States Consider Restrictions on AI-Driven Health Insurance Claim Denials
Health insurance companies are reportedly using AI systems to deny patient claims without human review, allegedly causing delays and harm. Multiple states are now considering legislation to restrict AI use in claims processing and require physician involvement in approval decisions.
What happened
Health insurance companies are allegedly using artificial intelligence bots and algorithms to swiftly deny patients routine or lifesaving care without human review of claims. UnitedHealthcare has been accused in a class-action lawsuit of using AI to wrongfully deny claims.
In response to patient and doctor frustrations, lawmakers in more than a dozen states are considering measures designed to regulate prior authorization and claims reviews, including limiting the use of AI in reviewing claims and requiring that insurers' review boards include licensed physicians, dentists or pharmacists with clinical experience.
Reported impact
In a survey by the American Medical Association, 93% of doctors said that insurers' prior authorization practices delayed 'necessary care' for their patients. Twenty-nine percent said such delays had led to a 'serious adverse event,' such as hospitalization, permanent injury or death.
In 2023, insurers selling plans on the marketplaces created under the Affordable Care Act denied a combined average of 20% of all claims.
Governance controls
Under the Biden administration, the Federal Trade Commission and the Department of Justice took a firmer hand against health care corporations alleged to be engaging in behavior resulting in limited and more expensive care for patients. The administration also approved rules requiring that beginning in 2026, Medicare implement new requirements.
Classification
Sources and evidence
This record was researched and written by the Index, based on the following original reporting.