AI Watch: Who’s Monitoring Health Insurers’ Use of Technology?

Health insurers are increasingly turning to artificial intelligence to streamline claims, detect fraud, and predict patient needs. But who keeps an eye on how these powerful tools are being applied?

Regulatory Oversight

• Centers for Medicare & Medicaid Services: Testing AI models that flag suspicious billing patterns.
• State Insurance Commissions: Drafting guidelines to prevent discrimination against vulnerable populations.

Corporate Self‑Regulation

• Internal audit teams routinely evaluate fairness and accuracy before deployment.
• Some firms hire external data scientists for blind reviews, comparing algorithmic decisions against human judgments.

Independent Research

• Academic labs and nonprofit think tanks publish reports on AI successes and pitfalls.
• Findings often reveal hidden biases, such as higher denial rates for patients from certain zip codes or with specific medical histories.

Consumer Advocacy

• Digital platforms allow consumers to report adverse experiences with automated claim decisions.
• Grassroots pressure pushes insurers toward transparent explainability practices, letting policyholders understand why a claim was denied or approved.

Future Certification

• An industry‑wide certification program could set standards for data quality, algorithmic fairness, and ongoing performance monitoring.
• Such a program would build trust among all stakeholders.

The Bottom Line

The landscape is shifting toward greater accountability. As AI becomes a core component of insurance operations, continuous oversight will be essential to protect patients and ensure equitable access to care.