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AI cannot fix a broken claims paradigm
Manijeh Berenji1, Michele Kowalski-McGraw2, Larry Ozeran3
1School of Medicine and Joe C. Wen School of Population and Public Health, University of California, Irvine, 856 Health Sciences Quad, Ste 5600, Irvine, CA 92697.
The American Journal of Managed Care
|June 23, 2026
Summary
Artificial intelligence (AI) shows promise for improving healthcare claims processing. However, AI alone cannot resolve systemic issues in the claims paradigm, requiring a more comprehensive approach.
Area of Science:
- Health Informatics
- Artificial Intelligence in Healthcare
Background:
- Healthcare claim denials are increasing due to data inaccuracies, staffing shortages, and outdated systems.
- Economic pressures and declining collections necessitate faster and cleaner claims processing.
Purpose of the Study:
- To evaluate the perceived and actual impact of artificial intelligence (AI) on healthcare claims processing.
- To identify barriers to AI adoption in managing healthcare claims.
Main Methods:
- Analysis of a feature article discussing AI's role in reducing claim denials.
- Review of cited reasons for claim denials and provider concerns regarding AI implementation.
Main Results:
- Providers anticipate AI can strengthen the claims lifecycle, but adoption remains low.
- Key concerns hindering AI adoption include accuracy, compliance, and training requirements.
- Providers are exploring AI solutions to stabilize finances and streamline operations amidst changing policies.
Conclusions:
- Artificial intelligence (AI) is viewed as a potential tool for improving healthcare claims, but it is not a standalone solution.
- Addressing the "broken claims paradigm" requires more than just AI; systemic improvements are essential.
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