Medicare AI Scrutiny
Federal Lawmakers Pressure Medicare Advantage Insurers Over AI and Prior Authorization Rules
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A group of U.S. senators is demanding answers from UnitedHealthcare and two other major Medicare Advantage insurers over their use of artificial intelligence to deny patient care, according to Missoulian. The lawmakers are zeroing in on a specific issue: prior authorization denials for post-hospital rehab care, which helps elderly patients recover after surgeries or serious illnesses.
Medicare Advantage plans cover more than 33 million Americans — roughly half of all Medicare enrollees. Critics say insurers are using AI tools to automatically reject claims that a doctor has already approved, leaving patients stranded without care they need, Billings Gazette reported.
Senators Target Three Insurance Giants by Name
The senators sent formal letters to UnitedHealthcare, along with two rival Medicare Advantage carriers. The letters demand that the companies explain how they use AI in their claims review process, according to NWI Times. Lawmakers want to know whether AI tools are making final decisions on patient coverage — or whether a human doctor reviews each case.
Prior authorization is a rule that requires patients or doctors to get insurer approval before receiving certain treatments or care. Senators argue the process has become a tool to delay or block care, especially for seniors moving from a hospital to a rehab facility, Journal Times reported.
AI Denials Leaving Seniors Without Post-Hospital Rehab
Post-hospital rehab — also called skilled nursing care — helps patients recover from strokes, hip replacements, and other serious medical events. Insurers have increasingly used AI-driven tools to cut short the length of stay they will cover, sometimes after just a few days, The Eagle reported.
Families and patient advocates say denials often come suddenly, with little explanation. A doctor may certify that a patient needs two more weeks of rehab. The insurer's AI can override that judgment in seconds. Senators say that gap between what doctors recommend and what AI approves has grown wider, according to Greensboro.
Congress Has Scrutinized UnitedHealthcare Before
This is not the first time Congress has gone after UnitedHealthcare over claim denials. The company, the largest Medicare Advantage insurer in the U.S., has faced multiple federal investigations in recent years. A 2023 Senate report found that Medicare Advantage plans denied care at far higher rates than traditional Medicare, Columbus Telegram reported.
UnitedHealthcare has also faced intense public scrutiny since the December 2024 killing of its CEO Brian Thompson. That event sparked a national debate about health insurance practices in America. Senators appear to be keeping that pressure alive with this new round of letters, according to Journal Now.
What Senators Are Asking Insurers to Prove
The senators are asking the companies to hand over data on how often their AI systems deny claims. They also want to know how many of those denials get reversed when patients appeal. Studies have shown that patients who appeal AI-driven denials win a large share of the time, Fremont Tribune reported.
Lawmakers are also pushing for rules that would require a licensed physician — not an algorithm — to review and sign off on any denial. The pressure comes as Congress debates broader reforms to Medicare Advantage oversight, according to Madison. Insurers have not yet publicly responded to the letters.
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