"How Is AI Impacting My Health & Healthcare?"
Commercial Health Insurance companies are increasing the speed of Denial of Care with Artificial Intelligence...1,400+ times faster | By Kimberly J. Soenen December 29, 2023 | By Kimberly J. Soenen
(Systemness | A Short Film about Denial of Care and White Collar Healthcare Crime.)
Commercial Health Insurance companies in the United States are implementing Artificial Intelligence (AI) to speed up “prior authorization” barriers to healthcare and denial of medical claims. Every big Commercial Health Insurance company reported new uses for AI in Denial of Care Harm-for-Profit in 2023, and the technology's role in prior authorization is under scrutiny in the courts and in the United States Congress.
Many / most all members of the U.S. Congress—and the President—run election campaigns that are in-part financed by the corporate healthcare, hospital chain and Commercial Health Insurance industries. This model is a gross conflict of interest and makes prioritizing Patient Safety, Best Practice, Quality of Care and Health Equity legislation unattainable.
Meanwhile, the 2023 political agreement of the European Union's Artificial Intelligence Act (AI Act) marks a transformative moment in the global AI landscape with the priority of protecting citizens from Harm-for-Profit, especially in the healthcare sector. The political agreement of the European Union's Artificial Intelligence Act (AI Act) marks a transformative moment in the global AI landscape. It aims to establish a comprehensive legal framework for AI development and deployment, prioritizing human-centricity, safety and trust. While still under final negotiation, the proposed Act holds significant implications for companies operating within the EU, presenting both challenges and opportunities.
“He (President Obama) knows and all America knows that our experience with employment-based insurance and these other Mickey Mouse things have been increasingly a total disaster. You have a $2.5 trillion industry with vested interests — the private hospitals that are for profit, the HMOs, the health insurance industry — making billions upon billions, and things getting worse. He knows and should act on the fact that time is running out.”
“The American people are hurting. Over a million Americans go bankrupt due to medical bills each year, and there’s a new study, incidentally, that will show that 50 percent of the bankruptcies are due to health costs; it will be 60 percent. So we have a worsening situation. And a man who wants to lead a country which is in great peril had best do some courageous things.”
“I really feel that we have to mount a national concern about this. As a doctor, up until a year ago, after sixty years of practice, I can testify that this system is — well, “broken” is a gross understatement. It’s wrecked. And it’s ruining people, and the public can’t put up with it anymore.
—Dr. Quentin Young, Longtime Obama Confidante and Physician to Martin Luther King, Criticizes Obama Administration’s Rejection of a Single Payer National Healthcare Program
(March 2009)
The United States has not yet taken a leadership role on AI regulation, oversight or protective legislation in the healthcare space. Consumer Rights, Privacy Rights, Human Rights and Discrimination Rights are all currently being violated by the Commercial Health Insurance industry.
Here are the hottest legal cases in the area of Patients’ Rights and Harm-for-Profit in 2023. “Hottest",” meaning, they have the power to reverse harm. (Annotated summary provided by Becker’s Healthcare.)
UnitedHealthcare and Humana are facing lawsuits alleging both companies used an AI tool to wrongfully deny patients medical care methodically. In November, the families of two deceased UnitedHealthcare Medicare Advantage members filed a proposed class-action lawsuit against UnitedHealth and NaviHealth, the developer of the AI tool, alleging the two members were wrongfully denied coverage of medically necessary post-acute care by UnitedHealthcare. A class-action lawsuit alleging Humana also used NaviHealth to wrongfully deny care was filed in December.
Scrutiny of the use of AI by Harm-for-Profit Commercial Health Insurance companies increased in 2023. Federal lawmakers and the American Medical Association called for more oversight of the use of AI in prior authorization, and In addition to federal lawmakers, states are ramping up scrutiny over how Commercial Health Insurance company board members and senior leadership across industries are deploying Artificial Intelligence for systemic Denial of Care.
Blue Cross Blue Shield of Massachusetts is using AI to do the same. In 2023 it had developed an algorithm that looks through its claims data and flags any suspicious activity before the claim is paid. While BCBS had a fraud detection program previously, it only reclaimed money after the claim was paid. BCBS of Illinois continues to be mired in ongoing fraud cases and White Collar Crime lawsuits. Most recently they paid a fine for fraudulently listing in-network physicians / clinics in their Members Handbook that do not accept the insurance. They were fined by the state but nobody in leadership was indicted or incarcerated for the crime.
In April, Google Cloud launched an AI-enabled platform for prior authorization and claims processing powered by a new data and analytics tool, Claims Data Activator. Blue Shield of California uses Google Cloud technologies to streamline its prior authorization process and help deliver timely clinical care for 4.8 million members. Prior authorization is one mechanism Commercial Health Insurance companies use to deny and delay medical care for persons in need. The AI-enabled platform automatically denies medical claims without being reviewed by a medical professional or medical practitioner. The software designers, AI engineers and software companies are soon to be on the hook for knowingly designing products that cause harm. Because the engineers and software designers do not have a medical license, they are also being examined for practicing medicine without a license which is a felony.
Health Care Service Corporation, in Illinois, which operates Blue Cross Blue Shield affiliates in Illinois, Texas, Oklahoma, Montana and New Mexico, said its AI technology can make prior authorization 1,400 times faster. That means, they are denying medical care to paying members at a rate that is 1,400 times faster than snail mail appeals and denials. BCBS expanded the technology to inpatient acute care, long-term acute care, inpatient rehabilitation, skilled nursing care, outpatient and inpatient hospice care, home health and outpatient services. This way, BCBS and HCSC can deny care to newborns through End-of-Life patients and still augment their profits through systemic denial.
In 2024, the rate and speed of Denial of Care will increase further as more people declare bankruptcy from paying out-of-pocket medical bills and Commercial Health Insurance industry shareholders continue to rake in historic profits.