The AI Arms Race In Health Insurance Utilization Review: Promises Of Efficiency And Risks Of Supercharged Flaws

Health insurers and health care provider organizations are increasingly using artificial intelligence (AI) tools in prior authorization and claims processes. AI offers many potential benefits, but its adoption has raised concerns about the role of the "humans in the loop," users' understanding of AI, opacity of algorithmic determinations, underperformance in certain tasks, automation bias, and unintended social consequences. To date, institutional governance by insurers and providers has not fully met the challenge of ensuring responsible use. However, several steps could be taken to help realize the benefits of AI use while minimizing risks. Drawing on empirical work on AI use and our own ethical assessments of provider-facing tools as part of the AI governance process at Stanford Health Care, we examine why utilization review has attracted so much AI innovation and why it is challenging to ensure responsible use of AI. We conclude with several steps that could be taken to help realize the benefits of AI use while minimizing risks.