Tag Archives: healthcare

AI in Healthcare

19 Jul

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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I helped create Medicare Advantage. Here’s why I believe it needs reform.

17 Jun

An Architect of MA Speaks Out – In an op-ed published by The Hill on Sunday, former Republican Rep. Jim Greenwood of Pennsylvania — who helped write the Medicare Modernization Act that created Medicare Advantage — said plainly: “The program no longer lives up to [its] promise. I never imagined that Medicare Advantage would become a vehicle for such waste and abuse. It’s time to fix it.”

Read Jim Greenwood’s own words here.

Republicans Turn Against Medicare Advantage: A Growing Conservative Revolt

Republican leaders are increasingly criticizing Medicare Advantage (MA), marking a significant shift from traditional bipartisan support for the privatized Medicare program that now covers more than half of all beneficiaries.

Leading Conservative Voices

Former Republican Representative Jim Greenwood of Pennsylvania, who helped create the Medicare Modernization Act establishing Medicare Advantage, publicly declared that “the program no longer lives up to [its] promise.” Greenwood acknowledged that what was intended to drive innovation through private competition has been overtaken by “a handful of massive insurers who are gaming the rules for profit.”

Two Republican physicians in Congress, Representatives Greg Murphy of North Carolina and John Joyce of Pennsylvania, co-chairs of the GOP Doctors’ Caucus, wrote that “profit-driven insurance companies have destroyed [Medicare Advantage’s] model.” They specifically criticized insurers for using prior authorization to delay or deny necessary care and for “upcoding” – exaggerating patient illness severity to collect more taxpayer dollars.

Financial Impact

Medicare Advantage now costs taxpayers 22% more per beneficiary than traditional Medicare, according to the Medicare Payment Advisory Commission (MedPAC), resulting in $83 billion in overpayments to private insurers last year alone. This represents a dramatic departure from the program’s original cost-saving promise.

Industry Accountability

Conservative advocacy leader Phil Kerpen warned that Medicare Advantage is “becoming increasingly costly and unstable,” pointing to the Department of Justice’s criminal investigation into UnitedHealth as evidence of systemic problems1. He called for stronger disclosure rules, better plan comparison tools, and serious action against prior authorization abuse.

Political Implications

This Republican criticism represents a crack in the insurance industry’s protective wall of bipartisan political support, potentially opening the door for meaningful Medicare Advantage reforms that the insurance lobby has successfully fought for years.

What can you do? – Join in the fight to create universal health care for everyone. Some helpful links:

One Payer States

Health Care for All Washington

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How Primary Care and Community Organizing Can Bring Us Universal Health Care Now

1 Jun


by Ron Lovell, HCFA-WA Board Member

At our May 2nd Wednesday Speaker Series, we heard an inspiring presentation by Dr. Michael Fine, writer, community organizer, family physician, and President of Primary Care for All Americans.  His talk was based on his experience with organizing primary care clinics in several cities in the eastern United States. Read on for a recap and/or view his complete presentation on our YouTube channel.

First, Dr. Fine outlined the failures of the U.S. healthcare market, emphasizing poor health outcomes, high costs, and deep health disparities. He argued the root cause is inadequate access to robust primary care for all Americans, noting only 43% of adults have a meaningful primary care relationship. He highlighted primary care’s proven ability to reduce costs and improve public health, drawing comparisons to other essential community services like police, fire, and education.

He then described successful community-based models (e.g., Scituate, Rhode Island) and advocated for building a social movement, starting locally, to ensure universal primary care. He detailed strategies such as community meetings, local workgroups, playbooks, and local funding. He stressed the need for a massive increase in primary care workforce and fairer reimbursement models, calling for a shift from fee-for-service to per-person payments.

HCFA-WA volunteer Dr. John Sobeck led the Q&A Session. He was joined by Primary Care Innovator Dr. Garrison Bliss who addressed these questions:

  • the critical shortage of primary care providers and the need to expand training and residencies
  • the imbalance in reimbursement that drives clinicians away from primary care
  • panel sizes for sustainable primary care practice (ideally 300-500 patients per doctor).
  • funding models, including local government and employer-based approaches
  • concerns about cherry-picking patients and ensuring equitable access
  • the role of direct primary care and its affordability for communities
  • incentivizing new graduates to serve in underserved areas, including loan forgiveness and community support
  • collaboration between organizations (Health Care for All-Washington, Whole Washington) toward single-payer and universal healthcare goals

Key Takeaways:

  • Universal primary care is essential, affordable, and achievable through community organizing.
  • The U.S. must address workforce shortages, payment reform, and health disparities.
  • Social movements, not just legislation, are needed to drive systemic healthcare change.
  • Ongoing community engagement, collaboration, and advocacy are critical for progress.

For more details on Dr. Fine’s work, please see this additional resource: The Path to Health Care for All Starts with Community-based Primary Care

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