Patients in the US are using AI to fight the AI bots that health insurers use to deny care. Amid states’ attempts to curb health insurers’ use of artificial intelligence, patients and doctors are arming themselves with AI to fight claim denials and medical bills.
New businesses and nonprofits have been launching artificial intelligence-powered tools to help patients navigate the confusing, complex world of health insurance, creating a bot-to-bot battle over care.
Use of AI to understand health insurance
Companies are creating easy-to-use AI chatbots that can help patients understand their medical care and better advocate for themselves.
With rising denials, patient confusion is increasing, and they are turning to AI to make disputing health insurance denied claims simpler.
One company, Sheer Health, helps patients and providers understand health insurance and billing, and has recently added an app that allows people to ask questions about coverage and costs.
Jeff Witten, cofounder of Sheer Health, explained the app’s creation, telling Stateline, “You would think there would be some sort of technology that could explain in real English why I’m getting a bill for $1,500.”
Other services use AI to catch billing errors and translate medical jargon into easily understandable English.
Some patients also use AI chatbots online, such as ChatGPT or Grok, for help with their insurance issues.
A 2024, peer-reviewed study titled "Risks of Artificial Intelligence (AI) in Medicine,” which was published in the Pneumon Medical Journal, noted that “although AI makes it extremely easy to access medical information, the crucial concern is that this information is not always properly validated.”
A poll published by the healthcare research nonprofit KFF in 2024 found that although a quarter of adults under age 30 use an AI chatbot at least once a month for health information or advice, most were not confident that the advice or information they received was correct.
Challenging denied claims
Historically, denied claims get challenged less than 1% of the time, according to a KFF survey, and over 50% of those appeals are unsuccessful.
AI tools could make it easier to understand the claims-filing process, making it more accessible to challenge insurance denials.
There are still limits; AI can be inaccurate and vulnerable to mistakes. People who aren’t medical experts might not notice its errors.
These mistakes can derail the entire appeal due to incorrect medical information, making it harder for the patient to receive the coverage they are entitled to.
AI has enabled lightning-fast decisions on patients’ coverage and care that couldn’t be made without it; however, without human oversight and intervention, many lawmakers believe it can have significant, concerning ramifications for patient care.
“Where I worry is when you have insurance companies or other players using AI to completely replace customer support and human interaction,” said Witten.
It is important that AI is not the only thing reviewing patient care in complicated cases. Health insurance approval and coverage procedures can be life-or-death, and having only AI review them may be unwise.
Dr Caroline Green from the University of Oxford told the BBC, “It is important that people using these tools are properly trained in doing so, meaning they understand and know how to mitigate risks from technological limitations... such as the possibility of wrong information being given.”
What are states doing about AI in healthcare?
State legislators are trying to pass new regulations that will monitor and govern how medical professionals use AI in healthcare.
In the last year, more than 12 states have passed laws that will begin to regulate the use of AI in healthcare and health insurance.
Carmel Shachar, assistant clinical professor of law and the faculty director of the Health Law and Policy Clinic at Harvard Law School, told Stateline, “It doesn’t feel like a satisfying outcome to just have two robots argue back and forth over whether a patient should access a particular type of care.”
The role of AI in health insurance companies has led to an increase in denied claims. 41% of doctors said their claims are denied more than 10% of the time, an increase from three years ago.
UnitedHealthGroup has been in trouble with federal lawmakers recently for its use of algorithms to deny care to seniors. At the same time, other insurers face lawsuits and investigations alleging they have used algorithms to deny coverage for procedures.
The insurers claim AI is improving their efficiency and reducing costs; however, without human input, many people are being denied coverage for medical care they would previously have received, leading states to step up oversight.
Some states have made it illegal to use AI as the sole decision-maker in medical necessity denials.
AI in healthcare offers many benefits, reducing wait times and increasing access to information. At the same time, experts note the need for safeguards to address potential risks posed by misinformation and limitations in understanding complex clinical situations, which may affect patient care.