Cigna Hit With Lawsuit Over Controversial AI Technology Use

August 09, 2023 | 4 minutes read

Can you assess a medical claim in just 1.2 seconds? A class action lawsuit alleges that healthcare insurer Cigna can. New York-based nonprofit newsroom, ProPublica, reported the use of an AI system named PXDX to mass-deny health insurance claims. It’s not the first instance where profit trumps American medical needs or where AI potentially jeopardizes the well-being of everyday individuals. Let’s delve into the allegations against Cigna and the role of artificial intelligence in healthcare: its benefits and pitfalls

Cigna’s PXDX System

PXDX is shorthand for procedure to diagnosis. It is an apt name for a program that is supposed to scan medical tests and procedures that are linked to confirming a diagnosis, matching them against what an insurer thinks is necessary, and approving or denying an insurance claim. However, like with everything, there are exceptions to the rule. Sometimes doctors may have to order a series of tests to properly diagnose their patient. Medicine is a science but there are times when guesswork comes into play. These variables are hard to pinpoint and make using artificial intelligence for the sorting of claims a complex issue.

Dr. Alan Muney is a former pediatrician who designed the AI-based PXDX system for Cigna. The system was created to easily match and approve textbook insurance claims where the symptoms, tests, and diagnoses aligned as expected while rejecting those that did not. This streamlined process was put in place as a cost-saving measure because having a doctor or nurse review each claim would be exceedingly expensive. But is that a reason to put artificial intelligence in charge of processing medical insurance claims?

Artificial intelligence is an amazing tool but it should not be used to replace the human mind, something that the actors and writers striking in Hollywood can support, and it certainly shouldn’t have the final say over something as complicated as reviewing insurance claims. A denied claim could mean paying hundreds if not thousands out of pocket for necessary medical tests and procedures, putting Americans into financial hard spots.

Is Cigna Choosing Money Over Medicine?

While using AI to streamline tedious and often expensive processes isn’t necessarily a bad thing, removing human review from the process altogether is. Artificial intelligence is only as smart as the materials it was trained on through machine learning and by the functions it is programmed to follow. In the case of PXDX, it scans insurance claims for the diagnosis and checks it against a list of pre-approved tests. As mentioned before, not all journeys to the proper diagnosis are linear. This is where situational context and the medical experience of a licensed doctor or nurse would come in handy.

Except when PXDX rejects claims, often thousands a minute, they are sent to doctors who do not have to open the patient’s file to apply an electronic signature and formalize the rejection. ProPublica and their inside sources claimed that these formalized rejections are done in bulk, resulting in hundreds of thousands of denied claims.

A possible motivation for the mass rejection is that the percentage of refuted claims being much smaller than the amount rejected, leading to a lower cost of doing business on Cigna’s end. While cheaper for the company, these denials can be expensive for those who then have to either go through the hassle of refuting the rejection or begrudgingly pay out of pocket for their treatment.

This isn’t the first time Cigna has been sued. In 2022 a lawsuit was filed claiming that Cigna took advantage of Medicare and Medicaid, government healthcare programs, to gain more money than they were spending. The issue of potentially shady dealings in the healthcare industry isn’t unique to Cigna, GoodRx was accused of selling sensitive information about their customers, claiming that it wasn’t in violation of their privacy under HIPPA.

A Better Way To Use AI For Healthcare

Artificial intelligence doesn’t have to be used in a way that has negative consequences. Medical charts and patient files are filled with personally identifiable information, payment information, and other sensitive data that shouldn’t be left unsecured. Hospitals, clinics, and doctors’ offices all have security cameras and calls to insurance companies may be recorded for training purposes. This amounts to documents, videos, images, and audio recordings that may need to be redacted to circulate them to comply with requests by patients, lawyers, and law enforcement.

Removing sensitive information from documents shouldn’t be a hassle. With an all-in-one, AI-powered solution like CaseGuard Studio, you can redact in just a few clicks. The artificial intelligence technology used by the software is constantly evolving, being trained on new assets, and improving the overall performance of CaseGuard when redacting all types of files. And while the redactions may take longer than 1.2 seconds it allegedly takes PDPX to review an insurance claim, its bulk processing features make it a breeze to redact thousands of documents, videos, audio files, and images.

Watch the video below to learn more about bulk document redaction with CaseGuard Studio.