The increasing use of AI to deny health insurance claims

Vidya Sethuraman
India Post News Service

Artificial intelligence and algorithms are a part of many businesses these days, including health insurance. The killing of United Healthcare CEO Brian Thompson in New York sparked a national debate over Americans’ profound frustration with the healthcare industry. Even while decrying Thompson’s killing, many people fault insurers like UnitedHealth for the high price of healthcare and for denying care to those in need.  An investigation by ProPublica this year revealed that insurers now routinely deny millions of claims with the use of AI. Critics note healthcare AI is often riddled with racial and economic biases, which increasingly determines who gets treated versus who does not. Millions of claims are increasingly rejected without a doctor ever opening a patient’s file.

Speakers at the EMS briefing discussed growing consumer dissatisfaction with health insurance providers, and the impact of AI on health insurance coverage and the high rate of denials.

Dr Katherine Hempstead, Senior policy officer at the Robert Wood Johnson Foundation said health insurance is often the most dysfunctional, fragile and poorly functioning example of the fraught relationship between policyholders and insurers across the insurance industry. There’s a fundamental powerlessness for policyholders when providers say something is necessary, but insurers say it’s not and there’s a tremendous amount of fragmentation as to what’s covered between states or between plans. People need insurance, but they generally do not trust insurance companies and assume the worst motives.

California State Senator Josh Becker, author of SB 1120, the Physicians Make Decisions Act, which limits the scope of AI by requiring doctors to make final decisions, said we need the human element to ensure that health care decisions prioritize patient well-being over automated processes.

Governor Gavin Newsom signed Senate Bill 1120 (SB 1120), The Physicians Make Decisions Act, authored by Senator Josh Becker (D-Menlo Park). SB 1120 safeguards patients’ access to necessary medical treatments by mandating necessary health care provider oversight when insurers utilize artificial intelligence (AI) algorithms to decide on healthcare providers’ requests to offer medical services. “Artificial intelligence is an important and increasingly utilized tool in diagnosing and treating patients, but it should not be the final say on what kind of healthcare a patient receives,” said Becker. The Physicians Make Decisions Act ensures that the human element will always determine quality medical treatments for patients.”