Health Affairs June 20, 2024
Health insurance companies increasingly use artificial intelligence (AI) and machine learning (ML; a branch of AI) tools—often developed, trained, and tested with real-world data—to accelerate claims, coverage, and prior authorization decisions. Unfortunately, too little is known about these algorithms’ underlying data, development, testing, and performance to judge their reliability and ability to promote equitable care delivery.
Several news reports emerged in 2023 highlighting large-scale, potentially inappropriate denials of health care claims and prior authorizations. For instance, an ongoing investigation by ProPublica and the Capital Forum reported that in 2022, Cigna—a health insurance provider that covers or administers health care plans for 18 million people—used an AI technology called PxDx to deny or reject more than 300,000 claims for services or...
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