Is AI Behind Your Health Insurance Denial?
Struggling with a health insurance claim denial that feels robotic and unfair? You’re not alone. But, there’s hope.
In my last blog post, I Fought My Health Insurance Denial — And Won, I shared my recent experience with a claim denial. If you're new here, the short version is this: my insurance company denied a prior authorization that my doctor said I needed. I didn't accept that "no." I gathered my evidence, wrote my appeal, and eventually won.
However, something has been nagging at me, and I want to talk about it with you today. Because I have a feeling I'm not the only one running into this.
A Quiet Comment That Stuck With Me
When I contacted my doctor's office about appealing my claim denial, I asked if they'd seen this happen to other patients, especially since it was such a shift from my previous experiences. Off the record, they told me they'd been seeing a noticeable uptick in denials for cancer care prior authorizations, including MRIs, exactly like the one I'd fought for.
Their theory? Insurance companies are increasingly using AI to review and decide on these requests. And in their experience, more of those requests were coming back denied than before.
I'll be honest with you. I have no way of proving that AI played a part in my own denial. But, when I looked at the decision, it just didn't add up. The reasoning felt off. It didn't reflect what my doctor had clearly documented. It had the strange, tidy logic of something that was not human and hadn't really looked at me — my history, my situation, my whole picture.
I can't say for certain. But, I suspect a computer, not a person, told me no first.
What the Research Is Starting to Show
If that quiet comment felt like a hunch, a recent report covered by The New York Times gave it some weight. The reporting dug into how insurers are leaning on AI to process prior authorizations and claims — and raised real questions about how these tools may be contributing to more denials, sometimes with very little human review behind them.
Reading it, I felt a fresh wave of concern for every patient sitting where I sat, staring at a denial letter and wondering what they did wrong.
Here's the truth I want you to hold onto: you didn't do anything wrong.
Caught in the Middle
This is the part that frustrates me most. When AI enters the picture, patients like us can end up stuck squarely between two powerful systems.
On one side, your healthcare provider recommends the care they believe you need. On the other, your insurance company is increasingly powered by automated tools that decide whether that care gets approved. And, when those two sides disagree, guess who's left holding the paperwork, the phone calls, and the anxiety?
We are.
For those of us living with a chronic condition, this weight lands especially hard. You're already budgeting your energy carefully, choosing where to spend the good hours in your day. A denial doesn't just threaten your care. It drains the very reserves you were counting on for living your life. That's a lot to carry, and I won't pretend otherwise.
But, I've learned that being caught in the middle doesn't mean being powerless. It means we have to advocate a little louder. And the good news is, we absolutely can.
What You Can Do When AI Says No
Here's what my experience taught me, boiled down to steps you can actually use.
1. Don't accept the first or second "no"
A denial is not a verdict. Often, it's just the opening move. Many denials get overturned on appeal. The hope is that at least somewhere in the appeal process, a human will look at your case.
If you take one thing from this post, let it be this: appeal, appeal, appeal.
I walked through exactly how to do this in my earlier post, I Fought My Health Insurance Denial — And Won. If you're staring down a denial right now, start there. It covers how to build an appeal that's hard to ignore. If your first appeal is denied, don't stop there. You have the right to appeal again.
2. Note the Specific Reason For Your Denial
Your insurance company is required to tell you why your claim was denied. When you compare the rationale against what your doctor has clearly outlined in your records, any gaps or inconsistencies become powerful evidence in your corner.
3. Loop In Your Care Team
Your healthcare provider's office deals with denials constantly. A letter of medical necessity from your doctor, or a peer-to-peer review, can carry real weight. You don't have to fight this alone.
4. Fight fire with fire. Use AI, too
Here's the part I find genuinely empowering. If the system is using AI to decide against us, we can use AI to advocate for ourselves.
That's exactly what I did. Use AI tools to:
Understand the jargon. Paste confusing sections of a denial letter and asked for plain-language explanations.
Organize your argument. I asked an AI tool to help me structure a clear, professional appeal letter around the facts of my case.
Find the right language. I used AI to make sure I referenced the correct medical necessity criteria and framed my points the way an insurer would take seriously.
A quick, honest note: never paste sensitive personal details you're not comfortable sharing, and always double-check anything AI produces against your own records and your doctor's guidance. Think of it as a research assistant, not the final word. Used that way, it leveled the playing field in a way that genuinely surprised me.
Please note that this blog post is not intended as legal advice. If you need assistance, please consult your healthcare provider, insurance company, patient advocate and/or legal counsel for advice tailored to your specific circumstances. This is my experience that I am sharing so you can use this knowledge to the extent it is relevant to your situation.
Want Someone In Your Corner?
Together, we can bridge the gap between your doctor’s recommendations and the steps you can take for yourself. Let’s build your confidence to speak up and keep moving forward when it matters most. Find out more HERE.
Stay Vigilant And Don’t Give Up
I want to leave you with this.
The systems deciding our care are changing fast, and not always in ways that favor us. That means our vigilance matters more than ever. Read your letters closely. Question the reasoning that doesn't sit right. Keep your records. And, never talk yourself out of appealing because you assume the answer won't change.
It can change. Mine did.
You are the expert on your own body and your own needs, something no algorithm or AI bot can claim. So the next time a denial lands in your inbox, take a breath, lean into your resilience, and remember: you have the right to appeal and it's worth using.
Advocating for your health is hard enough without doing it alone. If you're ready for steady, personalized support as you navigate the healthcare system and everything else chronic illness throws your way, I'd love to walk alongside you. The THRIVE coaching package is built around you, your energy, your goals, your pace. Explore THRIVE and book your free consultation call.
You have more power in this fight than the system would like you to believe. Use it.
If you are facing an insurance denial, what's one step you could take today to advocate for the care you deserve?
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