New AI And insurance claims

A bill is making its way through the Legislature to stop the negative effects of AI on patients’ health insurance claims. House Bill 2175 would put safeguards in place to ensure that claims are not arbitrarily denied by AI (Artificial Intelligence).

The Arizona Medical Association is backing the bill. AI is used in the medical world for healthcare, it is also used by insurance companies toreview and deny of medical claims. According to the bill’s sponsor, Rep. Julie Willoughby, HB2175 is among the first legislation in the nation to prohibit the use of AI in reviewing and denying claims for medical necessity and prior authorization requests.

The bill would guarantee that cases involving medical judgment are reviewed by licensed medical professionals. Individuals who have the training, experience, and ethical responsibility to make clinical decisions. With Willoughby being also a nurse. Dunn is a Board member of the Arizona Medical Association and a family practice doctor in the East Valley.

Dr. Michael Dunn from Family Physician and ArMA Board Member joins “Arizona Horizon to talk about these claims and updates.

“We’re seeing insurance companies are using artificial intelligence to review and some cases deny health care claims and prior authorizations. They mostly deny they’re doing this, but the evidence is starting to be somewhat overwhelming that they are”, said Dr. Micheal Dunn.

Can you spot AI’s footprint?

“Absolutely. Usually because the reasons for the denial are silly, and they don’t make a whole lot of sense. They dont follow good medical judgment” said Dr. Micheal Dunn.

“We had one last week, a patient came in, an occupational injury, she was bit by a cat. And needed to have the wound cleaned out. She needed a tetanus shot. And the insurance company, without getting into too much detail with the coding and stuff. We built an appropriate level of code to get paid for the code to get paid for the visit. The insurance company sent back a denial or what we call a down code. And they downloaded it two levels, which represented probably $100 less in payment for us. When we read through what the explanation was, it was very clear it was a human had not reviewed that,” said by Dr. Micheal Dunn.