Health insurers are looking to AI as a means to boost profits, as health care costs rise and profit margins fall, reports Casey Ross for Stat News.
At UnitedHealth, the top brass believe that AI could save them $1 billion in 2026. How? By helping UnitedHealth and the other Medicare Advantage insurers to deny and delay even more care than they already delay and deny. The insurers claim that AI will help them to reduce fraud and unneeded care.
Of course, insurers have been using AI for some time now. And, the evidence suggests that, too often, inappropriate denials result. Stat previously reported on UnitedHealth using AI to deny people rehabilitation services inappropriately.
Of course, AI will cut health care spending, but at what cost to people needing health care? And, how can the government protect people from insurers abusing AI to cut costs and maximize profits? There is no government body that has the resources to investigate insurers’ use and misuse of AI on an ongoing basis. Moreover, insurers claim their AI software is proprietary, meaning that it really can’t be studied adequately.
Meanwhile, insurers accuse health systems and other providers of increasingly using AI to document and inflate the care they provide. Of course, the insurers don’t like it when providers use AI. Why should patients like it when insurers use AI? AI is not on the ground with the treating physician understanding patient needs. AI might speed up the insurer’s decision-making process as to when to cover care, but how often will the AI tool overrule the treating physician and keep people from getting needed care?
UnitedHealth’s newest AI product, Optum Real, will determine whether the insurer should pay for care and help physicians and patients understand the costs of particular treatments. Will insurers actually be denying even more services through their AI tools? With AI, McKinsey, a consulting firm, believes insurers will spend roughly 10 percent less on care.
In Massachusetts, the latest data shows that insurers denied more than one in five claims in 2024. That’s more than twenty percent of all payment requests.
Here’s more from Just Care:
- UnitedHealth accused of preventing nursing home residents from getting needed hospital care
- 2025: Government finalizes new Medicare Advantage policies
- Medicare Advantage costs and prior authorization rules impede access to care
- Does UnitedHealth use flawed AI to deny care in Medicare Advantage?
- OIG finds widespread inappropriate care denials in Medicare Advantage
