Health insurers are using AI to decide whether to cover treatments recommended by doctors. These tools can delay or deny care that should be covered, all in the name of saving money.
(And there’s no public information on how it makes decisions, and no outside testing to ensure they're safe, fair, or effective.)
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Having built the ruleset for BCBS and its franchises, whoever wrote this article doesn't have a clue how prior auth works.
If anyone's interested, the relevant forms are EDI-278 , EDI-270 and EDI-837.
Here's one "rule" = Insured is transported to an emergency room with a COPD incident, in an ambulance.
The insurer will pay for the ER visit, will also pay for the ambulance.
Another instance, patient is transported to an outpatient clinic - in an ambulance. Insurer will pay for treatment, not for the ambulance ride.
India Savage Anderson
The Conversation U.S.
Domingos Faria
tuban_muzuru