Medical Insurance Giants: Stop Using AI to Turn Down Patient Claims!

Medical insurance is facing increasing scrutiny, particularly regarding the use of Artificial Intelligence (AI) in evaluating and denying patient claims. This trend raises significant concerns about potential health risks for patients, yet local legislative efforts may help to address these issues.

AI offers efficiency and cost-reduction benefits across various sectors, but its application in healthcare, especially concerning insurance claims, necessitates careful consideration. The deployment of AI in denying claims and requiring prior authorizations threatens patient safety and erodes trust in a system designed for vulnerable individuals.

House Bill 2175 (HB2175) has emerged as a pivotal measure to counteract these challenges. This legislation mandates that medical decisions are not obscured by AI systems, or “black boxes,” which lack transparency. Instead, it ensures that qualified medical professionals conduct reviews of cases that involve clinical judgment, safeguarding patients’ rights.

For patients routinely dealing with insurance denials, these challenges are all too familiar. Recent reviews of claims from a prominent workers’ compensation insurer revealed that several were downcoded—meaning they were reimbursed at lower rates than billed. The analysis suggested AI involvement in these decisions, highlighting discrepancies that persist despite appeals. The slow and arduous process of contesting these automated decisions leaves both doctors and patients frustrated.

Insurance should function as a safety net, protecting patients from overwhelming financial burdens in times of need. However, the increasing reliance on AI systems means decisions are frequently made without human empathy or insight. Rather than having medical professionals assess cases individually, algorithms determine approvals and rejections, often lacking the necessary accountability.

Rep. Julie Willoughby champions HB2175, emphasizing the importance of addressing the limitations of AI models that reflect historical biases within their training data. If these biases permeate the decision-making process, certain patients may be unjustly disadvantaged, thereby prioritizing cost-cutting over patient care and resulting in negative health outcomes.

The removal of the human element from medical decisions poses significant risks. Though algorithms can analyze extensive data sets, they lack the capacity to interpret the unique complexities of an individual’s health situation. A national physician leader recently indicated that to combat AI-driven denials, practices are increasingly preemptively reviewing their own billing with AI assistance—a troubling trend that redirects focus away from patient care into a software competition.

AI certainly has a role in healthcare, serving as an effective tool for administrative operations and even aiding in decision-making. Nevertheless, its application in determining patient care must maintain human oversight as an essential component.

Arizona’s legislative framework stands at a crossroads, with potential to secure patient protections and encourage ethical AI use in insurance procedures. Technology should enhance the healthcare experience, not detract from it. As AI becomes increasingly intertwined with daily life, it is crucial to remember that no algorithm can replicate the experience, empathy, and ethical responsibility of trained medical professionals. The implications are too significant to ignore.

Dr. Michael Dunn, a family medicine physician with over 27 years of experience, serves patients in the East Valley. He can be reached at flyingdoc1@yahoo.com.