Insurance Companies Are Using AI to Process Medical Claims

As a practicing member of the medical/pharmaceutical/insurance complex (I am a clinical psychologist and routinely bill insurance companies for client care), I cringe when I hear about healthcare decisions made on the basis of financial concerns rather than patient well-being. As an individual undergoing my own healthcare journey, I am worried this has become the norm, not the exception.

In the past seven months, I have undergone two different surgeries with two different surgeons, both involving an overnight stay in the hospital. The first, which received pre-approval from my insurance company, was the culmination of several years of battling a painful autoimmune disorder. Two weeks after the procedure, I received a letter indicating that my insurer had determined that the surgery was unnecessary because I hadn’t had cancer. It took my well-known surgeon’s office six months to convince the payer that their artificial intelligence system and their expert, who trained in an unrelated medical field, had made a mistake.

Recently, I had to have a hiatal hernia repaired. The surgery took four hours and involved fixing an additional hernia that had shown up on a scan. Afterwards, I spent an uncomfortable night in a tiny hospital room on a medical, not a surgical, floor, dozing, peering through the broken blinds of my window, and repeatedly explaining to staff that I was on a restricted diet because of the type of surgery I had just had. Lunch proved confusing, since both a liquid and a soft diet tray were delivered to my room, but they finally agreed I could go home. Although the discharge papers indicated that I could start a regular diet, I knew that was wrong and contacted my surgeon’s office for guidance.

For about a week after the surgery, I sat around eating pudding and recounting my story with a Keystone Cops tone. That came to an end the day the insurance company informed me that it did not intend to cover my overnight stay because “You did not have an irregular heartbeat. You were thinking clearly. You did not have a bad infection or very low blood pressure. You did not need oxygen.”

Now, I don’t know what their criteria for the measures of my physical health status were. I know my blood pressure was fluctuating widely, and I failed the blow-in-the-tube respiratory test. I know that everyone who came in my room scanned my wrist bracelet, and some asked me to tell them my birthdate. But at no time did anyone administer a mental health exam to see if I was oriented as to time and place. No one asked me how clearly I was thinking after 24 hours on a liquid diet, pain medication, and very limited sleep, all of which can impair cognitive abilities.

I have extensive experience evaluating the clarity of other people’s thought processes. I have worked as a psychologist in a Veterans Affairs hospital, a college counseling center, in nursing homes, and in private practice. I have talked with elderly patients who can recount painstakingly clear details from their childhood but don’t recognize their adult son, people with schizophrenia who firmly believe that their hallucinations and delusions are real, and people who were too depressed to care for themselves. So, I assume the insurance statement “I was thinking clearly” was meant to indicate that I wasn’t hallucinating or incapable of taking care of myself.

The truth is that had I been thinking clearly, I would have checked myself out the evening of my surgery, regardless of the cost, the medical outcome, or my physician’s orders, and saved myself quite a bit of stress. However, in the American healthcare system, you don’t have the option of checking yourself in or out of the hospital on your own. You need orders from your doctor, and since I like and respect my surgeon, I chose to trust her recommendation and stay the night. Apparently, the insurance company chose not to consider her expert opinion.

Clearly, our healthcare system isn’t working well. We don’t have enough doctors and nurses, especially in rural areas. Qualified people are leaving their field due to stress, the rising cost of care is bankrupting patients, and many people are going without care at all. It is no wonder that I, along with many of my fellow Americans, have lost confidence in the system that provides that care. From AI rubrics producing unreadable insurance statements to random pharmaceutical costs, to arbitrary decisions about policy, the view from the patient's side of the curtain is disturbing, discouraging, and certainly not conducive to healing, physically, or mentally.

This is not a hypothetical problem. People are suffering and dying in a system that, at best, has technological and communication glitches and, at worst, prioritizes financial decisions over patient welfare. Maybe we should all pay more attention to how much the people we elect care about making sure that medical/pharmaceutical/insurance companies prioritize our well-being. At the very least, we need to support efforts to regulate the ways insurance companies make decisions and notify us of them.

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In the meantime, well-being is not merely the absence of illness any more than congeniality is the absence of hostility. A simple “we are checking with your physician to validate your need for an inpatient stay” would have sufficed. Instead, I added worry and anger to dealing with my recovery from an already painful experience. I don’t know how clearly I was thinking that night in the hospital, but if insurance companies truly value clarity of thought, then perhaps they should start by revising their own policies and statements and remembering that patients are people, not computers.