Journal: NPJ digital medicine
This publication discusses the growing use of AI systems by health insurers to automate claim decisions, with a focus on prior authorizations and coverage determinations in Medicare Advantage plans.
It highlights reports of AI-driven “blanket denials,” where large numbers of claims are denied rapidly and sometimes inappropriately, contributing to:
- Increased scrutiny of insurers, including public criticism, class action litigation, and congressional investigations
- Strained relationships between payers and providers, including major providers exiting insurer networks
- Added administrative burden and burnout for clinicians managing prior authorization and appeals
- Greater burden on patients who must navigate complex appeals or face delays and denials in care
The article calls for stronger transparency around how AI tools are designed, validated, and deployed in coverage decisions, alongside policy and oversight measures to ensure such tools support fair, patient-centered care rather than simply automating denials.