Pennsylvania considers requiring insurers to disclose how they use AI

A group of Pennsylvania lawmakers is introducing legislation to require payers' to disclose how they use AI in claims review and require human review of any AI-processed claims. 

In an Aug. 14 news release, Pennsylvania Rep. Arvind Venkat said a ProPublica report that alleged Cigna denied large batches of members' claims without individual review is an "example of the danger with algorithm-driven health insurance decision making." 

In a July 27 statement, Cigna said PxDX, the technology referenced in the ProPublica report, is more than a decade old and does not involve algorithms, artificial intelligence or machine learning. The technology is also an industry standard, with similar tools being used by other commercial payers and CMS, according to Cigna. 

"It is time to regulate AI in health insurance claims processes that may only accelerate such dangerous abdication of claims review responsibilities," Mr. Venkat said. 

The proposed legislation would: 

  • Require insurers to disclose publicly if claims evaluations use AI algorithms
  • Require algorithms to be based on clinical evidence 
  • Require clinicians that review denied claims to document their own review and reasoning of the decision before denying a claim 
  • Require payers to submit AI algorithms used in claims review to the state's department of insurance for review 

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