The insurance industry has many facets. In health care its roles range from health care coverage to disability and workman’s compensation to liability. Three important areas of concern, which all tie into the medical insurance claims process are:

(1) identification and management of risk

(2) understanding and controlling costs

(3) verifying that a claim is appropriate

Health care-related decision making can be much improved for all three areas listed above when it relies upon evidence-based studies and information in the form of medical algorithms

Risk Management

Health care procedures may entail risk. While the goal may be to improve the patient’s health, complications can have the opposite effect and are more regrettable if the procedure was not clearly indicated. Optimizing outcomes may require careful selection of patients and taking steps to mitigate risk factors impacting a surgery and its rehabilitation. Pre- and peri-operative algorithms can help to identify a patient who may be at increased risk for a complication, allowing for an early intervention or a change in management.

Appropriateness of Care

Care is appropriate when the diagnosis is known, an intervention is effective for that diagnosis, and it has the best profile for safety and cost. Concerns arise when the diagnosis is uncertain, clear indications are lacking, an intervention carries significant risk and cost is excessive. Although physicians dislike precertification, it is one way of establishing checks and balances in care. Algorithms can help by clearly documenting facts about a case quickly. Use of blockchain technology allows people to have confidence in how and why a decision was made.

More Appropriate Alternative for the Patient

Not all interventions are appropriate for a patient. Algorithms can help to identify situations when a procedure may be contraindicated or may have little benefit. The use of an evidence-based algorithm may be viewed as less arbitrary. It can also be a starting point for a meaningful discussion.

A situation that can be especially difficult is recognizing a patient with a terminal disease who may be better served by hospice than continued care proffering a false hope of cure.

Not Always What It Seems – Illegitimate Claims

While most claims are legitimate, insurers have to keep an eye out for a false claim with payment for a non-existent condition. An unscrupulous person can often find ways to “play the system” when delivery of care is fragmented. Algorithms are one way of monitoring data and identifying inconsistencies that might otherwise be missed.

Take Home Message

Insurance is incredibly important for financing health care. Insurance coverage decisions and the medical insurance claims process have a huge impact on patients’ lives. Every step should be taken to make the best decisions possible from the perspective of the insurance company and the patient. Medical algorithms can play a major role in improving insurance coverage decisions by standardizing processes and relying upon scientific medical evidence, in the form of medical algorithms, throughout the decision making process.