{"id":859987,"date":"2026-09-25T08:56:12","date_gmt":"2026-09-25T08:56:12","guid":{"rendered":"https:\/\/www.newsbeep.com\/us\/859987\/"},"modified":"2026-09-25T08:56:12","modified_gmt":"2026-09-25T08:56:12","slug":"ai-is-making-health-insurance-decisions-for-unitedhealth-medicare-and-more-and-putting-patients-at-risk","status":"publish","type":"post","link":"https:\/\/www.newsbeep.com\/us\/859987\/","title":{"rendered":"AI is making health insurance decisions for UnitedHealth, Medicare, and more \u2014\u00a0and putting patients at risk"},"content":{"rendered":"

The AI freakout of the past few weeks<\/a> has centered on nothing less than the risk of human extinction \u2014 on the possibility that artificial intelligence could wipe us all out. But the reality is, AI programs are already having a direct and sinister effect on people\u2019s physical health: UnitedHealth Group, the largest health insurer in the US, has been accused of using AI programs to deny payments to people, despite their doctors saying the care was necessary, and is facing a class-action lawsuit<\/a>.<\/p>\n

Humana<\/a> and Cigna<\/a> are facing their own litigation over similar allegations. Meanwhile, Medicare has launched<\/a> its own AI tool that will help the government determine whether to approve prior authorizations, and doctors are sending the federal government reports of patients at their offices who are in tears because they can\u2019t get the medicine to manage their chronic pain.<\/p>\n

The claims in the legal complaints are harrowing: Families are desperate for an elderly loved one who recently experienced a serious fall to be allowed to stay in a nursing home. Doctors are flummoxed when a patient who may need months of rehab is cut off by an algorithm after a couple of weeks.<\/p>\n

This is AI\u2019s threat to people\u2019s health right now.<\/p>\n

While the current conversation may be fixated on something more Hollywood, private insurers and the Trump administration are already deploying AI programs to vet people\u2019s health insurance claims \u2014 and the evidence is growing that these programs are not always doing a good job and are instead putting people\u2019s health at risk. Until these lawsuits are settled or policymakers can figure out a way to regulate how insurers use this new technology, it will be up to each of us to make sure that an AI program isn\u2019t being used to cheat us out of insurance benefits that we\u2019re entitled to.<\/p>\n

\u201cThe type of care that clinicians deliver is very sensitive to the patient\u2019s unique circumstances. That may not really show up as a number. There\u2019s not a numeric value that tells you the completeness and connection of a patient\u2019s social network,\u201d said Mika Hamer<\/a>, a health services researcher at the University of Maryland. \u201cThere really are a lot of factors that really can\u2019t be quantified and so aren\u2019t really suitable to go into these models. If we start to rely exclusively on the models, I think we run the risk of losing that human touch.\u201d<\/p>\n

Patients say private health insurers are using AI to deny claims<\/p>\n

Insurers and patients fighting over medical claims is nothing new: Policyholders want the most coverage they can get and payers have a business incentive to pay as little as they can. Health insurers have also used algorithms for decades: Plug in somebody\u2019s age, their weight, whether or not they smoke, and one of the old-fashioned algorithms<\/a> could spit out a rough estimate of how much medical care they would need before they died. Simple \u2014 and comparatively transparent.<\/p>\n

When you submitted a claim or sought prior authorization, there was supposed to be a human doctor who could review all of the relevant information on behalf of the insurer and make the final decision, in theory with the patient\u2019s best interests in mind. It didn\u2019t always work that way in practice<\/a>, of course, but that was the idea.<\/p>\n

What\u2019s different right now, according to Daniel Schwarcz<\/a>, a law professor at the University of Minnesota who has looked at health insurers\u2019 AI use, is that these newer programs can make very specific predictions about someone\u2019s future health based on the information that\u2019s fed into them, and those predictions are being used in the process of approving or denying medical claims. And exactly what went into making those predictions \u2014 and whether it is the AI or the human who ultimately holds the final authority \u2014 is often opaque from the outside.<\/p>\n

\u201cThe reason we want human review is we want human substantive judgment. We want AI to be supporting that,\u201d Schwarcz said. \u201cBut the difficulty is distinguishing between AI supporting meaningful human processing and AI basically replacing the human with the human just passively defaulting to the AI judgment. It\u2019s just incredibly hard to distinguish between those two in practice, particularly in rules or regulations.\u201d<\/p>\n

What you can do to protect yourself against health insurance AI<\/p>\n

Appeal, appeal, appeal: Experts say most claims are actually overturned on appeal. Don\u2019t take the first no for an answer.Look out for vulnerable people in your life. Insurers depend on people not understanding their rights or how decisions are being made to get denials to stick, and AI adds another layer of confusion.Push your elected officials to develop serious plans for overseeing AI use in healthcare. Proposals are starting to work their way through statehouses and Congress, but there is a lot of work left to do to figure out how to regulate this tech.<\/p>\n

And those questions are at the heart of the lawsuits brought against three major insurers in the past few years about their use of AI in processing claims.<\/p>\n

In May 2022, Gene Lokken, then 91 years old, fell in his home. He was taken to the nearby hospital in Tomahawk, Wisconsin, and treated for a broken leg and a broken ankle. Less than a week later, he was placed in the health system\u2019s hospice care because, according to the lawsuit filed by his family<\/a>, he was \u201cvery weak, not communicative, and in constant pain.\u201d<\/p>\n

But a month later, after receiving skilled nursing care, Lokken started to improve. By late June, his doctor had removed his splint and placed his leg in a removable boot. In July, he started physical therapy to get up and walk again. And for a while, his Medicare Advantage plan sold by UnitedHealth covered all of the services he needed.<\/p>\n

Until July 20. Around that time, according to the lawsuit, UnitedHealth denied any more services at the nursing facility where Lokken had been for the past two months. It insisted that he could be safely discharged and more time at the nursing care facility \u201cwas not medically necessary.\u201d<\/p>\n

The insurer\u2019s decision left Lokken and his physician \u201cdumbfounded.\u201d The physical therapist notes from the time said Lokken was still suffering paralysis and weakness after only a couple weeks of rehab. His family appealed, but UnitedHealth continued to deny the claims, asserting that because Lokken could feed himself and did not require help to clean himself, he did not need nursing care and could go home.<\/p>\n

From July 2022 to July 2023, Lokken remained at the nursing home, but his family had to pay between $12,000 and $14,000 monthly to keep him there. And on July 17, 2023, Lokken died \u2014 having never left the facility.<\/p>\n

The lawsuit alleges that the decision to stop covering Lokken\u2019s nursing-home stay was largely made by an AI algorithm, called nH Predict, which UnitedHealth follows so unquestioningly that employees were allegedly at risk of being disciplined or fired if their claims decisions went against the AI\u2019s projections. The complaint alleges that the AI model would typically start denying claims after two weeks of nursing home care \u2014 and the attorneys have more examples than Lokken.<\/p>\n

Glennette Kell required emergency surgery after a fall in late August 2023 and was referred to a nursing home rehab center. By mid-September, UnitedHealth was denying her claims for nursing care, despite the fact that, according to the lawsuit, she still could not walk. Kell had to pay $10,000 of her own money to cover the rest of her bills. Darlene Buckner suffered a heart attack in October 2023 and underwent triple-bypass surgery. She was readmitted to the hospital in late November because she was experiencing complications, but less than two weeks later, UnitedHealth allegedly denied any further treatment at the hospital because it was deemed medically unnecessary. At the time, according to the class-action lawsuit, Buckner was experiencing \u201can open infected wound near her heart from the open-heart surgery, she was on blood thinners, and was receiving antibiotics through an IV.\u201d<\/p>\n

UnitedHealth, in its responses<\/a> to the plaintiffs, has asserted that federal laws and regulations already require all claims decisions ultimately be made by a human doctor, not an AI program, and raised several other technical legal objections (such as saying the plaintiffs have not fully exhausted their administrative appeal options). The plaintiffs, however, allege that UnitedHealth employees \u201care instructed not to deviate\u201d from the AI model\u2019s projections, and then tell patients the AI-generated information is proprietary when they or their doctor try to inquire about why their claims are being denied.<\/p>\n

And, to be clear, UnitedHealth is not the only insurer being sued for using AI programs to deny claims. Humana is facing its own lawsuit<\/a> brought by other Medicare Advantage patients who allege the same nH Predict program also led to their claims being wrongfully denied. Joanne Barrows, then 86, fell in November 2021 and went to a rehab nursing facility after her hospital stay. And just two weeks later, Humana began denying her claims for further care, according to the complaint, leaving her and her doctor \u201cbewildered\u201d because she was under doctor\u2019s orders not to put any weight on her leg.<\/p>\n

And the third lawsuit, filed against Cigna, alleges<\/a> the company used a different AI algorithm that allowed its doctors to deny claims in huge batches \u2014 hundreds or thousands at a time \u2014 if they did not meet certain predetermined criteria. One patient, Suzanne Kisting-Leung, had claims denied for two ultrasounds done by her doctor to check for ovarian cancer, putting her on the hook for more than $700 in medical bills because, the lawsuit alleges, Cigna\u2019s AI program determined that the scans were not medically necessary. The plaintiffs say that their claims were instantly rejected, without their medical files ever being opened. As for the law that human doctors have to make the final call? According to the lawsuit, the algorithm \u201cenable[s] its doctors to automatically deny payments in batches of hundreds or thousands at a time for treatments that do not match certain pre-set criteria, thereby evading the legally required individual physician review process.\u201d<\/p>\n

These people, many of them elderly, had no idea AI was being used to make decisions about their coverage \u2014 until it was too late.<\/p>\n

\u201cFrom their perspective, you might as well have been speaking Esperanto. They just had no idea what it was that was being said to them when they were being told. They usually heard about it for the first time when they were being told that they needed to leave,\u201d Glenn Danas, one of the attorneys in the class-action litigation against United, Humana, and Cigna, told me. \u201cThey just had no idea what was going on or why this was being done to them.\u201d<\/p>\n

AI is now making decisions for traditional Medicare claims too<\/p>\n

It\u2019s not just private insurers either. The Trump administration is now pushing traditional Medicare and Medicaid to use AI to adjudicate insurance claims too. In June 2025, nearly two years after those lawsuits had been filed against Cigna, Humana, and UnitedHealth, the US Department of Health and Human Services announced<\/a> it would deploy a new program called the WISeR (Wasteful and Inappropriate Service Reduction) model to make prior authorization decisions for about a dozen procedures for the people on traditional Medicare in six states \u2014 \u201cleveraging enhanced technologies, such as Artificial Intelligence (AI) and Machine Learning (ML), along with human clinical review to ensure timely and appropriate Medicare payment for select items and services.\u201d It would be a pilot program, before federal officials decide whether to take the program nationwide.<\/p>\n

It was a quiet, massive change for traditional Medicare, which covers about half of the 66 million Americans on the program<\/a>. (Medicare Advantage plans, in which private companies administer Medicare benefits under slightly different parameters and which were the subject of the earlier AI-related class-action litigation, cover the rest.) People on traditional Medicare had historically not been required to get prior authorization for most services; now they would be, and a novel AI program would play a significant role in which claims get approved and which ones don\u2019t.<\/p>\n

From the start, physician and patient advocates warned about the potentially adverse consequences of the WISeR program; the Center for Medicare Advocacy said<\/a> the program would likely \u201ccomplicate, delay and even outright deny necessary care.\u201d According to media reports and internal government documents, that\u2019s exactly what has happened since the model went live in January.<\/p>\n

Sign up for the Good Medicine newsletter<\/p>\n

Our political wellness landscape has shifted: new leaders, shady science, contradictory advice, broken trust, and overwhelming systems. How is anyone supposed to make sense of it all? Vox\u2019s senior correspondent Dylan Scott<\/a> has been on the health beat for a long time, and every week, he\u2019ll wade into sticky debates, answer fair questions, and contextualize what\u2019s happening in American healthcare policy. Sign up here<\/a>.<\/p>\n

The Washington Post first reported<\/a> in March that physicians and their patients were experiencing approval delays or denials for medical services that should have been covered. One glitch led to a denial of payment for services that had been approved. Doctors noticed that certain procedures seemed to give the AI model problems \u2014 such as two competing treatments for incontinence \u2014 and were weighing whether or not to stop offering one of those services altogether. The Post reported on one Arizona patient who had been receiving steroid injections for chronic back pain before being denied multiple times after the AI program\u2019s launch. The pain became so severe, he said, that he could not exercise at all.<\/p>\n

Then this month, the Electronic Frontier Foundation released<\/a> a trove of documents it received in response to a Freedom of Information Act lawsuit related to the WISeR model. The documents revealed<\/a> aggressive denials \u2014 one company using the AI model had actually denied more prior authorization requests than it had approved \u2014 and there were delays even when the care was ultimately approved. One review took 83 days when the model was supposed to make a decision within 72 hours.<\/p>\n

The direct feedback from doctors in the federal documents obtained by EFF was devastating.<\/p>\n

\u201cWe have patients calling our offices crying in pain because their procedures are being delayed while awaiting approvals or guidance tied to this model,\u201d one doctor wrote. \u201cA 3-4 day delay for necessary pain procedures is already difficult for vulnerable patients, but when providers cannot obtain answers for weeks, the situation becomes unacceptable.\u201d<\/p>\n

According to the federal documents, the Trump administration was already discussing ways to expand the program. Despite the outcry from doctors and patients, and growing concern among their representatives in Congress, it doesn\u2019t look like WISeR is going away.<\/p>\n

How can we make sure AI doesn\u2019t take over insurance claims?<\/p>\n

AI is becoming a part of healthcare<\/a> \u2014 it is already happening. And many of those uses could be truly beneficial. Anthropic recently announced<\/a> an initiative to apply the theoretical findings of its AI models to real-life lab work that could lead to new drugs being developed in the future. In terms of scientific discovery and the potential to translate it into new treatments, the excitement among clinicians about its potential is palpable.<\/p>\n

And nobody denies that health insurance administration is chaotic and burdensome and would benefit from being made more efficient and streamlined \u2014 tasks which AI is at least superficially well-suited for.<\/p>\n

But as the past few years have already shown, rushed and sloppy deployment of AI to take responsibility for approving or denying payment for people\u2019s medical care has created serious problems. The issue is that this technology is being adopted more quickly than any regulator can oversee it. We don\u2019t really know how health insurers are using AI tools. We don\u2019t have a good framework for what keeping a \u201chuman in the loop\u201d of insurance decisions \u2014 which is what people want \u2014 would really mean, Schwarcz said.<\/p>\n

\u201cI think everyone agrees at a high level of generality, \u2018Yes, AI should be used to enhance human review and not to replace it,\u2019 but no one actually knows how to write rules to enforce it,\u201d he told me. \u201cI don\u2019t think that there\u2019s anything I\u2019ve seen that has effectively defined what it means for a human to be meaningfully in the loop in the sense of retaining independent judgment as opposed to just reviewing and deferring. It is incredibly hard to specify in rules or regulations a standard that is verifiable and enforceable. That is still, as far as I know, an unsolved problem.\u201d<\/p>\n

Some states have started adopting rules<\/a> requiring transparency for AI use in insurance claims, and lawmakers in Congress have put forward proposals<\/a> requiring human involvement, including the bipartisan Protecting Patients from Automated Denials Act. But these technologies are so ubiquitous and so flexible that rigorously regulating their use is going to be difficult. Meanwhile, the profit incentive for companies to adopt these tools and deploy them widely is extremely strong. We don\u2019t even know how widespread their use really is.<\/p>\n

Danas said he and his clients hoped their litigation would help with \u201cputting the brakes\u201d on AI\u2019s use in insurance. Until we figure out what to do from a policy perspective, what can each of us do in the meantime? Hamer told me that the old advice is still the best advice: If your claim is denied, appeal it. An enormous number of denied claims end up getting overturned on appeal.<\/p>\n

\u201cYou do not necessarily have to accept that the first answer from your insurance company is the final determination,\u201d she said.<\/p>\n","protected":false},"excerpt":{"rendered":"The AI freakout of the past few weeks has centered on nothing less than the risk of human…\n","protected":false},"author":2,"featured_media":859988,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[59],"tags":[181,191309,97,252,253,4530,1343,5599,74],"class_list":["post-859987","post","type-post","status-publish","format-standard","has-post-thumbnail","category-health-care","tag-artificial-intelligence","tag-good-medicine","tag-health","tag-health-care","tag-healthcare","tag-innovation","tag-policy","tag-public-health","tag-technology"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/859987","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/comments?post=859987"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/859987\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media\/859988"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media?parent=859987"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/categories?post=859987"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/tags?post=859987"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}