Insurance Companies Are Relying on AI to Process Medical Claims

For many years, going back to the beginnings of medical insurance in this country, processing claims relied on human expertise and analysis. Now, things are changing. A growing number of insurance companies use Artificial Intelligence (AI) to help process medical insurance claims. Some class action court cases have recently been filed questioning the denial of medical claim payments when AI was used. CBS News reported a class action case against the insurance carrier Cigna in California. The plaintiffs claimed that Cigna's algorithm, PxDx, was used to save the company money and time by denying payments without conducting a thorough, fair, and objective investigation of the claim. A similar Minnesota lawsuit against United HealthCare involved elderly patients using a Medicare Advantage plan who claimed they were denied medical claim coverage and compensation for post-acute care due to the use of a flawed AI model.

In June of 2023, an American Medical Association Board Member, Marilyn Heine, stated that AI speeds up  authorizations, but insurers needed to require human examination of the patient's records before a denial of care:  “AI is not a silver bullet.”

Your Insurance Company May Not Be Doing a Thorough Review of Your Claim