Update: We wrote this before news of UnitedHealthcare CEO Brian Thompson was fatally shot. Our thoughts and prayers go out to his family and everyone else impacted by his passing. While insurance disputes can be tough and financially disastrous, we do not condone taking these sorts of actions.
Original Article: While the public vs. private healthcare debate rages on, what many people may not know is that AI algorithms have been making healthcare decisions for many Americans and Europeans for years. These programs decide when to deny claims or reject care human doctors recommend by requiring authorization prior to treatment. The algorithm typically decides in less than 1 second, leaving patients to spend hours on phone calls trying to reverse the computer’s decision.
Cigna, UnitedHealthcare and Humana have been hit with class action lawsuits claiming many patients received unfair denials for care based on flawed algorithms. Some claims state the denials were wrong 90% of the time. That is a staggering amount of improper denials. But more importantly for these insurers, this means they pay less, which maximizes their own profits, all to the detriment of regular people.
In October 2024, a Senate committee began investigating these wrongful denials. The committee found that even though insurers claim the AI is not used to replace human reviewers and streamlines administration, the employees were pressured to approve whatever the AI recommended. The committee also found that CVS/Aetna had tested two AI models, one that would “maximize savings” and one that would “maximize auto-approvals”. It’s not hard to guess which model made more profits for the company and was ultimately adopted.
Hospitals and patients are the biggest losers when AI models are used to maximize profit. Many rural hospitals are bearing the brunt of these denials, leading to closures all over the country, which further complicates access to care for these patients.
We experienced this issue recently in one our our cases where a large surgery center bill was denied. As part of a personal injury case, we helped the client fight the claim that was denied 3 times by her insurer before getting her records in front of an independent doctor who immediately found the care to be reasonable and necessary. Imagine the thousands of claims that do not get paid or treatment that is not received because a patient does not have an attorney fighting for him or her. The insurers likely have this in mind because the worst offenders for unreasonably denying claims are Medicare Advantage plans which insure a large number of elderly people without the resources or understanding to fight the wrongful denials. Their health suffers as a result and the insurance companies keep more money in their pockets.
Hopefully the class action cases get some traction and force the insurers to change the AI programing or use more human reviewers. Otherwise, the government may have to step in to protect patients and provide them some fundamental rights, similar to the way the government has been helping with medical bill transparency. We will continue to keep an eye on this topic, as we expect some progress, regardless of the outcome of the class action cases pending.
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