As the use of artificial intelligence (AI) in healthcare claims management widens, the importance of careful oversight is needed. Any use of automation for claim denials should be scrutinized by providers to ensure the denial is appropriate. A recent Healthleaders report asked a key question all revenue cycle managers must consider: What is the balance between automation and human medical experts within the revenue cycle?1
“There are certain processes that require a human touch and personalized attention to ensure optimal outcomes,” Heathleaders’ Jasmyne Ray concluded in her piece. “Hospital executives are tasked with finding that delicate balance between automation and human involvement as they navigate the complex revenue cycle management landscape.”1
As healthcare leadership seeks balance, payers continue to use AI to process claims in greater numbers. Recent lawsuits are also calling into question the results of greater automation when used to automatically deny a healthcare claim without an accompanying review by a provider. Class action lawsuits filed against UnitedHealthcare (UHC), Humana and Cigna in 2023 claim misuse of AI in denying medical necessity claims. One suit alleges Humana and UnitedHealthcare “wrongfully deny Medicare Advantage (MA) members’ medical claims”2 using an AI tool owned by UnitedHealth Group (UHG). A separate lawsuit against Cigna was also filed in 2023 around the payer’s use of a procedure-to-diagnosis algorithm known as PxDx, which enabled the company’s medical directors to deny large batches of claims without reviewing patient medical records. The Cigna lawsuit alleges the carrier’s algorithm denied claims in batches, with 300,000 claims being denied in two months’ time in 2022.3
Read more in our compendium of AI use in utilization review, “The Use of AI in Claim Denials.”
SOURCES
- Ray, Jasmyne, “Finding the Balance: The Delicate Dance Between Automation and Human Touch in the Revenue Cycle,” HealthLeaders. June 2024.
- Emerson, Jakob, “Humana used AI tool from UnitedHealth to deny Medicare Advantage claims, lawsuit alleges,” Becker’s Healthcare. December 13, 2023.
- Minemyer, Paige, “Cigna hit in August with another lawsuit over claims denials through PxDx,” Fierce Healthcare. September 22, 2023.