The following is from CBS News’ Market Watch.
Cigna is using an algorithm to review — and often reject — hundreds of thousands of patient health insurance claims, a new lawsuit claims, with doctors rubber-stamping those denials without individually reviewing each case.
The class-action suit, filed in the U.S. District Court in Sacramento, alleges that Cigna’s actions violate California state law, which requires that insurers conduct a “thorough, fair and objective” investigation into each patient claim.
Instead, the lawsuit alleges, Cigna is relying on an algorithm, called PxDx, that saves the insurer money by denying claims.
The system also reduces the company’s labor costs by cutting the time needed by doctors to look at each claim, according to the complaint.
The litigation highlights the growing use of algorithms and artificial intelligence to handle tasks that were once routinely handled by human workers.
At issue in health care is whether a computer program can provide the kind of “thorough, fair, and objective” decision that a human medical professional would bring in evaluating a patient’s claim.
“Relying on the PXDX system, Cigna’s doctors instantly reject claims on medical grounds without ever opening patient files, leaving thousands of patients effectively without coverage and with unexpected bills,” the suit alleges.
It added, “The scope of this problem is massive. For example, over a period of two months in 2022, Cigna doctors denied over 300,000 requests for payments using this method, spending an average of just 1.2 seconds ‘reviewing’ each request.”
The case was brought by Clarkson Law Firm, which has also sued Google-parent Alphabet over its use of AI, claiming that the search giant stole data from millions of users to train the program.
In a statement to CBS News, Cigna called the lawsuit “highly questionable.”
“Based on our initial research, we cannot confirm that these individuals were impacted by PxDx at all,” the insurer said. “To be clear, Cigna uses technology to verify that the codes on some of the most common, low-cost procedures are submitted correctly based on our publicly available coverage policies, and this is done to help expedite physician reimbursement.”
The insurance claims review occurs after patients have received treatment and “does not result in any denials of care,” Cigna added.
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