The Algorithm Age

Medicare Advantage insurers have increasingly used artificial intelligence to decide whether to approve or deny medical services, especially for post-acute care, like stays in rehab facilities or nursing homes. Some of the largest insurers—UnitedHealthcare, Humana, and CVS—have used AI tools to speed up these decisions, which has coincided with more denials. For example, UnitedHealthcare more than doubled its rate of post-acute care denials between 2020 and 2022, during which it implemented a “machine-assisted” review process. These practices have drawn criticism from medical groups, including the American Medical Association, which warns that AI-driven denials can lead to unnecessary patient harm by blocking needed care. Here’s what to do if your prior authorization request is denied. Key Takeaways A Senate investigation reported that three of the largest Medicare Advantage providers used artificial intelligence to help review prior authorization r...

Over the past decade, health insurance companies have increasingly embraced the use of artificial intelligence algorithms . Unlike doctors and hospitals, which use AI to help diagnose and treat patients, health insurers use these algorithms to decide whether to pay for health care treatments and services that are recommended by a given patient’s physicians. One of the most common examples is prior authorization , which is when your doctor needs to receive payment approval from your insurance company before providing you care. Many insurers use an algorithm to decide whether the requested care is “ medically necessary ” and should be covered. These AI systems also help insurers decide how much care a patient is entitled to — for example, how many days of hospital care a patient can receive after surgery. If an insurer declines to pay for a treatment your doctor recommends, you usually have three options. You can try to appeal the decision, but that process can t...