Insurers use AI to automate processes such as prior authorization, where providers or patients must get insurer approval before receiving specific medical services, procedures, or medications. The high denial rates from AI-driven automation have frustrated physicians, leading them to counter by using AI tools themselves to draft appeals against the denials.
Asthma drugs, new weight loss drugs and biologics — a class of drugs that can be life-saving for people with autoimmune disease or even cancer — are routinely denied coverage by insurance companies. Data shows that clinicians rarely appeal denials more than once, and a recent American Medical Association survey showed that 93% of physicians report care delays or disruptions associated with prior authorizations.
“Usually, any expensive drug requires a prior authorization, but denials tend to be focused on places where the insurance company thinks that a cheaper alternative is available, even if it is not as good,” Dr. Ashish Kumar Jha, dean of the School of Public Health at Brown University, explained in an earlier interview with Computerworld.
