Was Your Insurance Claim Denied by an Algorithm? Understanding AI in Modern Claims Processing
If your health insurance claim was wrongfully denied, not only could you seek to force the insurance company to pay for your treatment, but you may also be able to seek damages from them for bad faith. The Inland Empire insurance bad faith lawyers at Quincey Law can help.
Companies, including health insurance providers, have increasingly been turning to artificial intelligence to review preauthorization coverage. The algorithms are often programmed in a way which could lead to wrongful and unnecessary denials. You can and should fight back when the insurance company has wrongfully denied your claim.
Let Quincey Law lead the fight for you when your insurance claim has been illegally denied. Speak to an Inland Empire insurance bad faith attorney to learn what you can do in this situation.
Insurance Companies Are Increasingly Using Algorithms to Process Claims
You may have been shocked to learn that the health insurance coverage that you expected from your carrier has been denied. This seems to be happening more often these days, and there is a reason for it. Health insurance companies are increasingly using artificial intelligence and algorithms in processing preauthorization requests for coverage, and the results are not good for consumers like you. Even though a new California law requires human input in processing claims, the algorithm could be pointing their employees in the direction of denying the healthcare coverage you need and to which you are entitled.
Health insurance companies claim that they use AI to both streamline operations and cut costs. Many times, when you hear an insurance company claim that they are doing something that cuts costs, it often comes at your expense. Cutting costs often means that insurance companies are trying to narrow the universe of claims that they pay. The health insurance company is trying to take human input out of the claims decision processing as much as possible, based on an algorithm and the use of other available information. A human may not even review your claim, until they have seen a recommendation from an algorithm to deny it.
In reality, what AI is doing in the healthcare industry is taking denials that were previously made through human decisions and making them systemic. Over 60% of physicians have reported that the use of AI has led to an increase in claims denial for necessary care. One study found that the denial rate for health insurance claims has risen by as much as 16 times (not 16%, but 16 times the amount of denials). Both patients and healthcare providers are being forced to bear this burden. An increasing number of physicians are reporting serious adverse health consequences for patients due to the use of AI, and patients having to pay out of pocket is actually the least serious of these effects. The prior authorization requirement already makes things cumbersome enough for health care providers and patients, and the use of AI is gravely exacerbating the situation.
Insurance Companies Must Have Human Input Into Your Claim Decision
The situation has become so bad that the California Legislature has passed a bill that requires human input in the claims process. Unfortunately, the human input could be as limited as merely signing off on the denial made by an AI algorithm, since the law does not outlaw the use of AI entirely. Health insurance companies using AI as the basis of the reason to deny your claim seems to be here to stay because humans can still confirm what they are told to do by the algorithm. It may be a very rare outcome for insurance company employees to overrule the algorithm and approve the care that you need.
Although the use of AI itself does not necessarily violate the law, it can rise to the level of bad faith when you are able to prove that the insurance company unreasonably denied your care that should have been allowed under the terms of your policy. You may be able to show that the insurance company failed to undertake a reasonable investigation before they denied your healthcare. If you can make these showings, you could be entitled to damages directly from the insurance company in a bad faith lawsuit. Consumers are increasingly suing health insurance companies over the wrongful denial of claims using AI.
Contact an Inland Empire Insurance Bad Faith Law Firm
You can take on the insurance company by contacting Quincey Law to take action to force them to pay your claim and potentially seek damages. Schedule a free initial consultation with an Inland Empire insurance bad faith attorney by visiting our website or by calling us today at (866) 945-9175.
Nicholas Quincey is the founder of Quincey Law, and has over a decade of experience of handling insurance claims denials and personal injury matters for people throughout California. We have pursued insurance bad faith claims for people involving life insurance, health insurance, homeowners and disability insurance. We also work with clients and families who need assistance filing and pursuing a personal injury matter. Learn more here.