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States try to rein in health insurers’ claim denials, with mixed results

  • Due to increasing scrutiny over health insurance companies' prior authorization practices, which patients and doctors say cause harmful delays and denials of care, lawmakers in more than a dozen states are considering measures to regulate claims reviews and limit AI use.
  • The increasing scrutiny stems from allegations that insurers use AI to deny necessary care without human review, as well as the high-profile killing of UnitedHealthcare CEO Brian Thompson, though there had been protests and outrage over the company's practices for months prior.
  • According to a survey by the American Medical Association, 93% of doctors reported that insurers' prior authorization practices delayed necessary care, and 29% said these delays led to serious adverse events like hospitalization, permanent injury, or death.
  • Dr. Mehmet Oz, during a March 14 confirmation hearing as President Trump's pick to lead the Centers for Medicare & Medicaid Services, defended the use of AI in reviewing claims, stating, 'AI can be used for good or for evil, and it to a large extent depends on whos using it and for what purpose,' while others like Timothy McBride emphasize the concentrated power of insurers.
  • States like Pennsylvania, which passed bipartisan legislation in 2022 to streamline prior authorization, and Texas, which created a 'gold card' standard in 2021 exempting physicians with high approval rates from prior authorization, are attempting reforms, though only 3% of Texas physicians had achieved gold card status by the end of 2023, indicating mixed results and the need for further action.
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‘They won’t help me’: Sickest patients face insurance denials despite policy fixes

Sheldon Ekirch spends a lot of time on hold with her health insurance company. Sometimes, as the minutes tick by and her frustration mounts, Ekirch, 30, opens a meditation app on her phone. It was recommended by her psychologist to help with the depression associated with a stressful and painful medical disorder.

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Local News Matters broke the news in on Monday, March 24, 2025.
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