Solidarity President and Co-Founder Chris Faddis joins The BS Show to discuss how insurance claim denials by AI are no longer a possibility of the future, but a very really practice in today’s medical landscape. Read the transcript or listen to the interview below.
Bob Sansevere (00:00):
We are joined by Christopher Faddis, co-founder and president of the nonprofit Healthcare Sharing Ministry Solidarity HealthShare, which is an ethical, affordable alternative to traditional health insurance and is faithful to the moral teachings of the Catholic Church. Chris, I came across a story, and I want to ask you if it pertains as well to Solidarity HealthShare. And the story is this. 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 healthcare 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. And that’s an algorithm that does it, and it’s a twofold question, or one is if Solidarity HealthShare uses any algorithms along those lines, and we talked about it a few weeks ago, that these health insurance companies claim they’re going to accelerate authorization, and so it doesn’t take so long and people are left hanging and that’s a good thing.
(01:17):
But I guess the question there is should they be depending on AI to make these decisions of who gets and who doesn’t?
Chris Faddis (01:24):
Yeah, I think it’s important to note that. I mean, first of all, AI as we’ve talked about before, it’s good and bad. It can always be overused, but remember, in the insurance world, we’ve already been using forms of artificial intelligence or large machine model in a sense because in the insurance world, they’ve been using what’s called auto adjudication for a long time. So the system is built with rules so that when it reads a bill, it can say, this bill is covered or not, or this person is eligible or not. Those kinds of things. But when we get into things, the big issue here is about medical decision making. We’re talking about prior authorizations for surgeries, for cancer care, for complex medical cases, and to think that AI could fully-
Bob Sansevere (02:11):
They can’t
Chris Faddis (02:11):
Adjudicate that sort of a decision. It really can’t. And ultimately, and maybe it might be useful in gathering the data and putting the case in front of somebody so they can make a quicker decision. There’s lots of ways you can use AI to make the human experience better, where you’re using less time of a nurse or a doctor to review that particular case. But what we have seen happening and what the real issue is that everyone’s talking about is a lot of these companies, with UnitedHealth being one of the largest doing it, and most kind of egregious, have been using this AI to essentially fast track denials of care in particular related to prior authorizations for surgeries and testing. And then it’s triggering a much more complicated process that does not involve AI and also involves a lot of time of the doctor, a lot of time with the patient to go back and request approval. And it’s really, it was an increase of denial for these prior auth. I mean, rather than saying, Hey, we’re going to try to speed things up for patients at Solidarity, we do something called pre-notification, but in our pre-notification process, it takes us 24 hours to tell you whether or not that surgery is-
Bob Sansevere (03:18):
Which is pretty quick. I mean, sounds like that’s a
Chris Faddis (03:21):
Turnaround. Most insurance companies are taking four weeks.
Bob Sansevere (03:23):
Oh my
Chris Faddis (03:24):
Gosh. So to have the AI be faster, but for the purpose of denying is definitely not helping patients. So it’s an important conversation. I think that you definitely have to have eyes on from qualified medical professionals,
(03:37):
And it’s important. Now, to your point, our Solidarity, yes, we are looking at how to utilize AI to help us serve the member better, to help us be faster in how we respond, be faster in reviewing a case, be faster in supporting them, and then also give people some tools. I mean, one thing AI is really good for is giving you quick answers to problems. I don’t know how this works in Solidarity, how does it work? And the AI tool can get you the information from all of our information provided in the middle of the night when we’re not available on the phone. So there could be benefits, but unfortunately what we’re seeing is lots of abuse from these large insurance companies, and I’m glad to see that there’s going to be some things to step in and help change that.
Bob Sansevere (04:20):
Well, one thing that is distressing to me, and it’s the same story that talked about the prior authorization with AI, 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? Well, you cannot strictly adhere to that. Some people are going to have complications. You got to have a doctor, has them make that call. Not, I guess AI could recommend, but they cannot stick to. I know now it’s been a while since we had a kid, but you basically, it was best to have the kid after midnight then at 11:59 because then they counted differently.
Chris Faddis (04:57):
Right? Right. Yeah, they do different things. And I think it’s important. There’s all of this utilization review data out there that’s questionable. Who’s making the decisions about what’s the right amount of time to recover from surgery? Most of it is based on insurance and intel as opposed to medical intel. So to your point, it’s definitely important. It’s also unfortunately needed because sometimes the hospitals will take advantage of an insurance company. Well, there’s no limits here. This person can stay for 30 days. Well, they only needed two days. Right? No, you’re right. So that also happens. So you have a mixed bag. And I think to your point, too many of these decisions are in the hands of kind of a bureaucratic system and this kind of computerized decision making as opposed to, Hey, the doctor says this guy needs five days.
Bob Sansevere (05:42):
Well, listen to the doctor.
Chris Faddis (05:44):
Which is more how Solidarity works, by the way. But then you use that utilization review data to say to challenge when you know someone’s doing something improper.
Bob Sansevere (05:55):
Now, Chris, my experience and my recollection is because I’ve had some family members and we are members of Solidarity that had surgeries. I don’t recall it being a big issue. Are you, as you’re not as well, you mentioned you can turn it around in 24 hours, but do you have to authorize as many things as these traditional healthcare providers have to authorize?
Chris Faddis (06:15):
I don’t know for sure if it’s as many things. I don’t think it is. I think it’s probably less. The difference is for us, we are not authorizing it to question whether or not something’s necessary. We’re typically looking for ethical issues because obviously we want to make sure we’re not sharing into certain things. We also are also looking out for the member. Sometimes we do, unfortunately, find that some providers and doctors out there take advantage of folks. And then oftentimes we’re also making recommendations like, Hey, this is great. You can do this. We just wanted you to know that we also have stem cell therapy for your knee problem, and if you wanted to look at that before you go under surgery, we wanted give you that option. So that’s how we use it. It’s actually really meant to be making sure we’re caring for the patient as opposed to avoiding cost, which is we don’t have that motive of protecting our profits. We’re trying to make sure the members are getting the best care they can, but also have to watch out for them using that process.
Bob Sansevere (07:11):
Because we’re talking about AI and things like that. But one thing we don’t talk a great deal about, you and I sometimes talk off the air, Solidarity HealthShare has been, you co-founded it, how many years ago was it? Seven.
Chris Faddis (07:26):
Gosh. Well, we launched in 2016.
Bob Sansevere (07:28):
Wow. Oh my gosh. Nine years already. Okay.
Chris Faddis (07:30):
So 10 years next year.
Bob Sansevere (07:30):
Yeah. Well, what are the things that you’re working on now? I know there’s a lot of advancements that you’re doing, but what are some of the things that you’re really proud of that are in the works or that you can talk about in the works?
Chris Faddis (07:40):
Well, I mean, to this point, streamlining service is a big deal. And when we say streamlining service, we don’t mean making sure you can do all the work and we don’t have to do any kind of thing, which is sometimes for people mean how do we make sure you’re getting the most consistent and most effective answers? Last year, we took a big approach to our calls for doctors when doctor’s offices and medical providers calling in to a different call center, and they weren’t always getting the right answers. So we brought that in-house, getting answered faster than they ever were getting the answers quickly. It makes a better experience for our members. So using some different customer service tools to streamline that has been helpful. And we are actually playing with AI right now for that purpose. What’s shareable, Chris? How do I know if this bill is shared? Well use our AI tool and it’ll help you discern that that’s not going to do the job. But for you as a member to know that, and then we’re deploying a lot of other resources. I think I mentioned to you this concierge program that will launch this summer for folks that have a lot of member submitted bills where you’ll have basically a personal assistant to help you with all of that,
Bob Sansevere (08:46):
Which is terrific.
Chris Faddis (08:47):
There’s a lot of good things coming down the pipe and we’re pretty excited about.
Bob Sansevere (08:50):
Yes. And what’s interesting is it’s been about the last month. Eric Gabrielson is a guy who co-founded Project We, and what they do is they help businesses use AI applications. And I thought ai, I mean, I’m most interested in it because I want to use it after a Vikings game to basically use maybe President Trump given a review of the game or use celebrity reviews, what we can do.
Chris Faddis (09:14):
That’d be fun.
Bob Sansevere (09:15):
But there’s so much more, and I’m learning. I haven’t even gotten to the point where I would say we’re scratching the surface just so much that you can do. I’ve learned a lot from Eric and I have ’em on every Monday, and it’s, it’s so interesting that when you hear some of the stuff that AI can do, so I look forward to some of the things, not just what AI but that you’re doing, because you’re not just sitting still and just sitting. You’re not like in a boat on a pond just anchored. You’re moving.
Chris Faddis (09:45):
We’re always trying.
Bob Sansevere (09:46):
You’re always moving
Chris Faddis (09:46):
Lot of, I mean, you kind of have to, the industry moves so fast and you’re constantly trying to keep up with the games of the hospital system.
Bob Sansevere (09:54):
Absolutely.
Chris Faddis (09:54):
We just figured out, and honestly, Bob, it’s funny because two years ago we had this conversation about AI internally, and it was like, well, we’re going to just sit on that for a minute. We don’t have time for that. Let’s focus on the things. Let’s leave it alone. And now I feel like we’re like, we’re in this place where we’re definitely ready and we almost look at each other and we’re like, shoot, we should have started sooner.
Bob Sansevere (10:13):
But what you have to do is not look back. Just look forward to.
Chris Faddis (10:16):
There’s so, there’s so much more you can do now. And I also think there’s just a level of, you do sort of have to observe it and learn, and then you can start to think from there, this should be cool.
Bob Sansevere (10:26):
Well, Chris, thank you for that. And Solidarity HealthShare, SolidarityHealthShare.org. Check it out. Great alternative, true to traditional healthcare. We’re going to take a quick break and The BS Show will be right back.
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Solidarity HealthShare is a non-profit healthcare sharing ministry rooted in the teachings of the Catholic Church. Established in 2016, we operate on the Catholic principles of solidarity and subsidiarity, in accordance with the Church’s commitment to promoting life-affirming, faith-based healthcare.
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