Two articles to help healthcare consumers understand how artificial intelligence is impacting the healthcare you receive.
The first one explains how insurance companies use AI to control the services you receive through prior authorization and denials of care. The second one provides you with an AI resource to appeal denials of of care and, in many cases, get the appropriate care approved.
Prior authorization is a process used by health insurance companies that requires health care providers to obtain advance approval from the insurer before a specific medical service, treatment, procedure, or prescription drug will be covered for payment. This means your doctor or provider must get the health plan’s permission before you receive certain medical care or medications, except in emergencies.
The main purposes of prior authorization are:
- Controlling costs for the insurance company
- Ensuring medical necessity, safety, and cost-effectiveness of the requested care
- Sometimes, verifying that less expensive or safer alternatives have been tried first.
This process is also referred to by names like preauthorization, preapproval, or precertification.
“Emerging evidence shows that insurers use automated decision-making systems to create systematic batch denials with little or no human review, placing barriers between patients and necessary medical care,” said AMA President Bruce A.Scot, MD. Your physician should be able to make medical decisions with their patients without interference from unregulated and unsupervised AI technology.
This article describes how insurance companies use AI to limit the care you receive:
https://theconversation.com/how-artificial-intelligence-controls-your-health-insurance-coverage-253602
If prior authorization is not obtained, the insurer may refuse to pay for the service or medication, leaving the patient responsible for the cost. The responsibility for requesting prior authorization typically falls on the provider, who must submit documentation to justify the request.
Prior authorization can lead to delays in care, and approximately a quarter of these requests are initially denied; however, denials can often be appealed and overturned. Marketplace plans under the Affordable Care Act denied 19% of in-network claims in 2023, the most recent year for which data is available. Fewer than 1% of consumers appealed the denials, the research found, but when they appealed, over half the denials — 56% — were upheld.
This article gives you an AI tool that is effective in reversing denials of services that you need:
https://www.nbcnews.com/news/us-news/ai-helping-patients-fight-insurance-company-denials-wild-rcna219008
Claimable, a private company, is a pioneering healthcare technology company founded in 2024 that leverages artificial intelligence to help patients overturn unjust health insurance claim denials. The company launched its AI-powered appeals platform on October 2, 2024, marking a significant milestone in making healthcare appeals more accessible and effective for patients nationwide. This gives you the power of AI to overturn denials of care.
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