New AI tool counters health insurance denials decided by automated algorithms

https://www.theguardian.com/us-news/2025/jan/25/health-insurers-ai

New AI tool counters health insurance denials decided by automated algorithms

Class-action lawsuits allege algorithms turn down claims in seconds and critics say reform is needed for lasting change

Melody Schreiber
Sat 25 Jan 2025 07.00 EST

Insurance coverage denials have risen in recent years in the US, driven in part by automated algorithms powered by AI – and some recently launched artificial intelligence tools may fight back by generating automatic appeals.

But to see more lasting change, health experts say that the health insurance system needs greater reform to control high prices and ensure coverage.

UnitedHealth, Humana and Cigna are facing class-action lawsuits alleging the insurers relied upon algorithms to deny lifesaving care.

One of the lawsuits alleges that Cigna denied more than 300,000 claims in a two-month period, which amounts to about 1.2 seconds for each physician-reviewed claim. Such a practice is aided by algorithms, the lawsuit said.

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The lawsuit against them alleged that nH Predict has a 90% error rate, meaning nine out of 10 denials are reversed upon appeal – but that vanishingly few patients (about 0.2%) appeal their denied claims, leading them to pay bills out of pocket or forgo necessary treatment.

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(Always appeal.)