Primetime Living 11.26.25 - Flipbook - Page 12
12 A Special Advertising Section of Baltimore Sun Media Group | Wednesday, November 26, 2025
HEALTH
Presaging
Tomorrow’s Prior
Approval Using AI
Reliability and accuracy
of Artificial Intelligence
A
rtificial intelligence seems to be ubiquitous these days, showing up everywhere
we can imagine. Even a simple online search, no matter which search engine
you use, has an AI synopsis at the top, providing an overview. It’s being used in
marketing and… wait for it… medical decision-making. Good or evil?
Two scenarios.
Driving a friend to the hospital for a
knee replacement, while checking in, I
noticed the paperwork said, “one night.”
Huh? I asked the person who was making
sure everything was in order, “I thought
this was out-patient?” “It is,” she replied.
“But, just in case, we get authorization
from the insurance company for a onenight stay.” Interesting. My first experience with prior approval.
In 1997, Matt Damon starred in the
movie version of John Grisham’s bestseller, The Rainmaker. Damon’s character
is a true novice, having just graduated
from law school. He takes on the case of
a mother trying to save her son dying of
cancer, whose corrupt insurance company refuses to pay the claim for his treatment – a familiar practice known as prior
authorization.
Today or Tomorrow?
Right now, there are procedures that
are followed with slight variations based
on which insurance company is providing the service and for which demographic: Medicare, Medicaid, Medicare
Advantage, private, corporate, HSA and
so on. Each demographic can also have
different rules and requirements. All of
them have a version of the procedure,
the rule, called prior approval or prior
authorization.
Usually, there are medical personnel
who review the requests and determine
whether or not the insurance plan the
patient has will cover the cost.
However, what happens when artificial
intelligence becomes the decision maker,
deciding if you can or cannot have prior
approval from your insurance company
for your doctor’s decisions, your treat-
ment plan, your surgery, your hospital
stay – whatever it is you need to maintain
your health. And what happens if it takes
days or more than a week (yes, this can
happen) to let you know the decision?
AHIP, the national trade association
representing the health insurance industry, published the press release quoted
in this article, available on its website.
It also lists the participating insurance
companies, so far.
As you read what these companies
are doing, how they claim to make these
processes better for patients, think about
what could happen with AI as the decision
maker. Could it be better? Maybe. But it
could also be detrimental to patients’
care in a timely fashion. For instance,
what happens if AI reviews a medical
procedure and denies it. The patient’s
clinician asks for a review. That review
could cause harmful delay. Now what?
Health Plans Take Action to Simplify
Prior Authorization
“Health insurance plans today
announced a series of commitments
to streamline, simplify and reduce prior
authorization – a critical safeguard to
ensure their members’ care is safe, effective, evidence-based and affordable.
Building on health plans’ existing efforts,
these new actions are focused on connecting patients more quickly to the care
they need while minimizing administrative
burdens on providers,” the AHIP release
stated.
“These commitments are being implemented across insurance markets, including for those with Commercial coverage, Medicare Advantage and Medicaid
managed care consistent with state and
federal regulations, and will benefit 257
million Americans.
“For patients, these commitments will
result in faster, more direct access to
appropriate treatments and medical services with fewer challenges navigating
the health system.”
“The health care system remains fragmented and burdened by outdated manual processes, resulting in frustration for
patients and providers alike. Health plans
are making voluntary commitments to
deliver a more seamless patient experience and enable providers to focus on
patient care, while also helping to modernize the system,” said AHIP President
