The Use of AI in Claims Denials

A Compendium of Artificial Intelligence Use in Utilization Review

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Payers deny claims at a rate that climbs higher each year. However, the increasing use of artificial intelligence (AI) to automatically deny claims without review creates a new issue for hospitals and revenue cycle managers struggling to reduce denials. While healthcare insurance companies promote the use of AI as a denial mitigation tool to process claims more efficiently, three class action lawsuits filed late last year are raising concerns that insurance companies use AI to deny claims without ever examining patient records. As the use of AI in healthcare claims management widens, the importance of careful oversight is needed. Any use of automation for claim denials needs to be scrutinized by providers to ensure the denial is appropriate, which also satisfies numerous state insurance laws requiring proper evaluation of healthcare claim denials. This publication is a review of publicly available news articles discussing the use of AI in claim denials.

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