Healthcare giant Cigna faces a lawsuit alleging systematic claim rejections through an algorithmic system that processes denials in seconds, raising concerns about technology’s impact on patients. The suit, filed in California seeking class-action status, accuses Cigna’s digital claims system, PXDX, of wrongfully denying valid medical payments. Cigna defends the system while other companies embrace AI for claims processing. The case highlights the ongoing debate over AI’s role in healthcare and the potential consequences for patient privacy and access to care.
Cigna, a major healthcare and insurance corporation, is facing a lawsuit alleging that it systematically denies claims within seconds using an algorithmic system designed to automate the process. This development raises concerns about how technology might potentially harm patients as more healthcare organizations adopt AI and other new tools.
The lawsuit, filed in California and seeking class-action status, was brought by two plaintiffs who were denied coverage by Cigna. One of them, Suzanne Kisting-Leung, was denied coverage for an ultrasound due to a suspected risk of ovarian cancer. The other plaintiff, Ayesha Smiley, had her claim denied for a vitamin D deficiency test, as ordered by her doctor.
The complaint claims that Cigna’s digital claims system, known as PXDX, is an “improper scheme” designed to automatically deny valid medical payments owed to policyholders. After the lawsuit was filed, Cigna defended the software system, asserting that PXDX is a tool to expedite physician payments and has been mischaracterized.
The lawsuit follows a previous investigation by ProPublica, which revealed how Cigna’s algorithmic system approves and denies claims in batches. The algorithm compares diagnoses with what Cigna considers acceptable tests and procedures for those conditions. Last year, Cigna denied over 300,000 claims in just 1.2 seconds on average per claim, without requiring medical doctors to review patient medical records. The lawsuit argues that this violates California competition law for unfair and fraudulent business practices and also breaches the state’s insurance code by not adhering to a “reasonable standard” for claim processing.
The emergence of advanced technologies like artificial intelligence has sparked discussions about the future of work and its potential impact on various industries, including healthcare. While high-tech innovations could be beneficial in streamlining processes and aiding doctors with paperwork and diagnoses, concerns persist regarding patient privacy, access to care, and the rising costs of medical bills.
Cigna is not the only company incorporating new technology into its processes. Google’s cloud division introduced AI-powered tools for healthcare claims processing, and other companies like Blue Shield of California and Bupa are also utilizing similar technologies.
The plaintiffs’ legal representation, Clarkson Law based in Malibu, California, has a history of challenging tech giants concerning AI-related issues. They recently filed lawsuits against OpenAI, the company behind ChatGPT, and Google, creators of the Bard generative chatbot, for alleged data theft from millions of individuals, including artists and writers who copyrighted their works, to train and develop their AI products.