Automated claim denials are increasing. Here’s what’s happening and how to respond.
Insurers are using AI to deny claims—quickly and often inaccurately. Understanding the risks helps protect your revenue.
A recent investigation by *The Guardian* revealed that major insurance companies are now using artificial intelligence to review and deny medical claims. These tools are designed to reduce manual work and speed up processing—but the consequences for providers are significant.
The article reports that algorithms like nH Predict, used by UnitedHealth and Humana, are denying claims with a 90% error rate. That means 9 out of 10 denials are later overturned when appealed—suggesting that most were wrong in the first place.
For providers and medical groups, this shift presents several challenges:
– Rapid Denials: Claims that used to take days to review are now denied in seconds.
– Lack of Clinical Review: Many denials are issued without human input or a full understanding of medical necessity.
– Increased Workload: Teams are spending more time appealing denials that shouldn’t have happened.
– Delayed Payments: These delays in processing directly affect practice cash flow.
What can providers do?
– Strengthen documentation and code selection
– Track denial trends tied to automated reviews
– Prioritize timely and evidence-based appeals
At ADS Healthcare Solutions, we’ve adapted our RCM strategies to respond to this shift. Our team is already helping clients:
– Detect patterns in AI-related denials
– Escalate questionable denials to human contacts
– Create payer-specific appeal packets backed by documentation
While insurers turn to automation, providers need strong RCM support to stay ahead. If you’re seeing a spike in denials or need help appealing claims effectively, our team can help you navigate this new landscape.