SOCIAL
Payer Behavior: Automated Denials
the AI powered algorithm ‘nH Predict’, developed by naviHealth and leveraged by UnitedHealthcare and Cigna Healthcare, has yielded increased wrongful denials for member medical claims.
As a result, the organizations are currently facing a legal action filed in November of 2023. Cigna Group is also navigating litigation surrounding the wrongful denials of large batches of claims as a result of another automated claims review process called: PxDx.
Becker’s Healthcare reports that, “The lawsuit alleges the algorithm predicts how long a patient will need to remain in skilled nursing care and overrides physicians' determinations for the patient.” Optum, the care management company that acquired naviHealth in 2020 issued a statement saying, with regard to use of the nH Predict tool, “The tool is used as a guide to help us inform providers, families and other caregivers about what sort of assistance and care the patient may need both in the facility and after returning home. Coverage decisions are based on CMS coverage criteria and the terms of the member's plan. This lawsuit has no merit, and we will defend ourselves vigorously."
Read more here.
This news showcases the potential harm to patients as organizations seek to incorporate further automation and experiment with AI-driven algorithms - and highlights the benefits of partnership with an organization like HURC. With increased oversight on claims denials and embedded operators working alongside existing provider FTEs, HURC can identify and rectify wrongful claims generated by irresponsible and unethical automation in real-time.
Let HURC bridge the gap between payer and provider - allowing clinicians to focus on what matters most: the patient.
ProPublica: No One Knows How Often Payers Deny Claims
"Americans deserve information and data that has relevance to their own personal health and circumstances," an AHIP spokesperson told ProPublica in a recent report. Read more below about why transparency in the health insurance claim denials process is necessary!
Denied by AI: How Medicare Advantage plans use algorithms to cut off care for seniors in need
Something to watch out for! "Health insurance companies have rejected medical claims for as long as they’ve been around. But a STAT investigation found artificial intelligence is now driving their denials to new heights in Medicare Advantage, the taxpayer-funded alternative to traditional Medicare that covers more than 31 million people,"
While AI can provide many benefits, is there a point at which it could cause harm as well? Read more in the article below.