The 5 biggest payer AI developments in 2023

Payers are implementing artificial intelligence to detect fraud, speed up prior authorization and assist members' care. 

Several insurers reported new uses for AI in 2023, and the technology's role in prior authorization and claims denial is under scrutiny in the courts and in Congress. 

Here are five of the most read payer AI-stories Becker's reported in 2023: 

  1. UnitedHealthcare and Humana are facing lawsuits alleging both payers used an AI tool to wrongfully deny patients care. In November, the families of two deceased UnitedHealthcare Medicare Advantage members filed a proposed class-action lawsuit against UnitedHealth and NaviHealth, the developer of the AI tool, alleging the two members were wrongfully denied coverage of medically necessary post-acute care by UnitedHealthcare. A class-action lawsuit alleging Humana also used NaviHealth to wrongfully deny care was filed in December.

    An Optum spokesperson told Becker's the NaviHealth tool is not used in coverage decisions. The spokesperson said "coverage decisions are based on CMS coverage criteria and the terms of the member's plan. This lawsuit has no merit, and we will defend ourselves vigorously." 

  1. Scrutiny of payers' use of AI increased in 2023. Federal lawmakers and the American Medical Association called for more oversight of the use of AI in prior authorization, and Vice President Kamala Harris said AI has the potential to do harm in health insurance. In addition to federal lawmakers, states are ramping up scrutiny over how insurers across industries are deploying artificial intelligence for underwriting purposes.

  2. Blue Cross Blue Shield of Massachusetts is using AI to detect more fraudulent claims, an issue that costs the healthcare system billions of dollars every year and raises costs on health plan members. In January, the company said it had developed an algorithm that looks through its claims data and flags any suspicious activity before the claim is paid. While BCBS had a fraud detection program previously, it only reclaimed money after the claim was paid.

  3. In April, Google Cloud launched an AI-enabled platform for prior authorization and claims processing powered by a new data and analytics tool, Claims Data Activator. Blue Shield of California piloted Google Cloud technologies at that time to evaluate its ability to streamline its prior authorization process and help deliver timely clinical care for 4.8 million members.

  4. Health Care Service Corporation, which operates Blue Cross Blue Shield affiliates in Illinois, Texas, Oklahoma, Montana and New Mexico, said its AI technology can make prior authorization 1,400 times faster. The payer expanded the technology to inpatient acute care, long-term acute care, inpatient rehabilitation, skilled nursing care, outpatient and inpatient hospice care, home health and outpatient services.  

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