Class Actions Highlight AI-Assisted Payer Denials

As health care payers increasingly rely on artificial intelligence ("AI") to speed up patient claim adjudication and prior-authorization determinations, providers should be on the lookout for algorithms designed to deny claims with minimal human oversight. Two putative class action lawsuits filed against Cigna and UnitedHealth in November 2023 allege that the payers' respective AI models, "PxDx" and "nH Predict," were used in place of real medical professionals to wrongfully deny medically necessary care.

The lawsuit against Cigna alleges that Cigna uses its PxDx (procedure-to-diagnosis) algorithm to automatically review claims without conducting a thorough medical review of the claims as required by law and contract.¹ The lawsuit alleges that over a period of two months in 2022, for example, Cigna used PxDx to automatically review and deny over 300,000 claims, spending an average of just 1.2 second per claim.² Despite insurance laws and regulations in many states