Addressing the use of AI in the health insurance claims process

Pennsylvania House Democratic Caucus    August 14, 2023 | 1:40 PM

HARRISBURG, Aug. 14 – With the usage of artificial intelligence increasing, state Rep. Arvind Venkat, D-Allegheny, will introduce legislation to regulate AI in health insurance claims processes.

Venkat will introduce legislation to disclose the use of AI algorithms in health care claim evaluations, define such algorithms to subject them to current laws and regulations related to clinical evidence, and require specialized health care professionals that review claims and rely upon initial AI algorithms to document their review of the records and data prior to their individualized documented decision to deny a claim.

“As a recent example of the danger with algorithm-driven health insurance decision making, Cigna denied more than 300,000 claims, and health care professionals employed by Cigna only reviewed the cases for approximately 1.2 seconds each over a period of two months in 2022, which is unethical,” Venkat said. “With professionals spending approximately 1.2 seconds on a case and subsequently issuing rapid denials based on algorithmic decision making, individuals may receive unexpected bills for medically necessary treatments. It is time to regulate AI in health insurance claims processes that may only accelerate such dangerous abdication of claims review responsibilities.”

The legislation would also require health insurance companies to submit their AI-based algorithms and training datasets to the Department of Insurance and require the department to certify that the algorithms and datasets minimize the risk of bias based on categories outlined in the Human Relations Act and other anti-discrimination statues as applicable to health insurance in Pennsylvania.

In addition to Venkat, Reps. Tarik Khan, D-Phila.; Bridget Kosierowski, D-Lackawanna; Nick Pisciottano, D-Allegheny; Rob Mercuri, R-Allegheny; and Joe Hogan, R-Bucks are sponsoring this legislation.