The Guided Benefits Solution
Guided Benefits bridges the information gap between those calculating the costs of medical coverage and those covered. These calculations are based on the underwriter’s interpretation of claims data, AI recommendations based on purchased data, and medical history questionnaires (MHQs). All sources have ambiguities that can lead underwriters to increase quoted rates or decline to issue a quote.
Carriers are now using AI as the default to quote new business in this market. The only way to motivate an underwriter to override AI’s recommendations is to provide more comprehensive data through MHQs. We make completing MHQs easy, as the employee only needs to make a phone call. This process ensures that employees’ submissions are as accurate and comprehensive as possible.
This solution works best when employers designate Guided Benefits as the main point of contact for their benefits (no charge) throughout the year.
Claims Data
Current carriers calculate renewal rates by projecting claims incurred by those enrolled in a plan. However, the data’s integrity is problematic due to the following:
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Renewal rates only reflect claims from enrollees during the first 8 months of the plan year; changes in enrollment or medical conditions in the last 4 months are excluded.
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Medical conditions are misdiagnosed 10-15% of the time.
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Experts estimate that the error rate of medical bills are between 30-80%.
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Experts estimate that between 3-20% of all medical bills are fraudulent. This would include exaggerations of a medical condition severity to increase carrier payments.
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Hospital bills exceeding $10,000 typically include errors averaging $1,300.
Data Brokers & Artificial Intelligence (AI)
AI-driven underwriting is now the primary pricing method for groups with 5 or more employees. AI underwriting firms have created algorithms using information purchased through data brokers and have sold software access to carriers. Data brokers have access to information such as financial data, purchase histories, web browsing history, and medical data. Any of these sources may be used in the algorithm; however, the primary source of data is likely to be medical records. Medical records are purchased by AI Underwriting firms and are tokenized to comply with HIPAA. When carriers quote coverage, a census is entered into the AI software which responds with recommendations and reports group level medical conditions (may include age and gender) .
Potential issues include:
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Many of the same drawbacks noted in the Claims Data section such as the rate of medical misdiagnoses, medical billing error rates, and fraud.
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AI underwriting firms do not have access to everyone's claims history due to data costs. The gaps in the data include people living in rural areas, patients of independent providers who are not part of a major hospital system, as well as those obtaining care from stand-alone hospitals. Every missing record increases costs due to the unknown and may cause a decline to quote.
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Previously, underwriters could ask brokers about specific medical conditions, but with anonymized data, they can no longer identify or request such information about individuals.
Medical History Questionnaires (MHQ)
Employee medical information is collected via an online platform, which has a 76% one-star rating on Google due to its complexity and unintuitive design. This often leads to confusion and incomplete or inaccurate submissions. Common issues include:
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Providing vague or incomplete answers to questions.
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Neglecting to revise previous entries indicating the need for an elective procedure to reflect it's completion.
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The online MHQ does not ask if the plan participant is engaged with non-insurance programs that offset procedure or medication costs.
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Omitting recent physical exams that screen for common conditions.
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Adding new prescriptions while not changing the status of discontinued prescriptions.
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The online MHQ requests prognosis and details for every condition but fails to specify which information would be of value.
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The online MHQ asks the same questions for every condition leading to people with migraines being asked if they need a transplant, single males if they are pregnant, and if allergies are a Worker's Compensation claim.
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The online MHQ does not ask any general questions that would limit other questions from being asked. These include when was the last time you saw a doctor and why, when was the last time you filled a prescription at a pharmacy, and if they ever were seen at a hospital.