AI is denying your healthcare (and it's getting worse)

About this video

• Video Title: AI is denying your healthcare (and it's getting worse)
• Channel: Vanessa Wingårdh
• Speakers: Vanessa Wingårdh
• Duration: 00:15:44

Overview

This video explains how Artificial Intelligence (AI) is increasingly being used by healthcare insurance companies to deny claims, set policy prices, and determine the necessity of medical treatments. The presenter highlights cases where AI has led to claim denials, discusses the role of third-party AI companies like EviCore and NaviHealth, and explores the implications for both Medicare and Medicare Advantage, as well as the potential for AI to influence medical decisions and outcomes.

Key takeaways

• AI in Insurance Underwriting and Pricing: Insurance companies are using AI to assess risk, determine policy prices, and expedite underwriting processes, often leading to faster decisions but with a focus on cost savings for the company.
• AI for Claim Denials: AI is being employed to review medical requests and treatments, with a stated design goal of denying as many claims as possible, often based on criteria that may not align with a patient's immediate medical needs.
• Case Studies of AI Denials: Examples like Gene Lokken's denied rehabilitation coverage and Chris McNaughton's denial for necessary medication illustrate how AI can overrule doctor recommendations and lead to financial hardship for patients.
• Third-Party AI Companies: Companies like EviCore and NaviHealth, now owned by major insurers, develop and deploy AI systems that manage claims and prior authorizations, with their profit incentives potentially linked to cost savings through denials.
• The "Sentinel Effect": AI systems can create a "sentinel effect" where doctors avoid recommending certain procedures because they anticipate AI denials, leading to a decrease in necessary treatments.
• Medicare and AI: While traditional Medicare has limited AI use, Medicare Advantage plans are increasingly adopting AI for claim management, and even traditional Medicare will begin using AI for prior authorizations in some states, potentially incentivizing denials.
• Legality and Appeals: While using AI to deny claims outright may be illegal, loopholes exist. Patients are encouraged to appeal denials, and the video suggests using generative AI to assist in this process.