AMA calls for more regulatory oversight for insurers using AI

Key takeaways:

• The AMA adopted a policy advocating for insurers to require human examination of patient records before denying care.
• The organization supports automation to reduce burnout but says AI is not a panacea.

The AMA adopted policy advocating for greater regulatory oversight of insurers’ use of artificial intelligence at its annual House of Delegates meeting.

In light of recent advances and popularity in artificial intelligence (AI), the organization specifically called for more oversight of insurers’ using AI in reviewing prior authorization requests and patient claims, according to a press release, which said prior authorization is inefficient, costly, overused and responsible for patient care delays.

The AMA said it supports automation to reduce burdensome administrative paperwork that physicians must do or speed up the prior authorization process. The new policy advocates for insurers to implement a fair, thorough process based on clinical criteria and require a human examination of patient records before denying care.

As part of a review process using AI, Cigna, one of the United States’ largest insurers, denied more than 300,000 claims over a period of 2 months in 2022, according to a recent ProPublica article. Cigna used a system allowing physicians to reject a claim on medical grounds instantly, without opening the patient files, and spent an average of 1.2 seconds on each case. According to a Cigna representative, this process is not a prior authorization process; it takes place after the service has been provided.

AMA Board Member Marilyn Heine, MD, said in the release that using AI in prior authorization could be a “positive step toward reducing the use of valuable practice resources to conduct these manual, time-consuming processes.” However, “AI is not a silver bullet.”

“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,” Heine said in the release. “The bottom line remains the same: we must reduce the number of things that are subject to prior authorization.”

References:

• AMA adopts policy calling for more oversight of AI in prior authorization. https://www.ama-assn.org/press-center/press-releases/ama-adopts-policy-calling-more-oversight-ai-prior-authorization. Published June 14, 2023. Accessed June 14, 2023.
• How Cigna saves millions by having its doctors reject claims without reading them. https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims. Published March 25, 2023. Accessed June 14, 2023.