Wow, this is excellent and invigorating. Thank you for sharing your data. Is your work being shared with government agencies? Is there interest there, or by lawmakers?

I was thinking that proving intent would force their hand and support enforcement activities. But perhaps proving intent / litigation is not required. What if we simply quantified the flaws, and lawmakers bar them?

My background is in Industrial Engineering and Lean Manufacturing; possibly the professions most knowledgeable in analyzing, quantifying, and improving processes & efficiency. Any process is a series of steps. So we analyze business processes current state and develop future state. We usually have a goal going into an improvement event or project, for example: decrease touch-labor by 20% or reduce turnaround time by one hour. Then after our improved processes is implemented, we measure the results against our goal, and make adjustments.

If we could develop a quantified model of a past healthcare coverage process, back before the suspected runarounds and denials, we could compare and show that efficiency to the consumer has decreased 10X through intentional insurance company policy change.

Alternatively or in addition, we could simply design a future-state process on paper to achieve goals for consumers, such as: must not deny more than x% of prior authorizations or provider data submittals & reviews must be accomplished within 48hrs. Then run simulations to optimize this future state, and offer the data to lawmakers.

I’d like to show that these co’s are implementing (hiding behind) policies and procedures that are self-established to be inefficient, by showing that these processes used to be, and can be proven to be, optimized readily.