Mike Gawley Discusses AI Healthcare Lawsuit

Health Plan Weekly

Mike Gawley was quoted a number of times in the Health Plan Weekly story “Lawsuits Target Big-Batch Claims Denials by Cigna…" (subscription required). The article provides an overview of recent lawsuits filed by members of health plans and the U.S. Dept. of Labor over “unfair, systematic patterns of claims denials.” Industry sources have said that the processes behind claims denials in the commercial space — and the software that carriers use to make those claims — will almost certainly be under tremendous legal and political scrutiny over the next several years.

Commenting for the article, Mike said, “I really think the heart of the Cigna case is this inherent tension between individualized health care decisions and the bigger AI systems, which sort of by their nature operate in a black box.” He added that “while stakeholders want individualized care decisions to be well-reasoned and case specific, taking into account the individual factors for the patient,” software systems “deal in aggregate data.”

“I think this Cigna case is a really good example of what we've seen in a lot of applications of technology and health care,” said Mike. “Folks come in with really high hopes and with a lot of excitement, but then in application it doesn’t quite live up to the [technology’s] potential or creates unintended consequences. I think you see that a lot in data-crunching and unintended health care disparities that get exacerbated by that.”

Regarding Cigna’s response — which includes “splitting hairs about technical categorization of PxDx [the program it uses to evaluate claims] as a software product,” Mike said, “I think people are understandably skeptical and skittish of rushing into having AI make care decisions or clinical decisions.” He continued that his “understanding of [the Cigna] case is that the claims that are at issue aren’t even authorization claims. It’s not whether a patient could get treatment, it was just whether after treatment was provided, payment was made. That seems to me like an area that has a lot of potential for efficiencies."

This could lead to “a number of potential legal troubles” for the healthcare industry, he added. “It’s not going to come as any surprise that the law is slow to catch up with technology…I think there are currently steps being taken which are encouraging — steps for regulators and legislators to put some guardrails on the use of AI, in particular in health care. I really think that perhaps the most important guardrail we should have is in ensuring that there's some kind of human check on any AI decision that’s made. And I think that’s in large part what the Cigna case is about — the claim that they didn’t have that kind of effective check on a [software] decision.”

Despite these issues, Mike closed by saying, “Health care billing is really inefficient in a lot of respects, and so applying an AI model to analyzing claims — I think we’re going to see more and more of it…AI isn't going away.”

Twitter/X Facebook LinkedIn


Related Practices


Jump to Page

We use cookies on this website to improve functionality, enhance performance, analyze website traffic and to enable social media features. To learn more, please see our Privacy Policy and our Terms & Conditions for additional detail.