Latest news with #healthinsurance
Yahoo
an hour ago
- Health
- Yahoo
How artificial intelligence controls your health insurance coverage
Over the past decade, health insurance companies have increasingly embraced the use of artificial intelligence algorithms. Unlike doctors and hospitals, which use AI to help diagnose and treat patients, health insurers use these algorithms to decide whether to pay for health care treatments and services that are recommended by a given patient's physicians. One of the most common examples is prior authorization, which is when your doctor needs to receive payment approval from your insurance company before providing you care. Many insurers use an algorithm to decide whether the requested care is 'medically necessary' and should be covered. These AI systems also help insurers decide how much care a patient is entitled to — for example, how many days of hospital care a patient can receive after surgery. If an insurer declines to pay for a treatment your doctor recommends, you usually have three options. You can try to appeal the decision, but that process can take a lot of time, money and expert help. Only 1 in 500 claim denials are appealed. You can agree to a different treatment that your insurer will cover. Or you can pay for the recommended treatment yourself, which is often not realistic because of high health care costs. As a legal scholar who studies health law and policy, I'm concerned about how insurance algorithms affect people's health. Like with AI algorithms used by doctors and hospitals, these tools can potentially improve care and reduce costs. Insurers say that AI helps them make quick, safe decisions about what care is necessary and avoids wasteful or harmful treatments. But there's strong evidence that the opposite can be true. These systems are sometimes used to delay or deny care that should be covered, all in the name of saving money. Presumably, companies feed a patient's health care records and other relevant information into health care coverage algorithms and compare that information with current medical standards of care to decide whether to cover the patient's claim. However, insurers have refused to disclose how these algorithms work in making such decisions, so it is impossible to say exactly how they operate in practice. Using AI to review coverage saves insurers time and resources, especially because it means fewer medical professionals are needed to review each case. But the financial benefit to insurers doesn't stop there. If an AI system quickly denies a valid claim, and the patient appeals, that appeal process can take years. If the patient is seriously ill and expected to die soon, the insurance company might save money simply by dragging out the process in the hope that the patient dies before the case is resolved. This creates the disturbing possibility that insurers might use algorithms to withhold care for expensive, long-term or terminal health problems , such as chronic or other debilitating disabilities. One reporter put it bluntly: 'Many older adults who spent their lives paying into Medicare now face amputation or cancer and are forced to either pay for care themselves or go without.' Research supports this concern – patients with chronic illnesses are more likely to be denied coverage and suffer as a result. In addition, Black and Hispanic people and those of other nonwhite ethnicities, as well as people who identify as lesbian, gay, bisexual or transgender, are more likely to experience claims denials. Some evidence also suggests that prior authorization may increase rather than decrease health care system costs. Insurers argue that patients can always pay for any treatment themselves, so they're not really being denied care. But this argument ignores reality. These decisions have serious health consequences, especially when people can't afford the care they need. Unlike medical algorithms, insurance AI tools are largely unregulated. They don't have to go through Food and Drug Administration review, and insurance companies often say their algorithms are trade secrets. That means there's no public information about how these tools make decisions, and there's no outside testing to see whether they're safe, fair or effective. No peer-reviewed studies exist to show how well they actually work in the real world. There does seem to be some momentum for change. The Centers for Medicare & Medicaid Services, or CMS, which is the federal agency in charge of Medicare and Medicaid, recently announced that insurers in Medicare Advantage plans must base decisions on the needs of individual patients – not just on generic criteria. But these rules still let insurers create their own decision-making standards, and they still don't require any outside testing to prove their systems work before using them. Plus, federal rules can only regulate federal public health programs like Medicare. They do not apply to private insurers who do not provide federal health program coverage. Some states, including Colorado, Georgia, Florida, Maine and Texas, have proposed laws to rein in insurance AI. A few have passed new laws, including a 2024 California statute that requires a licensed physician to supervise the use of insurance coverage algorithms. But most state laws suffer from the same weaknesses as the new CMS rule. They leave too much control in the hands of insurers to decide how to define 'medical necessity' and in what contexts to use algorithms for coverage decisions. They also don't require those algorithms to be reviewed by neutral experts before use. And even strong state laws wouldn't be enough, because states generally can't regulate Medicare or insurers that operate outside their borders. In the view of many health law experts, the gap between insurers' actions and patient needs has become so wide that regulating health care coverage algorithms is now imperative. As I argue in an essay to be published in the Indiana Law Journal, the FDA is well positioned to do so. The FDA is staffed with medical experts who have the capability to evaluate insurance algorithms before they are used to make coverage decisions. The agency already reviews many medical AI tools for safety and effectiveness. FDA oversight would also provide a uniform, national regulatory scheme instead of a patchwork of rules across the country. Some people argue that the FDA's power here is limited. For the purposes of FDA regulation, a medical device is defined as an instrument 'intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease.' Because health insurance algorithms are not used to diagnose, treat or prevent disease, Congress may need to amend the definition of a medical device before the FDA can regulate those algorithms. If the FDA's current authority isn't enough to cover insurance algorithms, Congress could change the law to give it that power. Meanwhile, CMS and state governments could require independent testing of these algorithms for safety, accuracy and fairness. That might also push insurers to support a single national standard – like FDA regulation – instead of facing a patchwork of rules across the country. The move toward regulating how health insurers use AI in determining coverage has clearly begun, but it is still awaiting a robust push. Patients' lives are literally on the line. This article is republished from The Conversation, a nonprofit, independent news organization bringing you facts and trustworthy analysis to help you make sense of our complex world. It was written by: Jennifer D. Oliva, Indiana University Read more: Artificial intelligence in medicine raises legal and ethical concerns How can Congress regulate AI? Erect guardrails, ensure accountability and address monopolistic power Beyond AI regulation: How government and industry can team up to make the technology safer without hindering innovation Jennifer D. Oliva currently receives funding from NIDA to research the impact of pharmaceutical industry messaging on the opioid crisis among U.S. Military Veterans. She is affiliated with the UCSF/University of California College of the Law, San Francisco Consortium on Law, Science & Health Policy and Georgetown University Law Center O'Neill Institute for National & Global Health Law.
Yahoo
2 hours ago
- Business
- Yahoo
UnitedHealth Just Got a $418 Price Target -- Here's Why It Matters
June 20 - UnitedHealth Group (NYSE:UNH) received a price target hike from JPMorgan's Lisa Gill, who now sees the stock reaching $418, up from $405. The revised target suggests a potential upside of nearly 36%, according to a Thursday note. Warning! GuruFocus has detected 4 Warning Sign with UNH. Shares of the health insurance provider have fallen about 39% so far this year, pressured by rising costs in its Medicare Advantage business and weaker-than-expected first-quarter earnings. A recent CEO change also added to investor concerns. Gill adjusted her forecasts after a meeting with UnitedHealth's leadership. While acknowledging the pressure from higher physician visits and outpatient claims, she expects the company to refocus on profitability rather than aggressive membership expansion. Looking ahead, Gill anticipates slower Medicare Advantage enrollment growth through 2026. She said UnitedHealth may scale back its offerings and exit underperforming plans over the next year. Still, the analyst believes margins could come in at the low end of the company's 3% to 5% goal for the Medicare segment. If that plays out, earnings may beat current expectations. Gill maintained an Overweight rating, suggesting she remains optimistic about a potential rebound. Based on the one year price targets offered by 24 analysts, the average target price for UnitedHealth Group Inc is $380.92 with a high estimate of $677.00 and a low estimate of $270.00. The average target implies a upside of +24.00% from the current price of $307.20. This article first appeared on GuruFocus. Sign in to access your portfolio
CNA
3 hours ago
- Business
- CNA
Mount Elizabeth hospitals not always most expensive among private providers, CNA finds
SINGAPORE: Despite its reputation for premium pricing, Mount Elizabeth hospitals do not consistently charge the highest fees among private healthcare providers in Singapore, a CNA review of medical billing data has found. Based on typical bills for 10 common medical procedures listed on the Ministry of Health's (MOH) cost comparison portal, Mount Elizabeth topped the list in only three cases. The "typical bill" refers to the median cost paid by patients in 2023. While Mount Alvernia Hospital was found to be cheaper in some instances, it was excluded from CNA's comparison as it operates as a not-for-profit institution. In the three cases where Mount Elizabeth was most expensive, Mount Elizabeth Novena charged 5.1 per cent more for a knee arthroscopy, 11.3 per cent more for hernia repair and 38.2 per cent more for an appendicectomy compared with the next-most expensive private hospital option. However, the same data showed that Mount Elizabeth is not always the costliest option. For example, fibreoptic colonoscopy day surgery and iridectomy at Mount Elizabeth Orchard and Novena were cheaper than at other private hospitals. Insurer Great Eastern announced on Tuesday (Jun 17) that it has stopped issuing pre-authorisation certificates for policyholders admitted to the two Mount Elizabeth hospitals. Such certificates are still available for other hospitals and day surgery centres, it said. Pre-authorisation refers to the insurer's approval of coverage for medical costs before treatment. 'In the last few years, we have observed that certain private hospitals have been charging significantly more than others for the same treatment, same clinical outcome, similar level of complexity, as well as for procedures that are less complex," the insurer said on Thursday in response to CNA's queries. "The cost difference in total bill size typically ranges between 20 and 30 per cent but can sometimes go higher in some cases.' Based on MOH data, the typical inpatient bill for a knee arthroscopy – a surgical procedure to diagnose problems within the knee joint – at Mount Elizabeth Novena was S$22,559 (US$17,560) and S$22,208 at Mount Elizabeth Orchard. It was cheaper at Gleneagles Hospital, which charged S$21,456. For an appendicectomy – removal of the appendix – Mount Elizabeth Novena charged S$30,808, compared with S$22,297 at Raffles Hospital, while for hernia repair, Mount Elizabeth Novena charged S$35,944, higher than the S$32,288 charged by Gleneagles. In contrast, iridectomy, a surgical procedure primarily to treat glaucoma, was cheaper at Mount Elizabeth Orchard (S$2,367) and Mount Elizabeth Novena (S$2,602) compared with Farrer Park (S$3,874). Beyond MOH's data, CNA reviewed itemised hospital bills from Mount Elizabeth Orchard, Parkway East and Gleneagles over the past two years. While Mount Elizabeth charged marginally more for common items such as hygiene sheets and lignocaine injections (1.7 to 7.7 per cent higher), it charged less for other items, such as ECG electrodes. Mount Elizabeth Orchard and Novena are operated by IHH Healthcare Singapore, the country's largest private healthcare provider. Other hospitals under its umbrella – including Gleneagles and Parkway East – are not affected by Great Eastern's pre-authorisation suspension. CNA contacted IHH and Great Eastern for comment on the pricing differences. In response, IHH said that comparing the typical bill sizes across hospitals and interpreting them at 'face value' is 'overly simplistic' and 'misleading' in reflecting each hospital's value and affordability. 'The Table of Surgical Procedures is a ranked listing of procedures that focuses on the intent and outcome of the surgical procedure. It does not reflect the surgical access route or the technologies, facilities and equipment used. Neither does it reflect the expertise and skill of the healthcare practitioners involved,' an IHH spokesperson said. The spokesperson also said that the two Mount Elizabeth hospitals, due to their level of 'equipping and capabilities', tend to take in more complex cases across all specialties, as doctors also make 'active choices' on where to admit patients based on the patient's best clinical interests. 'It is therefore natural that the average bill sizes seen at these two hospitals be higher compared to other facilities,' the spokesperson added. Great Eastern referred CNA to its previous statement. Great Eastern said earlier that the move is part of its efforts to manage rising healthcare costs and ensure affordability for its policyholders. "We want to assure our policyholders that there is no change to their coverage, and they can still receive treatment and submit claims as usual with no impact to their benefits," a spokesperson added. The IHH spokesperson said that their analysis of publicly available data from MOH does not correspond to Great Eastern's claims that bills at Mount Elizabeth hospitals are 20 to 30 per cent higher. They added that they have formally written to the insurer and are 'awaiting their response'. IHH previously expressed "surprise" at Great Eastern's move, saying it has been in active discussion with the insurer over the past few months. 'We do not agree with GE's claim about higher prices at two of our hospitals for similar procedures and case profiles," its group COO and Mount Elizabeth CEO Yong Yih Ming said on Wednesday. "Each of our hospitals has different focus and areas of excellence - Mount Elizabeth Hospital and Mount Elizabeth Novena Hospital house facilities and equipment that allow specialists to manage patients and perform surgeries that are not available at other hospitals.' This is also why some of the more complex cases are managed at these two hospitals, he said. In response to media queries, MOH said on Thursday it is engaging Great Eastern to better understand the implications of its decision. Integrated shield plans (IPs) are commercial products, the ministry said. While MOH regulates the key parameters of these products for financial sustainability, insurers retain discretion over administrative processes like pre-authorisation. "However, IP insurers would have to ensure that policyholders continue to be able to access the full benefits of their policies in accordance with the terms and conditions for claims, as stated in their policy contracts," it added. MARKET DYNAMICS, COST STRUCTURE DRIVE PRICING VARIATION Experts told CNA that pricing differences across private hospitals are influenced by a range of factors, including the time and resources required and the hospital facilities used. 'Public hospital fees are subsidised by the government and are structured to ensure patient affordability. In contrast, private hospitals operate independently and need to factor in staffing, overheads, service-level costs and profitability when setting prices,' said Mr Joshua Siow, who is a partner at Simon-Kucher and its head of healthcare and life sciences in Singapore. For example, in the case of different drug prices, public hospitals rely on a centralised procurement system, which helps standardise prices across institutions, said Ms Verlene Law of The Reg Consultants, a regulatory service provider specialising in pharmaceutical and medical companies. Private hospitals procure drugs independently and prices can differ based on their supplier agreements and business models, she said. Private hospitals may also serve different patient segments or offer specialised clinical services that justify higher fees, said Mr Siow. "Patient experience, hospital infrastructure and differing target customer segments can contribute to variation," he said. "Importantly, some institutions may be equipped with specialised equipment or specialist capabilities that may not be routinely available at other centres.' He added: 'As for-profit institutions, private hospitals in Singapore operate independently and serve varied patient segments. In this context, pricing is shaped less by regulation and more by consumer choice – patients can select their providers, and hospitals must remain reasonably price-competitive to sustain demand.'
Zawya
4 hours ago
- Business
- Zawya
Prudential plc CEO Expresses Strategic Commitment to India in Meeting with Union Finance Minister Nirmala Sitharaman
Anil Wadhwani highlights Prudential's historic ties, its proposed new health insurance joint venture partnership with the HCL Group, existing joint venture partnership with ICICI, Prudential's Global Capability Centre, and alignment with India's 'Insurance for All by 2047' vision NEW DELHI, INDIA - Media OutReach Newswire - 20 June 2025 - Prudential plc ("Prudential") Chief Executive Officer, Anil Wadhwani, met yesterday with Smt. Nirmala Sitharaman, Union Minister for Finance and Corporate Affairs, Government of India, emphasising India's strategic importance to the UK FTSE100 insurer and asset manager operating across Asia and Africa. Prudential provides life insurance solutions in India through ICICI Prudential Life Insurance Company Limited, a preeminent life insurer and the first private insurance company listed in India. It also has a market-leading asset management presence via a separate joint venture with ICICI Bank, ICICI Prudential Asset Management Co. Ltd. Earlier this year, Prudential announced plans to establish a standalone health insurance joint venture with Vama Sundari Investments (Delhi) Private Limited, a promoter company of the HCL Group. During the meeting, Mr. Anil Wadhwani remarked: "We are deeply proud of our heritage in India, which began with our first branch in Kolkata in 1923. India is a core strategic market for Prudential. As the country advances towards its vision of 'Insurance for All' and continues to address the challenge of underinsurance, we see significant opportunities to bring our global expertise in protection, savings, and health solutions to serve the evolving needs of Indian consumers. Our long-standing connection with India, including our sponsorship of the historic 1983 Cricket World Cup, India's first World Cup victory, reflects our commitment to its growth and aspirations." Highlighting health as a shared strategic priority, Mr. Wadhwani conveyed the company's commitment to leveraging its global expertise and technology to help Indian consumers access affordable and quality healthcare coverage. This aligns with the Government of India's vision of "Insurance for All by 2047". India is not only a key strategic insurance market but also an incredible source of talent. Prudential recently launched a Global Capability Centre in Bengaluru. This strategic hub serves as a global centre for technology, AI, data analytics, cybersecurity, and innovation. Concluding the meeting, Mr. Wadhwani said: "India's economic progress over the past decade has been remarkable. With sustained capital investment in infrastructure and proactive government economic measures to stimulate growth, we remain excited about India's long term growth prospects. We look forward to continuing our constructive collaboration with the Indian government to support its development goals and to build enduring insurance and technology businesses." During the visit, Mr. Wadhwani also met with senior officials from the Department for Promotion of Industry and Internal Trade (DPIIT) and the Prime Minister's Office. On X: Hashtag: #Insurance #Business #Prudential The issuer is solely responsible for the content of this announcement. Background on Prudential in India Prudential has over 100 years of history in India. It has offered life insurance solutions in India since the 2001 establishment of ICICI Prudential Life Insurance Company Limited, a joint venture with ICICI Bank, and it has consistently been amongst the top companies in the Indian life insurance sector. ICICI Prudential Life is also the first insurance company in India to be listed on both the National Stock Exchange and Bombay Stock Exchange. Prudential also has a longstanding partnership with ICICI in ICICI Prudential Asset Management Company, one of India's largest asset management firms, through its asset management business Eastspring Investments. Prudential proudly sponsored the historic 1983 Cricket World Cup, a landmark moment when India lifted the trophy and inspired generations. About Prudential plc Prudential plc (UK) provides life and health insurance and asset management in 24 markets across Asia and Africa. Prudential's mission is to be the most trusted partner and protector for this generation and generations to come, by providing simple and accessible financial and health solutions. The business has dual primary listings on the Stock Exchange of Hong Kong (2378) and the London Stock Exchange (PRU). It also has a secondary listing on the Singapore Stock Exchange (K6S) and a listing on the New York Stock Exchange (PUK) in the form of American Depositary Receipts. Prudential plc (UK) is not affiliated in any manner with Prudential Financial, Inc. a company whose principal place of business is in the United States of America, nor with The Prudential Assurance Company Limited, a subsidiary of M&G plc, a company incorporated in the United Kingdom. Prudential plc
Malay Mail
4 hours ago
- Business
- Malay Mail
Prudential plc CEO Expresses Strategic Commitment to India in Meeting with Union Finance Minister Nirmala Sitharaman
Anil Wadhwani highlights Prudential's historic ties, its proposed new health insurance joint venture partnership with the HCL Group, existing joint venture partnership with ICICI, Prudential's Global Capability Centre, and alignment with India's 'Insurance for All by 2047' vision Centre Left: Smt. Nirmala Sitharaman, Union Minister for Finance and Corporate Affairs, Government of India; Centre Right: Anil Wadhwani, Chief Executive Officer, Prudential plc NEW DELHI, INDIA - Media OutReach Newswire - 20 June 2025 - Prudential plc ("Prudential") Chief Executive Officer, Anil Wadhwani, met yesterday with Smt. Nirmala Sitharaman, Union Minister for Finance and Corporate Affairs, Government of India, emphasising India's strategic importance to the UK FTSE100 insurer and asset manager operating across Asia and provides life insurance solutions in India through ICICI Prudential Life Insurance Company Limited, a preeminent life insurer and the first private insurance company listed in India. It also has a market-leading asset management presence via a separate joint venture with ICICI Bank, ICICI Prudential Asset Management Co. Ltd. Earlier this year, Prudential announced plans to establish a standalone health insurance joint venture with Vama Sundari Investments (Delhi) Private Limited, a promoter company of the HCL the meeting,remarked: "We are deeply proud of our heritage in India, which began with our first branch in Kolkata in 1923. India is a core strategic market for Prudential. As the country advances towards its vision of 'Insurance for All' and continues to address the challenge of underinsurance, we see significant opportunities to bring our global expertise in protection, savings, and health solutions to serve the evolving needs of Indian consumers. Our long-standing connection with India, including our sponsorship of the historic 1983 Cricket World Cup, India's first World Cup victory, reflects our commitment to its growth and aspirations."Highlighting health as a shared strategic priority,conveyed the company's commitment to leveraging its global expertise and technology to help Indian consumers access affordable and quality healthcare coverage. This aligns with the Government of India's vision of "Insurance for All by 2047".India is not only a key strategic insurance market but also an incredible source of talent. Prudential recently launched a Global Capability Centre in Bengaluru. This strategic hub serves as a global centre for technology, AI, data analytics, cybersecurity, and the meeting,said: "India's economic progress over the past decade has been remarkable. With sustained capital investment in infrastructure and proactive government economic measures to stimulate growth, we remain excited about India's long term growth prospects. We look forward to continuing our constructive collaboration with the Indian government to support its development goals and to build enduring insurance and technology businesses."During the visit, Mr. Wadhwani also met with senior officials from the Department for Promotion of Industry and Internal Trade (DPIIT) and the Prime Minister's X: Hashtag: #Insurance #Business #Prudential The issuer is solely responsible for the content of this announcement. Background on Prudential in India Prudential has over 100 years of history in India. It has offered life insurance solutions in India since the 2001 establishment of ICICI Prudential Life Insurance Company Limited, a joint venture with ICICI Bank, and it has consistently been amongst the top companies in the Indian life insurance sector. ICICI Prudential Life is also the first insurance company in India to be listed on both the National Stock Exchange and Bombay Stock Exchange. Prudential also has a longstanding partnership with ICICI in ICICI Prudential Asset Management Company, one of India's largest asset management firms, through its asset management business Eastspring Investments. Prudential proudly sponsored the historic 1983 Cricket World Cup, a landmark moment when India lifted the trophy and inspired generations. About Prudential plc Prudential plc (UK) provides life and health insurance and asset management in 24 markets across Asia and Africa. Prudential's mission is to be the most trusted partner and protector for this generation and generations to come, by providing simple and accessible financial and health solutions. The business has dual primary listings on the Stock Exchange of Hong Kong (2378) and the London Stock Exchange (PRU). It also has a secondary listing on the Singapore Stock Exchange (K6S) and a listing on the New York Stock Exchange (PUK) in the form of American Depositary Receipts. Prudential plc (UK) is not affiliated in any manner with Prudential Financial, Inc. a company whose principal place of business is in the United States of America, nor with The Prudential Assurance Company Limited, a subsidiary of M&G plc, a company incorporated in the United Kingdom.
