Corporate health insurers’ use of AI to deny coverage is too often killing and disabling people. People in Medicare Advantage, people in State health insurance exchanges and people with job-based coverage are all at risk. Now, Axios reports that a class of people are suing Cigna for using computer software to “deny payments in batches of hundreds or thousands at a time.” Why not? It maximizes Cigna’s profits, and Cigna has so far been able to get away with it.
Mounting evidence shows that corporate insurers offering Medicare Advantage plans too often deny costly and critical care, including nursing home stays, rehab, home care and hospital care. This is care they are paid to cover and that traditional Medicare covers.
The Clarkson law firm filed the lawsuit in California claiming that Cigna is violating state law. Cigna is supposed to thoroughly and fairly review insurance claims under California law. Computer algorithms is clearly at odds with that requirement. It’s hard to believe that a judge could find that a speedy computer review of a claim could be fair and thorough. But, these days, anything’s possible.
The lawsuit claims that Cigna’s AI system denied 300,000 requests for authorization over two months in 2022. The system spent an average of 1.2 seconds on each claim. Thorough? Fair? One Cigna medical director, Cheryl Dopke, denied 60,000 claims in one month. Thorough? Fair? Hardly. California law requires individual review. And four out of five claims that were reviewed were overturned on appeal.
Use of AI is the latest way health insurance corporations can inexpensively and swiftly turn a huge profit. Who’s designing the computer software algorithms? What’s their goal? As many denials as possible is what’s in Cigna’s economic interest. You have to wonder what questions Cigna asks about the algorithms before buying the software.
Even some Republicans in Congress appear concerned, including House Energy and Commerce Committee Chair Cathy McMorris Rodgers (R-Wash.). She wrote Cigna for an explanation. Members of Congress appear to appreciate that people in Medicare Advantage and Medicaid are at risk of wrongful denials. But, what is she and her fellow members of Congress willing to do about it?
Here’s more from Just Care:
- OIG finds widespread inappropriate care denials in Medicare Advantage
- Congress urges administration to address delays of care in Medicare Advantage
- Be a Hero tells Congress to end Medicare Advantage wrongful delays and denials of care
- Medicare Advantage: Beware of inappropriate nursing home stay denials
- Medicare Advantage enrollees face higher likelihood of hospital care denials
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