Physicians call for more regulation of health insurers using AI

© Tierney - stock.adobe.com

Medical policy regulators need more power over insurance companies using artificial intelligence to analyze prior authorization (PA) requests for patients.

The American Medical Association (AMA) announced this month its House of Delegates has adopted policy calling for greater oversight – and fewer administrative burdens for physicians when seeking approval for patient care.

Insurance companies already are using augmented intelligence (AI) in their review processes. Doing so, they must “implement a thorough and fair process that is based on clinical criteria and includes reviews by physicians and other health care professionals with expertise for the service under review and no incentive to deny care,” according to an AMA news release.

"The use of AI in prior authorization can be a positive step toward reducing the use of valuable practice resources to conduct these manual, time-consuming processes. But AI is not a silver bullet,” AMA Board Member Marilyn Heine, MD, said in the news release. “As health insurance companies increasingly rely on AI as a more economical way to conduct prior authorization reviews, the sheer volume of prior authorization requirements continues to be a massive burden for physicians and creates significant barriers to care for patients. The bottom line remains the same: We must reduce the number of things that are subject to prior authorization.”

AI in medicine

The public availability of the program ChatGPT, created by OpenAI, has sparked huge public interest in artificial intelligence and how it will affect medicine and other aspects of work and life. AMA discussed it and other programs that use large language models to “recognize, summarize, translate, predict, and generate text and other contend based on knowledge gained from large datasets,” according to an AMA analysis. Augmented intelligence is a “conceptualization of artificial intelligence” meant to supplement human intelligence, not replace it, according to AMA.

Problems not solved

It appears physicians and health insurers agree AI could be helpful in streamlining the prior authorization process for patients, but it remains to be seen exactly how AI will be used.

AMA cited a ProPublica review that found in two months of 2022, doctors at health insurer Cigna denied more than 300,000 claims in a review process that used artificial intelligence. The doctors spent an average of 1.2 seconds on each case. AMA’s new policy called for health insurers to require human examination of patient records before denying care.

While AI in health care may be problematic in the future, PA is a problem right now, according to AMA.

“While the AMA supports automation to speed up the prior authorization process and cut down on the burdensome paperwork required by physicians, the fact remains that prior authorization is overused, costly, inefficient, and responsible for patient care delays,” AMA’s announcement said.

Across the nation, lawmakers in 30 states have considered more than 90 bills related to prior authorization reform. At least a dozen remain under consideration for passage, and AMA pledged to continue advocating for reform to lower volumes, increase transparency, “promote automation, and ensure timely care for patients.”