The headlines are disturbing but predictable. The Trump administration will launch a program next year to find out how much money an artificial intelligence algorithm could save the federal government by denying care to Medicare patients. Meanwhile, a survey of doctors released by the American Medical Association in February found that 61% think AI is “increasing prior authorization denials, exacerbating avoidable harm to patients, and increasing unnecessary waste now and in the future.”
We’re witnessing the healthcare industry’s narrow view of AI in action: algorithms designed to say “no” faster and more efficiently than ever. But what if we are missing the most important opportunity?
The current problem with AI: created to deny, not to help
The recent expansion of AI-powered prior authorization reveals a fundamental flaw in the way we approach health technology. “The more expensive it is, the more likely they are to deny it,” said Jennifer Oliva, a professor at Indiana University-Bloomington Maurer School of Law whose work focuses on AI regulation and health coverage.
This approach creates a vicious cycle: Patients do not understand their benefits, seek inappropriate or unnecessary care, trigger costly prior authorization processes, face denials, appeal those denials, and ultimately give up or create even more administrative burden for everyone involved.
The human cost is real. Nearly three-quarters of respondents thought prior authorization was a “major” issue in a July poll published by KFF, and we’ve seen public discontent over insurance denials dominate the news in December, when the shooting death of UnitedHealthcare’s CEO led many to anoint his alleged killer as a folk hero.
A Better Vision: The AI Concierge Approach
What if instead of using AI to more efficiently deny care, we used it to help patients access appropriate care more effectively? This is where the AI Concierge concept transforms the entire equation.
An AI Concierge does not wait for a claim to be filed to make a decision. Instead, proactively:
- Educate patients about their benefits before they need care
- Guides them to the right suppliers. within your network
- Explains coverage limitations. in plain language before appointments
- Suggest preventative alternatives that could avoid more costly interventions
- Streamlines pre-authorization ensuring patients have the correct documentation up front
The quantified business case
The financial argument for AI Concierge services is compelling:
Impact on revenue from star ratings: A half-star increase in Medicare star ratings is worth about $500 per member. For a 75,000-member plan, that translates to $37.5 million in additional funding. An AI Concierge directly improves the patient satisfaction scores that drive these ratings.
Operational efficiency gains: Healthcare providers that implement AI-based patient engagement systems report 15-20% increases in clinic revenue and 10-20% reductions in overall operating costs. Clinics using AI tools see 15-25% increases in patient retention rates.
Cost avoidance through prevention: Using AI to help patients access appropriate care could save up to 50% on treatment costs while improving health outcomes by up to 40%. This happens by preventing more costly interventions through the appropriate utilization of preventive care.
The HEDIS connection
HEDIS measurements provide the perfect framework to demonstrate the value of AI Concierge. With 235 million people enrolled in plans reporting HEDIS results, improving these scores directly impacts revenue through bonus payments and competitive positioning.
An AI Concierge naturally improves HEDIS performance by:
- Preventive care measures: Proactive targeting increases screening and immunization rates
- Closing the care gap: Identify and address gaps before they become costly problems
- Patient engagement: Improves medication adherence and management of chronic diseases.
Beyond pilot programs
While government initiatives like the WISeR pilot program focus on “reducing wasteful and inappropriate services” through AI-powered denials, forward-thinking healthcare organizations have the opportunity to differentiate themselves with AI-powered patient empowerment.
The math is simple: preventing a $50,000 hospitalization through proactive care coordination offers a better return on investment than efficiently rejecting the claim once submitted.
AI Healthcare Concierge Implementation Strategy
For healthcare leaders considering AI Concierge implementation:
- Phase 1: Implement AI-powered benefit explanation tools that reduce call center volume and improve patient understanding.
- Phase 2: Integrate predictive analytics to identify patients at risk for costly interventions and guide them toward preventative alternatives
- Phase 3: Expand to comprehensive care navigation that optimizes both patient outcomes and organizational performance.
The competitive advantage
While competitors invest in AI to process denials more quickly, organizations implementing AI Concierge services are investing in:
- Member Satisfaction and Retention (15-25% improvement rates)
- Star rating improvements ($500 member value per half star)
- Reduction of operating costs (10-20% typical savings)
- Income protection through a better member experience
Conclusion: Choose your AI future
The current trajectory of AI in healthcare, focused on optimizing denial, represents a huge missed opportunity. As one doctor noted about the Medicare pilot program: “I will always, always think that doctors know what is best for their patients.”
AI Healthcare Concierge services align with this principle by providing patients and providers with better information, earlier intervention, and more effective care coordination. The technology exists. The business case is proven. The patient’s need is urgent.
The question is not whether AI will transform healthcare, but whether we will use it to build walls or bridges between patients and the care they need.
The choice is ours. Let’s choose wisely.
