AI represents a promising frontier, especially in healthcare, where leveraging vast information could revolutionize problem-solving. However, a shadow looms over AI, as anticipated by many. In the realm of health insurance and patient care denials, AI has already stirred controversy, leading to a notable class action lawsuit.
According to reports from healthcare News, Health Insurance Plans, a major Medicare Advantage Plan insurer, faces legal action for employing artificial intelligence within an algorithm that allegedly resulted in unjustly denied care for numerous individuals. Quoting the lawsuit’s introduction, the plaintiffs claim:
“The core of this class action stems from the unlawful use of artificial intelligence (AI) in lieu of qualified medical professionals, leading to the wrongful denial of essential care owed to elderly patients under Medicare Advantage Plans. This denial overrides the diagnoses provided by treating physicians, relying on an AI model with a purported 90% error rate.”
The plaintiffs further contend that the technology empowers the company to “aggressively deny coverage,” knowing they won’t face repercussions for these erroneous rejections. The complaint emphasizes that those refused care are predominantly elderly, with only a small fraction contesting these unjust denials.
The Problem with Appeals
Insurers overriding a patient’s doctor’s care recommendations are not a novel occurrence. In traditional Medicare denials, a regulated appeals process exists. Through personal experience, we’ve observed that unfair Medicare payment denials can often be rectified by presenting evidence of the patient’s need for disputed care, with a reasonable chance of obtaining payment. The decision rests with an impartial hearing officer, not the insurer.
However, this clarity is less apparent with Medicare Advantage plans, especially for those requiring extended care in nursing homes. These individuals may lack the means to navigate the appeals process effectively. The class action lawsuit alleges that Health Insurance plans exploit this ambiguity, purposefully using the algorithm to deny care. These claims remain unproven pending litigation, which will eventually yield a verdict or settlement, the outcome of which remains uncertain.
This lawsuit is not an isolated incident regarding AI. It underscores the steadily emerging risks associated with the largely unregulated use of AI, as warned by pioneers of this technology. Particularly concerning is the harm to vulnerable elders, highlighting the need for AI regulations in healthcare coverage. The lawsuit’s outcome remains unknown, yet the issue being brought before the court demands attention.
During the annual open enrollment period, extensive promotion of Medicare Advantage plans occurs across media. However, potential customers aren’t cautioned that companies might have devised strategies to limit the benefits they offer, such as extended care in a rehab facility post-hospitalization. A successful outcome for the plaintiffs in this case could likely prompt alterations in the use of AI-driven algorithms for healthcare coverage determinations.
The Takeaway:
If you or an elder in your family, covered by Medicare, are contemplating switching insurers during the open enrollment period, exercise extreme caution in scrutinizing the insurer’s track record regarding care denials and their provided information about the appeal process for coverage refusals. Inquire specifically about the appeal procedure if this information isn’t readily disclosed. You have the right to inquire about the frequency of care denials by their company and how these denials are typically appealed, including the average duration of appeals.
However, keep in mind that salespeople might prioritize selling their product and might not provide satisfactory answers to these crucial questions. Be wary if the insurer’s representative evades or is unable to address these specifics when questioned.
While care denials can occur, they should never disproportionately affect essential care issues or frequently override a treating doctor’s recommendations for necessary treatment. Learn from the lawsuit highlighted in this context. AI has the potential to exacerbate such issues until regulatory frameworks are established to govern its use across various sectors, including the insurance industry, by our legislative bodies.
