Federal lawmakers concerned AI gives payers 'new ways to deny care'

Federal lawmakers are continuing to raise concerns about insurers' use of algorithms and AI to approve or deny claims. 

In a June 8 Senate Finance Committee hearing on healthcare consolidation, Sen. Ron Wyden, an Oregon Democrat and chair of the committee, said he is "increasingly concerned by the potential for abuse when it comes to the use of big data and algorithms in healthcare." 

"If insurance companies are getting bigger, and buying companies that specialize in developing algorithms, it strikes me that they are going to be in a position to invest in new ways to deny care," Mr. Wyden said. "That strikes me as a prescription for trouble." 

Karen Joynt Maddox, MD, associate professor of medicine at Washington University in St. Louis, told the committee there needs to be more oversight and regulation of algorithms to approve and deny claims. 

"It's a space that's moving too fast right now on the technological and business side for us to have the policy regulation in place to begin to deal with it," Dr. Maddox said. 

In May, members of the Senate Permanent Subcommittee on Investigations sent letters to CVS Health, Humana and UnitedHealth Group seeking internal documents detailing how the companies decide to approve or deny claims, including how the payers use artificial intelligence in the process. 

In 2021, around 17 percent of in-network claims were denied by commercial insurance plans, according to KFF.

In Medicare Advantage, payers denied between 3 and 12 percent of prior authorization requests. 

In March, ProPublica reported Cigna used a computer algorithm to review large batches of claims. Physicians then signed off on the denied claims without reading them, the report alleged. 

A Cigna Healthcare spokesperson told Becker's the report was a "mischaracterization of our process for accelerating payment of claims for routine, low-cost screenings." 

"We should figure out how to harness the algorithms for good rather than evil … algorithms should make prior authorization a 30-second enterprise, and preserve patient access to care," Dr. Maddox said. "Right now, because it's being done in an unregulated and unknown manner, we're seeing people get out ahead who are in the business of trying to deny care."

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