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Providers tell lawmakers insurers are using automated tools to deny or downcode claims; insurers defend oversight and cite reform commitments
Summary
Hospitals, clinics and provider associations told a Senate committee that commercial payers increasingly use automated tools to downcode or deny claims without record review—straining small providers—while insurers and trade groups emphasized prior‑authorization reforms and fraud prevention.
Providers from a broad range of settings told the Senate Interim Committee on Health that automated claims review and utilization‑management practices have recently intensified administrative burdens and delayed payments.
Maggie Hudson, CEO of Santiam Hospital & Clinics, said multiple commercial payers in their market began using an AI tool identified as Optum’s Emergency Department Claim Analyzer to automatically deny or downcode high‑acuity emergency department claims without medical‑record review. Hudson said Santiam appealed more than 300 ED claims in the last 18 months and that, in her organization’s experience, overturned appeals are common but lengthy to…
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