Artificial intelligence isn’t just helping your doctor diagnose you faster—it’s quietly deciding if your health insurance will actually pay for your care. Over the past decade, major insurers have increasingly turned to AI algorithms to reduce costs and expedite decisions. But behind that promise lurks a troubling reality: these opaque systems can delay, limit, or deny the very treatments your doctor says you need.
A prime example is “prior authorization.” Before your doctor can treat you, insurers often demand proof that the care is “medically necessary.” Who makes that call? Increasingly, it’s an AI program comparing your medical records to secret internal rules. That same AI might decide how long you can stay in the hospital after surgery—or whether you’ll get rehab at all.
If your claim is denied, you technically have the right to appeal. But the odds are stacked against you: only about 1 in 500 denials ever get reversed, often because appeals take time, money, and persistence most sick patients don’t have.
Critics argue that some insurers exploit these algorithms to save money by stalling. If a patient can’t afford care out-of-pocket, or worse, doesn’t survive the long appeal process, the insurer pockets the savings.
Meanwhile, insurance AI tools fly under the radar. They’re not regulated by the FDA, and companies call them trade secrets. Some states are stepping in, and Medicare is trying to curb abuses, but loopholes remain.
Health law experts say it’s time to treat these systems like medical devices—subject them to rigorous safety checks and national oversight. Until then, remember: AI may be making life-or-death calls about your health care. And right now, you have very little say in how those decisions get made.