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Ted's avatar

I'm pleased to have found your 'stack, Doctor.

"While I cannot find good data on the gamification of risk adjustment in provider-led ACOs, after talking to several providers nationwide, I know that this is happening."

I'll just observe that you've placed your finger directly on the pulse of the matter. What you're describing is extremely common across all dimensions of goods and services paid for by underwritten indemnification. There is a direct corollary in automotive collision repair and automotive warranty repair.

There will always be a hierarchy of diagnostic severity, based on causality. There are always incentives for overstatement and understatement, according to loss ratios and actuarial assessments.

The "Holy Grail" is always that most elusive of standards; objective performance criteria. Administrative bloat is the inevitable outcome of cost control initiatives, which fuels vertical integration and leads to moral hazard stemming from conflicts of interest.

Thank you for your fascinating expose of the coding and claiming structure. Please continue; the work is important to understanding how to strike a balance between loss ratio control and good faith indemnification.

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Monte K. Jennings's avatar

It's way worse than you think. 53% of you premiums are returned to you as benefits by your health insurance company. 84% of health spending in the US is on avoidable chronic disease. If we automate the entire insurance process, and I can show you how, we can get back that wasted 47%. If we can educate people and put teeth in reading and following that education, and I can show you how, then we can get the US down to OECD levels of avoidable chronic disease. I can also show you how to do this. That song will chop another 25% from the cost of healthcare. Let's call that 60+% total savings.

I suspect that you will not listen, nobody does, but this problem has been solved, by us. Read my articles.

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