A lawsuit filed in the U.S. District Court in Sacramento accuses health insurance provider Cigna of using an algorithm, known as PxDx, to automatically review and deny hundreds of thousands of patient claims without individual evaluation by doctors. The lawsuit argues that these actions violate California state law, which requires insurers to conduct a thorough and fair investigation of each claim. By relying on the algorithm, Cigna can save money by denying claims and reduce labor costs by minimizing the time doctors spend reviewing each case.
The complaint includes the case of a Cigna customer, Suzanne Kisting-Leung, who had an ultrasound to check for ovarian cancer. Despite the ultrasound revealing a cyst on her left ovary, Cigna denied her claim, stating that the procedure was medically unnecessary. As a result, Kisting-Leung was left with a bill of $723 for the ultrasounds.
Similar to Kisting-Leung’s case, another Cigna customer had a vitamin D test ordered by their doctor, which was also denied without explanation. The lawsuit highlights the increasing use of algorithms and artificial intelligence in tasks previously handled by humans. The concern in healthcare is whether a computer program can provide the same level of thorough and fair decision-making as a human medical professional when evaluating patient claims.
The lawsuit alleges that Cigna’s doctors reject claims without opening patient files, leaving thousands of patients without coverage and unexpected bills. The scope of the problem is substantial, with over 300,000 requests for payments rejected within just 1.2 seconds of review each using the PxDx system.
This lawsuit was filed by Clarkson Law Firm, which has also sued Google-parent Alphabet over allegations of data theft for training AI programs.
Cigna denies the allegations and considers the lawsuit highly questionable. The insurer states that it uses technology to verify the correctness of codes on common, low-cost procedures to expedite physician reimbursement. Cigna asserts that its insurance claims review does not result in denials of care and that the individuals mentioned in the lawsuit may not have been impacted by the PxDx system.
Nevertheless, the lawsuit echoes a recent investigation by ProPublica, which highlighted similar denials of payment to Cigna customers. Though the treatment is provided, some customers are left with unexpected bills that they believed would be covered by their health plans.
According to a doctor who had worked at Cigna, they would sign off on the denials from PxDx in bulk without evaluating individual claims. This automated process allows for quick submission of denials. Kisting-Leung has appealed her denials but has not yet received payment for the ultrasounds. The lawsuit seeks damages and an injunction to prevent Cigna from continuing its alleged improper and unlawful claim handling practices.
Overall, this lawsuit raises concerns about the use of algorithms in healthcare and whether they can provide the same level of thoroughness and objectivity as human professionals when evaluating patient claims.
Denial of responsibility! VigourTimes is an automatic aggregator of Global media. In each content, the hyperlink to the primary source is specified. All trademarks belong to their rightful owners, and all materials to their authors. For any complaint, please reach us at – [email protected]. We will take necessary action within 24 hours.
