Hospital sues insurer over use of AI to deny $2M in claims
Blue Cross and Blue Shield of Kansas City (Blue KC) is being sued by a hospital that accuses the insurer of using artificial intelligence to wrongfully deny hundreds of medical claims, resulting in $2 million in underpayments.
AdventHealth Shawnee Mission said physician diagnoses at the facility were being flagged by AI provided by Apixio, which is contracted to work with Blue KC on claims audits. The hospital stated that 350 instances of patient care were ruled “clinically invalid,” despite diagnoses being made by physicians.
According to Shawnee Mission, Blue KC has repeatedly disregarded valid medical codes that justify the need for reimbursement, in violation of state and federal law.
“[Blue KC’s] unlawful and unethical actions undermine the fundamental principle that healthcare decisions in America should be made by doctors, with the medical expertise, legal responsibility and accountability for making treatment decisions for their patients and should not be made by auditors, accountants or artificial intelligence devices,” attorneys representing Shawnee Mission wrote in the lawsuit.
They added that the denied claims and underlying audit also violate contracts between the insurer and the hospital. Shawnee Mission believes the AI technology is to blame, but argues that Blue KC is still required to reimburse legitimate medical claims with accurate coding, regardless of the technology’s findings.
The lawsuit, initially filed in a county court, has been moved to U.S. District Court in Kansas City. Shawnee Mission is seeking damages.
Neither the hospital nor the insurer has commented publicly on the pending legal battle.
For more, read the full story from the Kansas City Star at the link below.
Chad is an award-winning writer and editor with over 15 years of experience working in media. He has a decade-long professional background in healthcare, working as a writer and in public relations.