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House of Representatives
Session of 2023 - 2024 Regular Session


Posted: August 14, 2023 07:29 AM
From: Representative Arvind Venkat and Rep. Joe Hogan, Rep. Tarik Khan, Rep. Bridget M. Kosierowski, Rep. Robert W. Mercuri, Rep. Nick Pisciottano
To: All House members
Subject: Regulation of Artificial Intelligence (AI) Use in Health Insurance Claims Processes
Artificial Intelligence (AI) represents the next frontier in technological advancement, with the potential to both aid and harm multiple areas in our economy. One area of particular need for regulation is the use of AI in health insurance. In 2022, it was revealed that, in only two months, Cigna denied more than 300,000 claims during a review process that relied upon computer algorithms for primary evaluation and that Cigna-employed medical professionals with a responsibility for claims reviews only spent roughly 1.2 seconds on each case, depending on the computer assessment to have done the in-depth review that should be performed and is mandated to require an individualized medical assessment (https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims). This short amount of time examining health insurance claims and rapid denials can leave individuals with unexpected and unpaid bills for medically necessary treatment. AI has the potential to only worsen this concern without appropriate regulation.
As AI is rapidly implemented by health insurers in their utilization review process, it is important for all Pennsylvanians, and especially patients and health care providers, to know what methods are being used to approve or deny their claims and that we place guardrails on the use of this technology in this sensitive area. For this reason, we will shortly be introducing legislation that would require health insurers to:
  1. Disclose to clinicians, subscribers, and the public that claims evaluations use AI algorithms
  2. Define ‘Algorithms used in claims review’ as clinical review criteria and therefore ensure they are subject to existing laws and regulations that such criteria be grounded in clinical evidence
  3. Require specialized health care professionals who review claims for health insurance companies and rely on initial AI algorithms for such reviews to individually open each clinical record or clinical data, examine this information, and document both their own review and reason for denial before any decision to deny a claim is conveyed to a subscriber or health care provider.
  4. Require health insurance companies to submit their AI-based algorithms and training datasets to the Pennsylvania Department of Insurance for transparency and require the Department of Insurance to certify that said algorithms and training data sets have minimized the risk of bias based on categories outlined in the Human Relations Act and other anti-discrimination statutes as applicable to health insurance in Pennsylvania and adhere to evidence-based clinical guidelines.
Please join us in this effort to improve the health insurance utilization review process to protect consumers and appropriately regulate the use of AI-based algorithms by health insurers.

Introduced as HB1663