Primetime Living 11.26.25 - Flipbook - Page 20
20 A Special Advertising Section of Baltimore Sun Media Group | Wednesday, November 26, 2025
Reliability of AI
Continued from page 13
1. Prior authorization isn’t going
anywhere.
Health insurers will still be allowed to
deny doctor-recommended care, which
is arguably the biggest criticism that
patients and providers level against insurance companies. There are horror stories
of people dying while waiting for treatment to be approved. The movie, cited
earlier, is a real-world example of what
happens when an insurance company
thinks it knows best. How will this commitment protect the sickest patients who
need expensive care?
2. Reform efforts aren’t new.
Per the American Medical Association,
“a majority of U.S. states are considering
legislation to ‘right size’ the time-wasting, care-delaying payer practice of prior
authorization. In all, nearly 90 prior-authorization reform bills have been considered
this legislative session in 30 states, and
more than a dozen are still on the table
for potential passage.”
Some states have also enacted “gold
card” programs for doctors that allow
physicians with a robust record of prior
authorization approvals to bypass the
requirements.
Nationally, rules proposed by the first
Trump administration and finalized by
the Biden administration are already set
to take effect next year. They will require
insurers to respond to requests within
seven days or 72 hours, depending on
their urgency, and to process prior authorization requests electronically, instead of
by phone or fax, among other changes.
Those rules apply only to certain categories of insurance, including Medicare
Advantage and Medicaid.
Beyond that, some insurance companies committed to improvement long
before the announcement. Earlier this
year, UnitedHealthcare pledged to reduce
prior authorization volume by 10%. Cigna
announced its own set of improvements
in February.
3. Insurance companies are already
supposed to be doing some of
these things.
For example, the Affordable Care Act
(ACA) already requires insurers to com-
municate with patients in plain language
about health plan benefits and coverage.
But denial letters remain confusing
because companies tend to use jargon. For instance, AHIP, the health insurance industry trade group, used the term
“non-approved requests” in a recent
announcement.
Insurers also pledged that medical professionals would continue to review prior
authorization denials. AHIP claims this is
“a standard already in place.” But recent
lawsuits allege otherwise, accusing companies of denying claims in a matter of
seconds.
4. Health insurers will increasingly
rely on artificial intelligence (AI).
Health insurers issue millions of denials
every year, though most prior authorization requests are quickly, sometimes
even instantly, approved.
The use of AI in making prior authorization or prior approval decisions isn’t
new – and it will probably continue to
ramp up, with insurers pledging to issue
80% of prior authorization decisions “in
real-time” by 2027.
A review of information on AHIP’s website claims, “Artificial Intelligence (AI) is
Never Used to Deny Prior Authorizations
Based on Clinical Issues Without Medical
Review.” This refers to Medicare and
Medicare Advantage and Medicaid
Managed Care. And it says that “100%
of Commercial health plans reported that
AI or algorithms are never used to deny
prior authorization requests that involve
medical necessity or clinical considerations without clinician and/or practitioner review.” Information on other types
of insurance didn’t have this disclaimer or
was not available.
Results from a survey published by
the American Medical Association in
February indicated 61% of physicians are
concerned that the use of AI by insurance
companies is already increasing denials.
5. Key details remain up in the air.
Oz said CMS will post a full list of participating insurers this summer, while other
details will become public by January.
While the AMA, which represents
doctors, applauded the announcement,
“patients and physicians will need specifics demonstrating that the latest insurer
pledge will yield substantive actions,”
the association’s president, Bobby
Mukkamala, said in a statement. He
noted that health insurers made “past
promises” to improve prior authorization
in 2018.
A report by NBC News says, “Private
health insurers use AI to approve or
deny care. Soon Medicare will, too.” A
pilot program testing the use of artificial
intelligence to expand prior authorization
decisions in Medicare has providers, politicians and researchers asking questions.
Meanwhile, a survey of physicians
published by the American Medical
Association in February found that 61%
think AI is “increasing prior authorization
denials, exacerbating avoidable patient
harms and escalating unnecessary waste
now and into the future.”
“Burdensome prior authorization
requirements that conflict with evidence-based clinical practices and create hurdles for patient access to safe,
timely, and affordable treatment have
been a major impediment to patient care
for decades.
More recently, health insurers have
turned to AI decision-making tools that
generate prior authorization decisions
with little or no human review. These AI
tools have been accused of producing
high rates of care denial – in some cases,
16 times higher than is typical.
The pilot program, designed to weed
out wasteful, “low-value” services,
amounts to a federal expansion of an
unpopular process called prior authorization, which requires patients or someone
on their medical team to seek insurance
approval before proceeding with certain
procedures, tests, and prescriptions. It
will affect Medicare patients, and the
doctors and hospitals who care for them,
in Arizona, Ohio, Oklahoma, New Jersey,
Texas, and Washington, starting Jan. 1
and running through 2031.
The future is now.
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