Cigna Accused of Algorithm Denying Health Claims
Cigna is being accused of using a computer program to deny people's health insurance claims. Cigna Accused of Using a Computer Program to Deny Health Insurance Claims
A lawsuit filed against Cigna alleges that the company is using an algorithm to review and deny hundreds of thousands of patient health insurance claims without proper individual review by doctors.
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| Cigna Accused of Algorithm Denying Health Claims |
The suit claims that Cigna's actions violate California state law, which requires insurers to conduct a thorough and fair investigation into each patient claim. Instead, Cigna relies on the algorithm called PxDx to save money by denying claims and reducing labor costs.
Examples cited in the lawsuit include denial of coverage for medically necessary ultrasounds and vitamin D deficiency tests, leaving patients with hefty costs.
The legal case is about using computer programs and artificial intelligence (AI) to do tasks that humans used to do. In healthcare, the question is whether a computer program can make fair and objective decisions like a human medical professional when evaluating a patient's claim.
The lawsuit claims that Cigna's doctors use a system called PXDX to automatically reject medical claims without even looking at patient files. This leaves many patients without insurance coverage and unexpected medical bills.
The problem seems to be widespread, with over 300,000 requests for payments denied in just two months in 2022. Each request is reviewed very quickly, in about 1.2 seconds.
The lawsuit was filed by Clarkson Law Firm, which has also sued Google's parent company, Alphabet, for allegedly using AI to steal data from millions of users.
Cigna responded to the lawsuit, saying it is highly questionable. The company stated that they haven't confirmed if the people mentioned in the lawsuit were actually affected by PXDX.
They explained that they use technology to check if certain medical procedure codes are submitted correctly according to their coverage policies, to speed up payments to doctors.
Cigna added that the review of insurance claims happens after patients have already received treatment and does not result in any denials of care.
However, the investigation by ProPublica raised concerns about similar denials of payment to Cigna customers. Even though the patients receive treatment, some of them end up with bills they thought would be covered by their health plan.
One doctor who used to work at Cigna said to ProPublica that they approve denials from PxDx in groups, without checking each claim individually. The doctor explained, "We simply click and submit," and they can do 50 denials in just 10 seconds.
Kisting-Leung, the person mentioned in the case, has challenged the two denials she received for the ultrasounds, but she still hasn't been paid for them. The lawsuit is seeking compensation for damages and also wants Cigna to stop its alleged improper and illegal ways of handling claims.
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