Medicare Advantage insurance companies are increasingly using artificial intelligence to decide whether to approve or reject health services, particularly for acute care, such as staying in rehabilitation and nursing homes. Some of the largest insurers, UnitedHealthCare, Humana, and CVS, have used AI tools to accelerate these decisions, consistent with more rejections. UnitedHealthcare, for example, has more than doubled the rejection rate after acute care from 2020 to 2022, implementing a “machine support” review process during that time.
These practices have attracted criticism from medical groups, including the American Medical Association, which warn that AI-driven denials can lead to unnecessary patient harm by blocking care that is needed. Here’s what to do if a previous approval request was rejected:
Key takeout
According to a Senate survey, three of the largest Medicare advantage providers used artificial intelligence to help consider pre-authentication requests after acute treatment. During the period when AI tools were reported to have been adopted, the advance permit denied rate rose from 54% to 108%, depending on the insurance company. Insurance companies say advance approval helps manage costs and helps keep coverage more affordable, but critics argue that it could delay or block necessary care.
What is prior permission and why is it important?
Prior permission is when the insurance company reviews the treatment or prescription to determine whether it is medically necessary before agreeing to payment. This means that not only the doctor, but the insurance company will determine whether care is covered or not. If the request is denied, you may need to delay treatment, pay yourself, or go without it.
Services that often require prior approval include:
Imaging test medical equipment to ensure planned surgery
Organizations such as AHIP (American Health Insurance Plan), advocating on behalf of health insurance providers, have long advertised approvals as a way to keep health insurance affordable. In a 2023 pamphlet, Ahip said without prior approval, the insurance company may be on the hook for unnecessary procedures that do not improve health outcomes, with no prior approval.
However, according to the nonprofit KFF, advance approval affects millions of seniors each year. Medicare Advantage (MA) enrollees enjoy low premiums and extra medical benefits, but MA providers frequently require prior approval before covering hospitalized patients and long-term care services.
As doctors scramble to justify health care decisions and insurers take the time to issue final decisions, it can cause delays for those receiving care simply by requiring prior approval. Still, over 3.2 million advance permission requests were completely or partially denied in 2023 for each KFF data.
How AI is changing processes
A report from the Senate subcommittee found that UnitedHealthcare, Humana, and CVS will increasingly use automation and predictive technologies, including artificial intelligence, to consider prior permission requests for post-acute care. During this period, the refusal rates for these services have risen significantly, particularly in UnitedHealthCare and Humana. The report raises concerns that these systems may prioritize cost reduction over patient care, making it difficult for older people to access medical care recommended by doctors.
An AIP spokesman was asked about the use of AI when AI rejects prior approval requests for care after acute treatment. Possible. ”
Doctors are more skeptical. Sixty-one percent of those surveyed by the American Medical Association (AMA) expressed concern about the use of AI in refusing to care.
In a statement, AMA Bruce A. Scott, president of MD, said: “It shows that insurers use automated decision-making systems to create systematic batch refusals with little or no human reviews, placing barriers between patients and the medical care they need.”
The accuracy of these tools is also a problem. In one rank lawsuit, insurers argue that they used the AI ​​model despite knowing that almost all denials were reversed upon appeal.
What should I do if my pre-approval request is rejected?
It is possible that Medicare Advantage providers can still appeal if they refuse prior approval for the doctor’s recommended treatment.
Here’s how:
Please call your health insurance provider. You can also receive a letter from the insurance company explaining the decision. Understand why the treatment or prescription was rejected. If information is submitted incorrectly, you or your doctor may be able to submit revised documents to correct the error. Call the office or schedule another appointment to discuss your options.You may be able to appeal five times. Each appeal is in front of a high-level entity that includes an independent reviewer, the Medicare Hearings and Appeals Bureau, the Medicare Appeals Council, and ultimately the Federal District Court for judicial review.
Conclusion
While advance approvals help insurers manage costs and keep premiums more affordable, the increased use of AI in these decisions raises concerns. The automated system is linked to a higher rejection rate after acute treatment. For many older people, it means paying from the pocket and going without the care recommended by the doctor.
