The United States has seen an increase in insurance coverage denials in recent years, due in part to automated algorithms that utilize AI. Some recently launched artificial intelligence tools could fight back by generating automated appeals.
But for more lasting change, health care experts say the health care system needs even more major reforms to curb high prices and ensure coverage.
UnitedHealth, Humana and Cigna are facing class action lawsuit lawsuit Insurers claim they relied on algorithms to deny life-saving care.
One of the lawsuits alleges that Cigna denied more than 300,000 claims over a two-month period. 1.2 seconds For each claim reviewed by a physician. According to the complaint, this activity is aided by algorithms.
In 2020, UnitedHealth Group acquired NaviHealth and its care prediction algorithm called nH Predict. UnitedHealth uses it and outsources it to other insurance companies, including Humana. (A UnitedHealth Group spokesperson denied that the algorithm is used to determine coverage. Humana did not respond to a request for comment.)
In cases against them, nH Predict has a 90% error rate, meaning 9 out of 10 denials are reversed on appeal, but very few patients appeal denied claims (approximately 0.2 %), and patients will be responsible for paying their own bills. Withholding necessary treatment.
That number is investigation The nonprofit KFF found that fewer than 0.2% of people who purchased insurance through HealthCare.gov dispute a claim denial within their network.
When it comes to prior authorization (the practice in which doctors and patients must obtain insurance company approval before beginning treatment or medication), some of the requests denied by Medicare Advantage plans (Medicare-approved plans run by private companies) , less than 10% were challenged. According to another KFF 2022 investigation.
The clinic now has an entire department dedicated to processing and appealing previous authorization decisions.
According to one survey, nearly half of U.S. adults say they have received an unexpected medical bill or had to pay a co-pay. investigation From the Commonwealth Fund.
Four out of five people said these delays caused them worry and anxiety, and nearly half said delays in treatment made their symptoms worse. Most people didn’t know they could appeal a denial.
However, for those seeking to appeal, the process can be so complicated that they may have no choice but to give up.
Two of her three sons have severe food allergies, so Deirdre O’Reilly was worried about sending one of them to college out of state. When he had a reaction, he went to the emergency room as usual.
But this time, the insurance company refused to cover the entire cost of the visit, about $5,000, according to a denial document seen by the Guardian. O’Reilly said she tried to appeal four times, but each time her insurance company, Blue Cross Blue Shield of Vermont, gave her a different reason.
“My son didn’t have a choice. He was going to die if he didn’t go to the nearest emergency room,” O’Reilly said.
She should know. She is an intensive care physician at the University of Vermont. She has seen similar refusals occur in her own patients, such as a premature baby who was refused an oxygen machine.
“It’s gotten out of control. A lot has changed in the 20 years I’ve been a doctor,” she said. “I can’t believe that people have to go through situations like this just to get medical insurance, which is a basic need.”
And many do not have the same medical expertise or the time or resources to commit to a lengthy appeals process.
“I was persistent,” she said. “But at a certain point, I could only fight so far.”
A Blue Shield of Vermont spokesperson said in a statement that the company cannot comment on individual health records, but denied using algorithms to manage care. “Most” of the prior authorization decisions were made by the insurer’s team of doctors and nurses based on national guidelines, she said.
Vermont is one of several states that recently passed legislation to reduce the burden of prior authorization.
Automatic denials, in particular, have come under intense scrutiny from federal and state lawmakers.
After newsletter promotion
According to the U.S. Senate, the three largest Medicare Advantage providers, UnitedHealthcare, CVS, and Humana, which together provide nearly 60% of Medicare Advantage coverage, use technology and automation to improve preauthorization applications. It is said that there is a high rate of rejection. report Released in October.
Appealing these denials will incur the following costs: $7.2 billion Annual administrative costs for health care providers are increasing, according to an analysis of data from the U.S. Centers for Medicare and Medicaid Services.
The agency recently announced new rules Regulates prior authorization for Medicare Advantage plans.
For those looking for details on why their claim was denied, ProPublica has service To enable patients to submit records requests.
Some patients and companies have developed AI tools to appeal deniability in the form of “.bot battle”.
Companies have launched new generative AI tools to help with this. hospital and patient Meanwhile, one open source large-scale language model developed by engineers promises to help patients. ”fight health insurance”.
“Nobody liked the system we put in place a few years ago, which also used algorithms, but they were simple,” said Michelle Mello, a health policy professor at Stanford University School of Medicine. says. “And now, no one likes having AI involved. But I think there is a constructive role for improving algorithms.”
AI can help Make sure the forms are coded and formatted according to each insurance company’s specifications to avoid kickbacks due to incomplete requests, she said. May also be available to insurance companies approve File insurance claims faster.
UnitedHealth Group CEO Andrew Whitty said on an earnings call last week that most of the denials were due to errors in filling out or submitting forms, and executives said UnitedHealthcare’s 2024 revenue is approaching $300 billion, and the company said it expects that number to reach $300 billion. 340 billion dollars in 2025.
Witty estimates that 85% of denied claims could be avoided “with a more standardized approach to technology across the industry.”
Whitty said it’s especially important to change to industry standards, rather than each company having a different format or process.
But experts say human oversight of automated processes is a necessary change.
“These algorithms don’t always work correctly, so there are concerns that they will further remove the human aspect from the system,” said Micah Hammer, assistant professor of health policy and management at the University of Maryland Graduate School. said. of public health.
California recently enacted a law banning AI from making insurance coverage decisions and requiring physician oversight.
But addressing AI alone won’t solve some of the problems underlying the automation decision, such as rising medical and drug costs, Hammer said.
“One in every five dollars of U.S. GDP is spent on health care,” Hammer said. “This is quite a large system. It’s going to require a major overhaul.”
