What does AI actually do in prior authorization if it doesn't deny claims?

According to Sutter, AI auto-approves low-risk requests and routes others for additional scrutiny by a human. It determines which cases 'enter the denial risk pathway,' but it doesn't click the deny button itself.

Why are providers concerned about AI in claims processing?

Providers don't know which requests will trigger AI denial because payers treat the AI's criteria as proprietary. This forces them to add more clinical detail upfront without guarantee of approval, creating a 'pitching to a black box' situation.

Has anyone successfully automated prior authorization with AI?

Ensemble Health Partners has worked with a national payer on touchless prior authorizations for radiology cases, achieving a 92% success rate. The process returns within an hour, but it hasn't moved beyond that specialty yet.

AI in HealthcareAI Regulation & PolicyTop Companies' AI MovesAI Business & IndustryTop Companies AI2h agoAug 25, 2026, 06:31 JST3 min read

AI doesn't deny care, but shapes review, says expert

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Key takeaway

Insurers say AI doesn't deny care. But an expert says it routes cases for review, creating a black box for providers.
This shifts burden to providers.
Transparency is key to knowing if AI improves efficiency or just denials.

3 Key Points

What happened
UnitedHealth Group CFO Wayne DeVeydt said at the company's Q2 earnings call in July that AI does not determine whether care is approved or denied. Cigna and Aetna have echoed that AI is never used to deny claims, but insurers still invest billions in AI for administrative tasks like prior authorizations and claims processing.
Why it matters
Stacie Sutter from Ensemble Health Partners says payers' claims are technically true—AI doesn't click deny—but it routes which cases go to a clinician and in what condition. This creates an information asymmetry: providers don't know what the AI looks for, since payers often treat that as proprietary, forcing them to invest more time and resources upfront to avoid denials or delays.
What to watch
Sutter calls for transparency, urging payers to share approval rates, denial rates, and outcomes by AI-routed vs. non-routed requests, broken down by service type and specialty. Ensemble has achieved a 92% success rate with touchless prior authorizations for radiology cases with a national payer, but scaling beyond that may require payer engagement and robust systems.

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Context & Analysis

The debate over AI's role in insurance denials has centered on whether algorithms make final decisions, but the reality is more subtle. UnitedHealth Group's CFO and others maintain AI doesn't approve or deny, which is technically accurate: the technology doesn't press the deny button. However, as Sutter explains, AI determines which cases are auto-approved as low-risk and which are routed for human review, shaping the outcome before a clinician ever sees the claim. This routing function is where the power lies, and it's what providers are struggling to navigate.

The information asymmetry is the core tension. Payers position their AI knowledge as proprietary, leaving providers to guess what triggers scrutiny. This has led to an 'AI arms race,' where providers invest in tools like ambient documentation and AI scribes to improve clinical detail upfront, trying to avoid denials or delays. Yet this effort may be misdirected without transparency. Sutter's call for payers to disclose approval rates, denial rates, and outcome comparisons between routed and non-routed requests is aimed at leveling the playing field.

The Centers for Medicare and Medicaid Services is even testing AI for Medicare prior authorizations in six states, though it has faced criticism for low approval rates. This context underscores the stakes: the question isn't whether AI belongs in healthcare, but whether it's making care more efficient or denials more efficient. Without transparency, that distinction remains obscured, and providers are left chasing ghosts.

FAQ

What does AI actually do in prior authorization if it doesn't deny claims?: According to Sutter, AI auto-approves low-risk requests and routes others for additional scrutiny by a human. It determines which cases 'enter the denial risk pathway,' but it doesn't click the deny button itself.
Why are providers concerned about AI in claims processing?: Providers don't know which requests will trigger AI denial because payers treat the AI's criteria as proprietary. This forces them to add more clinical detail upfront without guarantee of approval, creating a 'pitching to a black box' situation.
Has anyone successfully automated prior authorization with AI?: Ensemble Health Partners has worked with a national payer on touchless prior authorizations for radiology cases, achieving a 92% success rate. The process returns within an hour, but it hasn't moved beyond that specialty yet.