Should You Be Worried About AI in Health Insurance Claim Reviews?
Should You Be Worried About AI in Health Insurance Claim Reviews?
Insurance claim reviews are increasingly being done by Artificial Intelligence. While AI can speed up decisions and lower costs, the many people are worried about how it's being used and whether it's getting the right results.
Insurance Claim Denials Increasing
Insurance claim denials are going up. A 2023 STAT News investigation showed that UnitedHealthcare denied 22.7 percent of requests for post-hospital care in 2022. That’s double the rate from 2020. This increase started when they began using an AI tool called nH Predict.
Even worse, many of these denials were wrong. A lawsuit says about 90 percent of these claims were approved later when someone appealed. This means the system may be denying care too quickly.
The American Medical Association (AMA) is also worried. They found that AI is being used to deny care more often. In some cases, denials are happening 16 times more than usual.
What AI Means for Insurance Claim Reviews
AI can be good or bad, depending on how it is used. It can help both insurance companies and patients, but it also has risks.
Pros of Using AI in Insurance Claim Reviews:
- Quicker answers. AI can review claims fast, so you do not wait as long.
- Fewer mistakes. AI can spot errors that humans might miss.
- Lower costs. Using AI can make processing cheaper, which may lower your insurance bill.
- Fraud prevention. AI can catch false or repeated claims.
Cons of Using AI in Insurance Claim Reviews:
- Too much trust in technology. Sometimes, AI says no to care even when a doctor says it’s needed.
- No clear reasons. Companies do not always explain how the AI makes decisions.
- More denials. Some insurers may use AI mainly to save money, not to help patients.
How This Affects Real People
Insurance claim reviews are not just numbers. They affect real people. Imagine a cancer patient who is told their chemotherapy is no longer covered. Or an older adult recovering from surgery who is forced to leave rehab early. These decisions often come from AI tools, not doctors.
Appealing a claim denial can take weeks. During that time, a patient’s health may get worse. Missing care can mean more problems later.
Insurance Claim Reviews Protection Laws
Some lawmakers are trying to fix this. Several states have passed or introduced bills that ensure a doctor makes the final decision on insurance claim reviews so they can decide whether the treatment is medically necessary. AI can be used to gather information, but the final medical decision is made by a provider.
In Arizona, House Bill 2175 requires a real doctor look at any insurance claim review that involves medical judgment. That way, AI doesn’t make life-or-death choices alone.
California passed Senate Bill 1120 that ensures that health insurers cannot rely solely on AI tools to deny or modify coverage, particularly when medical judgment is involved.
On a national level, Medicare and Medicaid’s new prior authorization rule says insurance companies must give faster answers and explain denials clearly. This helps patients know what’s going on and fight unfair decisions.
Still, not all states have strong rules. Some laws that could help were not included in recent federal healthcare changes. That means rules may depend on where you live.
How a Patient Advocate Can Fight Insurance Claim Denials
Getting a denial from your insurance company can feel overwhelming. But you do not have to deal with it alone.
At Umbra Health Advocacy, we help people like you understand their rights. We help challenge unfair insurance claim denials and guide you through the system. Our team knows how to deal with both traditional and AI-based denials.
Here’s what you can do if your claim is denied:
- Ask why. Get the denial reason in writing. Ask for the review notes.
- Appeal quickly. Every insurer has a time limit for appeals. We can help with the paperwork.
- Keep records. Save letters, bills, and medical info. These documents help prove your case.
- Know your rights. In many places, you can ask for a review by an outside expert.
Read more about appealing insurance claim denials.