Patients Turn to AI Tools to Challenge Health Insurers’ Claim Denials

Health insurers are leaning on artificial intelligence to speed utilization management and prior authorization, contributing to elevated denial rates for ACA plan claims—nearly one in five in recent years, or roughly 73 million in-network denials in 2023. With fewer than 1% of consumers filing appeals, new software firms are selling $40–$50 tools that generate customized appeal letters in minutes. Indiana University law professor Jennifer Oliva told PBS the industry has entered an AI “arms race,” cautioning that payers can mine data to identify members least likely to appeal or outlast lengthy disputes. Lawsuits and reporting suggest algorithms are already influencing coverage decisions, and an NAIC survey found 71% of insurers use AI in utilization management. Oliva argues for front-end regulation requiring transparent, validated determinations grounded in medical necessity and meaningful human review, rather than rubber-stamping algorithmic outputs.

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