Class Actions Spotlight AI-Assisted Payer Denials

As well being care payers more and more depend on synthetic intelligence (“AI”) to hurry up affected person declare adjudication and prior-authorization determinations, suppliers must be looking out for algorithms designed to disclaim claims with minimal
human oversight. Two putative class motion lawsuits filed towards Cigna and UnitedHealth in November 2023 allege that the payers’ respective AI fashions, “PxDx” and “nH Predict,” had been used instead of actual medical professionals
to wrongfully deny medically needed care.

The lawsuit towards Cigna alleges that Cigna makes use of its PxDx (procedure-to-diagnosis) algorithm to robotically assessment claims with out conducting a radical medical assessment of the claims as required by legislation and contract. [1] The lawsuit alleges that over a interval of two months in 2022, for instance, Cigna used PxDx to robotically assessment and deny over 300,000 claims, spending a median of simply 1.2 second per declare.
[2] Regardless of insurance coverage legal guidelines and rules in lots of states requiring physicians to assessment claims earlier than payers could deny them on the premise of medical necessity, the
lawsuit means that physicians employed by payers to assessment insurance coverage claims (usually known as “medical administrators”) are signing off on denials with out even taking a look at them.

The swimsuit towards UnitedHealthcare is restricted to Medicare Benefit plans. It alleges that UnitedHealth’s AI mannequin, nH Predict, has a identified 90% error charge and denies claims by forcing unrealistic expectations of Medicare Benefit sufferers’
restoration in post-acute care settings. The algorithm overrides the opinions of actual life treating physicians who deemed the underlying care was medically needed.[3] 

Each lawsuits depend on solely a small share of sufferers interesting wrongfully denied claims. Certainly, the place solely about 0.2% of policyholders attraction denied claims, the bulk will find yourself paying out-of-pocket prices or forgoing the rest of prescribed
post-acute care. [4] In Medicare Benefit circumstances particularly, this could imply the aged are pressured out of care amenities or should deplete their financial savings to proceed
receiving medically needed care the place an algorithm has disagreed with their treating doctor.

Not solely are these algorithms getting used to disclaim claims, additionally they are getting used to vary human conduct. The UnitedHealthcare swimsuit alleges that the defendants have arrange worker targets as a way to preserve expert nursing facility stays inside 1% of
the times projected by nH Predict, and that “[e]mployees who deviate from the nH Predict AI Mannequin projections are disciplined and terminated, no matter whether or not a affected person requires extra care.” [5]

Whereas this conduct is regarding, sufferers and suppliers alike have recourse via interesting claims and by proactively looking for to barter contracts with payers to ban these practices. Suppliers may have already got agreements in place that
permit for suppliers to hunt recourse via litigation towards the payer for such use of AI. Thompson Coburn’s Well being Care Group has a workforce of attorneys obtainable to help with these points.