can be interpreted as well, and some states are far more charitable about it than others. This is fairly understandable when it comes to state-implemented programs (which the states are paying for) but somewhat inexplicable when we're talking about the federal programs, which are federally funded down to the workforce that
I worked for an agency that had Deloitte (Score:3)
Again with the no Funny (Score:2)
...for another rich target story.
fyi $$ (Score:2)
Just for the record, the Federal govt in 2023 spent over $800 billion on Medicaid, and about $900 billion on Medicare. That, I don't believe, includes the state contributions to Medicaid. States do not contribute to Medicare.