AI is being used extensively in the area of the pre-authorization of your medical claims. Prior to approving a medical service or procedure, insurance companies often require a pre-authorization process where doctors must submit detailed information about the medical necessity of the service or procedure. AI algorithms can analyze this information to quickly determine whether the service or procedure meets the insurer's criteria for coverage.
Lawfully, AI is not supposed to autonomously make these decisions without human intervention. The final decision on whether to approve or deny a claim is supposed to rest with human reviewers who use the information provided by AI systems as one of many factors to consider. So what happens when those human reviewers are doctors that reflexively sign the denial in less than two seconds without reading or even opening the patient file?
Well, increased profits for the Government Healthcare Complex and a fresh glimpse at the utopia of AI medicine. This whole article is worth your time to read. It is an excellent glimpse behind the curtain. The following is from ProPublica:
The company [Cigna] has built a system that allows its doctors to instantly reject a claim on medical grounds without opening the patient file, leaving people with unexpected bills, according to corporate documents and interviews with former Cigna officials. Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method, spending an average of 1.2 seconds on each case, the documents show. The company has reported it covers or administers health care plans for 18 million people....A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments....'We literally click and submit,' one former Cigna doctor said. 'It takes all of 10 seconds to do 50 at a time.'...Cigna does not expect many appeals. In one corporate document, Cigna estimated that only 5% of people would appeal a denial resulting from a PXDX review.
