Been reading a lot on here about AI taking over utilization review for aetna which is currently done by nurses. We are definitely seeing an increase in automation being used so I totally believe the plan is for that to take over a majority of our jobs in the future. My question is does the company realize that we are seeing how poorly it is doing at making accurate decisions and that it is going to cost the company money in the end? Also the more common it becomes the worse it gets because the providers and facilities get to know how to get an approval from the system after a while and use that to their advantage? I have seen it happening in multiple areas where things are being approved to be paid where it never would have been if the utilization review people had looked at the clinical to make a determination. Do they just not care or are they unaware? Maybe they need to rethink getting rid of people to do this job.
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Automation was and still is a disaster. Simple appendectomies approved as inpatient status. Some cases approved and no clinical is ever received so who knows what they were admitted for or if they meet criteria to be there. Karen is so worried about saving money, meanwhile automation continues to throw money away. Meanwhile we are wasting time reviewing many maternity cases that should be auto approved by automation. We are wasting all this time trying to figure out if a member meets the mandated maternity days.
Nuance ( not sure if this is a subsidiary or just a vendor CVS uses) is working with Microsoft and are developing Medical AI now
Any mo--n who thinks AI can replace people at this time even with advancement at this point is crazy. Computers can do a few things they still can't think like a person, they can't think outside a box, they can't interact with another AI and get them to work together. Unless they want the answer for everyone to be you all get the same meds, get the same illness and same answer and everyone is a cookie and AI is the cookie cutter. No deviation can be done. Your answer for everyone is NO. You have cancer no meds go on hospice. You have the Flu put yourself on hospice.
To the user who mentioned the assist edge and what it is doing - very interesting. I wonder if there is any way that the UMs can slow or confuse that program, like any specific changes to the way they work or how they work. Most likely not, but I know these people would love the chance to fight back against something so awful. These nurses truly care about what they do and the people it effects, which is something a bot will never be capable of. I know of one UM who is related to someone very high up who used to be w/ the company and still has a lot of pull there today due to various connections. Not many know who she is but some supervisors have wondered why she is not able to be touched or messed with. She told me she is at the point of being ready to pull the strings that she does not usually entertain pulling to help protect herself and those around her, but she doesn't know if it'll do any good or even what to say about whats going on. Going to tell her to read this because knowing more about things like that assist edge might help.
The poster suggesting the providers are becoming keen to the automation process is correct. I've witnessed various specific ICD codes being used that thwart the algorithm and cases are approved that shouldn't be. It's not hard for a provider to trend that certain ICD codes are approved rapidly by just checking cross checking their request for authorization, and the time it takes for Availity to reflect the approval.
Eventually, this will impact the bottom line. Perhaps they're ok with "shrinkage" happening in the clinical department, but this is an anathema to evidenced-based care and medical necessity. Contrary to preventing fraud, waste, and abuse. Utilization Management maintains the fiscal integrity healthcare system and slows its rising cost. It also prevents members/patients/public from being subjected to unnecessary care that doesn't occur at the right place, the right time, or the right level of care.
Data supports that 1 in 10 hospital admissions results in an adverse outcome. Being admitted to an acute setting is not a "safe space." Healthcare is a utility, and when its risks are not managed -- people can get hurt or sicker.
There's new AI/ Automation tools installed on computers as of this week. "AssistEdge Record and Playback." Based on the developer's website, the tool can be quite powerful with the right coding.
Essentially, its purpose is to monitor the methodology in which the user interacts various platforms to backward engineer a bot to do the same work based on human input it has observed. In this, it records keyboard entries, data fields, screen shots, and more in a "lightweight" data output so that they can basically create multiple bots that complete various UM functions. These bots can be monitored from a centralized program.
Of course it will not be able to interpret clinical nuance, but it doesn't really have to if it's being fed historical metrics based on cases that have been approved or denied in the past.
So basically, they're harvesting the work product of the UM Dept and will likely attempt to reduce complete reliance on the clinician.
There’s a project that I am working on that will
Probably highlight this, will anyone listen? I doubt it.
Personally it seems like Karen ly--h is destroying 2 good companies. Both have gone downhill since she took over. They waste money on a new system that is garbage when it would have been cheaper to update ATV. I have seen auto approve ridiculous stuff even IP stays when a person was not even there 24 hours. Also they are using overseas Philippine nurses like other companies bc it’s cheaper. Sponsors are going to see their dollars climbing and leave. I don’t think leadership cares
Some leadership is very aware. Sherri Call was pushing automation, most of it was a disaster and now she is gone (several months ago). Now there will be a separate org under a different VP, separate from Joanne that will be handling all the support work for UM. May include further attempts at automation, but no one knows. Or rather, the people who know aren’t telling those of us doing the actual work.