AI Arms Race

AI Arms Race: Providers Catching Up to Payers in Claims Review

The healthcare sector is in the midst of an escalating AI arms race as providers adopt the same artificial intelligence technologies payers are leveraging for claims review. Insurers currently lead this race, using AI to streamline processes such as prior authorizations, but experts predict providers will soon narrow the gap.

Insurers’ AI Advantage

Leading payers, including UnitedHealth, Humana, and Cigna, have integrated algorithmic decision tools to assess claims and determine coverage eligibility. These technologies allow insurers to flag services that fall outside plan criteria, ostensibly increasing efficiency.

This trend is expanding, as evidenced by Blue Shield of California’s announcement of a partnership with Salesforce to pilot claims automation technology in early 2025. The nonprofit insurer claims this initiative will reduce prior authorization decision times from weeks or days to mere seconds, benefiting providers and patients alike.

However, provider experiences paint a more contentious picture. Reports from lawmakers and healthcare executives suggest AI-driven claims processes lead to a surge in denials. For example, Providence CFO Greg Hoffman revealed that AI adoption by payers resulted in a 50% increase in underpayments and initial denials over two years, forcing providers to significantly increase manual interventions to resolve claims.

A Battle for Balance

The imbalance in AI adoption has prompted providers to take action. Experts like Jeffrey Cribbs, a vice president analyst at Gartner, see this as a forced “arms race” in which both sides are continually refining their tools. While payers focus on flagging potential exceptions, providers are working to develop systems for more efficient claims submissions and dispute resolution.

Providence’s strategy includes outsourcing revenue cycle management to R1, a 10-year partnership designed to quickly address rising claims denials. Hoffman explained that building equivalent AI systems internally would take years, making partnerships essential for staying competitive in the short term.

Collaboration Among Providers

On the provider side, executives like Sara Vaezy, EVP and Chief Strategy Officer at Providence, emphasize the need for collaboration. She advocates for coalitions to share data and establish AI standards, which would allow providers to compete more effectively.

Panelists at HLTH echoed this sentiment. Amit Phull, Chief Physician Experience Officer at Doximity, argued that AI could eventually “level the playing field” for providers by reducing the time required for claims documentation. Deloitte principal consultant Bill Fera added that AI would allow providers to quickly analyze policies and determine whether a patient qualifies for coverage under plan terms.

The Road Ahead

Despite the current disparity, experts believe AI will eventually equalize the claims review process. Providers are beginning to invest in tools that will help them handle vast amounts of data efficiently, offering clarity in disputes and cutting down documentation time.

“It’s still early innings,” Phull said, “but the technology is going to go a long way toward leveling that playing field.”

For now, however, insurers maintain the upper hand. As providers navigate the complexities of AI adoption, partnerships and collaboration may prove critical in ensuring they remain competitive in this rapidly evolving landscape.

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