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What role does AI play in healthcare insurance denials?

On Behalf of | Mar 26, 2024 | Denied Insurance Claims

The use of artificial intelligence (AI) is increasingly becoming a part of our daily lives, from the way we interact with chatbots to find information online to seeing images of past presidents seemingly sharing a friendly tea in whimsical settings. Although the benefits are many, the risks are serious. The creators behind the photos noted above released the images throughout media platforms to remind the public of the ease with which fake photos can spread and the answers given by chatbots are not always accurate.

Even knowing these risks, large corporations and government agencies often use AI and similar technological advances as a normal part of operations. When it comes to sorting through information like patient records and data, this can perpetuate biases and result in unjust health insurance denials.

How big of a problem is this?

Unfortunately, the issue is large enough to trigger major lawsuits. Both UnitedHealth and Humana have moved forward with legal claims stating insurers have used AI tools to guide insurance coverage decisions. The lawsuits argue the insurers are relying too heavily on these tools to adjust or deny coverage.

Is this legal?

The United States Centers for Medicare and Medicaid Services (CMS) recently released guidance that states that although MA plans can use algorithms and software tools to assist in making coverage determinations, the organization must ensure the decision complies with applicable rules. This includes a review of the patient’s individual circumstances.

An example given within the explanation is that of coverage for termination of post-acute care services. CMS explains that providers or MA plans can use these tools to help predict a potential stay but that this must only be one part of the analysis — not the sole basis for the change. The insurer must also review the individual patient’s situation and provide a detailed explanation for any changes or denial.

What should I do if there is a change or denial to my healthcare coverage?

The first step is to review the reason for the denial or change. Keep copies of this information. If the denial or change seems unreasonable, consider moving forward with additional action. In some cases, it is possible to pursue an appeal. It is helpful to have copies of all documents related to the claim as well as notes from conversations with insurance providers.