In the United States, in recent years, refusal to insurance has been increasing due to automatic algorithms utilizing AI. Some recently released artificial intelligence tools may counterattack by generating automatic objection.
However, medical experts say that the medical insurance system requires higher -priced reforms in order to achieve more permanent changes to suppress high prices and secure security.
United Health, Humana, and Signa faced a collective lawsuit for refusing to care for life care due to algorithm.
One of the litigation claims that CIGNA has refused more than 300,000 claims in two months, which is equivalent to about 1.2 seconds per claim made by a doctor. According to the complaint, this act is supported by algorithm.
In 2020, the United Health Group acquired a care forecast algorithm called Naviherus and its NH Predict. United Health is outsourced to other insurance companies, including Humana. (The United Health Group’s spokeswoman denied that this algorithm was used to determine the application range. Humana did not respond to comments.)
In the lawsuits to them, the incorrect rate of NH Predict is 90%, which means that 9 out of 10 denials are canceled by appeal, but few patients have appealed for rejected claims (about 0.2. %) Claims that the patient will pay the invoice at his own expense. Avoid the necessary treatment.
According to a non -profit organization KFF survey, this number has shown that less than 0.2% of those who purchased insurance through Healthcare.gov have denied that they have been rejected in the network. 。
When it comes to pre -approval (comparison that must obtain an insurance company’s approval before treatment or medication starts), it is rejected by the Medicare Advantage Plan (Medicare Approval Plan by Private Companies). , Less than 10 % were claimed. According to another KFF survey, 2022.
Currently, the clinic has the entire department that concentrates on the processing and objection of the previous approval decision.
According to the Commonwealth Fund, almost half of the adults in the United States have unexpectedly received medical expenses invoices and charged for their own payments.
Four of the five said that these delays were causing concerns and anxiety, and almost half said that the state had worsened due to the delay in treatment. Most people did not know that they could appeal to the denial.
However, for those who want to appeal, the process is very complicated and may have to give up.
Diadora O’Reilly was worried that one of the three sons had severe food allergies, so one of them would go to a university outside the state. When the reaction came out, he went to the emergency treatment room as usual.
However, according to the negative document confirmed by the Guardian, the insurance company refused to compensate for the entire visit (about $ 5,000). O’Reilly tried four times, but the insurance company Brucros Blue Shield (Vermont) gave a different reason.
“My son had no choice. He was about to die if he didn’t go to the nearest emergency treatment room,” said O’Reilly.
She must know. She is a centralized physician at Vermont University. She has seen a similar refusal, such as premature babies who have been refused to wear an oxygen inhalor, occur in her own patients.
“I can’t control it. I’ve changed a lot in 20 years since I became a doctor,” she said. “I can’t believe that people have to experience this situation just to receive medical insurance, which is the basic needs.”
And many do not have similar medical expertise and do not have the time or resources spent on long -term appeal procedures.
“I was persistent,” she said. “But at some point, I could only fight so far.”
The Blue Shield Vermont spokeswoman denied the use of algorithms in care management, although in a statement that could not comment on personal health records. Most of the prior approval decision was performed by an insurance company doctor and a nurse team based on the national guidelines.
Vermont is one of some of the states that have recently passed a bill to reduce the burden of pre -approval.
In particular, automatic refusal is exposed to severe monitoring by Federal and State members.
We will send the most important headline and highlights by email every morning
Privacy notification: Newsletters may include information on content provided by charity, online advertising, and external organizations. See our privacy policy for details. We use Google Recaptcha to protect the website, with Google Privacy Policy and Terms of Use.
After the news letter promotion
According to the US Senate report announced in October, United Healthcare, CVS, and Humana, the three major providers of med care advantage, also provide almost 60 % of the Medicare Advantage compensation range. He says that he has rejected prior approval requests at high rate using technology and automation.
According to data analysis from the US Medicea Medicade Service Center, the denial of the denial is more than $ 7.2 billion per year for medical providers.
The agency recently announced new rules that regulate pre -approval of the Medicare Advantage Plan.
For those who want to know the details of the reasons why the claim has been rejected, Propublica has launched a service to enable patients to submit recording requests.
Some patients and companies have developed AI tools to appeal for denials in the Battle of Bot.
Companies have launched a new generation AI tool to enable hospitals and patients to create drafts on appeals, but one of the large -scale language models of open source developed by engineers is the patient’s “healthy”. We promise to support the “fight against insurance”.
According to Michel Mero, a medical policy professor at Stanford University School of Medicine, “I don’t like the system we introduced a few years ago. This system was also a simple one, but it was simple.” I have stated. “And now there is no one who likes AI to be involved, but I think it has a constructive role in improving the algorithm.”
She said that AI would help confirm that the form is codeized and formatted according to the specifications of each insurance company, and that the request is incomplete and not kicked back. 。 It can also be used by insurance companies to make insurance applications more quickly.
At the United Health Group’s Andrew Witty’s Chief Executive Officer (CEO), most of the rejections occurred due to mistakes in filling and submitting the form last week, and executives were United Healthcare in 2024. The company said it would be about $ 300 billion, and the company expects the number to $ 300 billion. In 2025, $ 340 billion.
Witty estimates that 85% of the rejected claims can be avoided by “more standardized approaches in the industry”.
Witty said that it is particularly important to change to industry standards, rather than having different formats and processes.
But experts point out that it is necessary for humans to monitor automated processes.
According to Mika Hummer, an assistant professor of medical policy and management at Maryland University Graduate School, “these algorithms do not always function correctly, so there is a concern that the human aspects may be further removed from the system.” Was stated. In public health.
California has recently banned the application of insurance by AI and has enacted laws that require a doctor’s supervision.
However, Hummer said that dealing with AI alone would not solve some of the problems under the decision of automation, such as soaring medical care and pharmaceuticals.
Hummer said, “$ 5 in US GDP is spending a health care,” said Hummer. “This is a completely large system. You will need a large -scale review.”
