NAIRO AI Committee

Dialog with AI Expert: What AI can and cannot do

In 1995, Bill Gates appeared on The Late Show with David Letterman to explain this strange new thing called …. THE INTERNET.

Most people did not understand.  Letterman joked, “Why would I want to read baseball scores on a computer when I have the radio?”

AI is increasingly being adopted into UR to streamline review processes, improve efficiency, and potentially reduce costs. AI tools and agents can automate tasks, analyze patterns, perform deep research, and provide decision support, but they may also introduce potential risks like over-reliance and algorithmic bias. NAIRO has observed a dramatic increase in states creating bills around the use of AI in UR. We have noticed that states have taken a wide-ranging approach to regulating AI into their respective UR regulations, but all agree that some form of human oversight is needed. For example, these bills are currently in process:

• Illinois House Bill (HB) 35 (2025) proposes to create the Artificial Intelligence Systems Use in Health Insurance Act, which provides the Department of Insurance with regulatory oversight of health insurance coverage including oversight of the use of AI systems or predictive models to make or support adverse consumer outcomes.
• Maryland HB 820 (2025) Requires that certain carriers, pharmacy benefits managers, and private review agents ensure that AI, algorithm, or other software tools are used in a certain manner when used for conducting UR.
• New York Assembly Bill 8556 (2025-2026) prescribes requirements and safeguards for the use of an AI, algorithm, or other software tool for the purpose of UR for health and accident insurance.
• Rhode Island Senate Bill (SB) 13 (2025-2026) - Use of Artificial Intelligence by Health Insurers, which promotes transparency and accountability in the use of AI by health insurers to manage coverage and claims.
• Tennessee SB 1261 (2025-2026) Insurance Agents and Policies, which imposes requirements for health insurance issuers using AI, algorithms, or other software for UR or utilization management functions.

NAIRO believes there are important benefits in incorporating AI in UR, including increased efficiency and speed. For example, AI can automate routine tasks like data extraction, prior authorization requests, and initial case reviews, freeing up human reviewers for more complex cases. It can also enhance accuracy and consistency. Foundation AI models such as Google’s Gemini 2.5, Open AI’s GPT 4.5 and others now have the context and reasoning capabilities. They can analyze large datasets and identify hidden patterns that could easily be missed by humans, leading to more accurate and consistent decisions. It would result in improved decision support by providing evidence-based recommendations and highlighting relevant clinical information to facilitate human reviewers in making informed decisions.

Reviewer anonymity is an ongoing issue in the independent review industry. The current industry standard for independent review organizations (IROs) is to prevent the disclosure of the reviewer’s identity unless required by contract, statute, or law. The rationale for maintaining anonymity centers on maintaining the overall quality and integrity of the independent review and maintaining the safety of the reviewer. By allowing the reviewer to remain anonymous, NAIRO believes that reviewers are shielded from undue influence and potential harm. Anonymity allows a reviewer to make the most appropriate decision without outside pressure from other review stakeholders. The National Association of Insurance Commissioners (NAIC) Uniform Health Carrier External Review Model Act (Model Act) and several states have enacted specific language protecting reviewer’s identities and their ability to make unfettered decisions. For example, Section 14 of the Model Act holds IROs harmless for their decisions¹. Recently, the Alaska Legislature released Bulletin B 25-05 protecting the identity of IRO reviewers pursuant to AS 21.06.060(f) and (g).

Consumer advocates and treating providers have countered that disclosing a reviewer’s identity allows for additional transparency in the review process. Recently, many treating or attending providers have disclosed reviewers’ identities to stakeholders, including to the insured. Treating providers can access the reviewer’s name from peer-to-peer conversation. In the external review process, the insured is informed of the IRO assigned to their case but does not have access to the reviewer’s name. Information about the reviewer’s qualifications and experience is shared as part of the review decision. In some cases, there have been reported incidents of threats or harassment against reviewers, including actions against reviewers’ medical licenses. As a result of this trend, qualified reviewers may decline to participate in the independent review process, which could severely limit reviewer availability, access, and the overall scope of reviewer coverage from both a geographic and specialty perspective. To offset this potential hazard, reviewers may demand an increased rate of payment to continue to provide IRO reviews. The potential scarcity of reviewers could also force IROs to raise their rates to ensure they can provide appropriate specialty coverage of all review types. Since the insurer pays for state sponsored external reviews in most circumstances, they may pass on the increased cost directly to the insured by raising premiums and related fees.

Imagine a world where technology and Artificial Intelligence (AI) are seamlessly integrated into our daily lives, revolutionizing our experiences in unprecedented ways. Entrepreneur Steve Brown, upon being diagnosed with a rare form of cancer, took charge of his own care team and developed an AI-powered platform aimed at enhancing medical care. This initiative turned his personal challenge into a movement for improved healthcare solutions. One of the agents—an AI oncologist named "Dr. Haddad"—identified previously overlooked patterns, resulting in not only improved insight into his condition but also the establishment of a new pathway for care that holds potential to impact numerous lives.

What began as Brown's mission for survival has evolved into a broader initiative focused on providing individuals with rare and challenging-to-diagnose conditions the opportunity for answers, healing, and hope. His platform, CureWise.com, is already creating a waitlist of patients and clinicians who envision a future enhanced by technology and driven by empathy.

California Senate Bill (SB) 636 could jeopardize the vitality and integrity of the independent utilization review process, and the National Association of Independent Review Organizations (NAIRO) stands firmly against the bill’s provisions pertaining to “duty of care” mandates.

The current version of SB 636 – “Workers’ Compensation: Utilization Review,” introduced by Senator Dave Cortese – would “require employers establishing a medical treatment utilization review process to ensure that utilization review physicians have the same duty of care to an employee as a treating physician.”

Technology solutions are fast-emerging in the clinical peer review space, from workflow tools that can streamline the medical review process to systems like natural language processing and machine learning that can unleash layers of efficiency.

While artificial intelligence-fueled technology, such as ChatGPT and Microsoft’s Bing chatbot, has grabbed headlines in recent weeks, it’s fair to wonder if AI is entering the medical claims review arena. Although it may be a tantalizing thought, experts say it’s not quite there yet.

While a full-fledged vision of artificial intelligence (AI) remains an elusive conquest within the healthcare industry, rapid advances in technology are showing the ability to improve workflow, enable faster decision-making and, overall, deliver a boost to medical review companies and affiliated stakeholders.

When it comes to new-age technology in healthcare, AI is still in a “science fiction” phase, says Ed Bolton, CEO and president of Nexus, a URAC-accredited independent clinical review and utilization management company based in Schertz, Texas, and immediate past president of the National Association of Independent Review Organizations (NAIRO).

Understanding the Vital Role, Challenges, and Opportunities of Independent Medical Review Services

CLICK HERE FOR THE PDF VERSION

Table of Contents

I. Introduction

Effective January 1, 2022, the No Surprises Act (NSA) ushered in sweeping changes to the dispute-resolution process between healthcare providers and payers, establishing a “baseball-style” arbitration system in which an independent arbiter settles payment differences for out-of-network (OON) charges.

The federal independent dispute resolution (IDR) process, which generally applies to group health plans, health insurance issuers offering group or individual health insurance coverage and Federal Employees Health Benefits (FEHB) carriers, includes the certification of IDR entities to make payment determinations.

As ransomware and other types of cyber crime grow increasingly prevalent, it is paramount that organizations in the medical review and utilization review space know how to best protect their business and client operations with adequate levels of cyber-liability insurance.

A growing area of coverage – yet one that can prove challenging to obtain or afford – cyber-liability insurance doesn’t prevent ransomware attacks and data breaches from occurring, but it provides a high level of defense against downstream risks. Most cyber-liability policies provide network security and privacy liability, limited protections against network business interruptions, media liability provisions and limited coverage of legal expenses.

A federal effort to confront escalating mental health issues – including a refocus on mental health coverage parity – was a central part of President Biden’s State of the Union address that he delivered to lawmakers March 2.

The United States is facing what the White House calls an “unprecedented mental health crisis.” Accelerated by the COVID-19 pandemic and the resulting worry, isolation and depression, mental health issues today impact every two out of five adults and an increasing number of children and adolescents.

A mental health parity law that took effect in California on January 1, 2021, means that independent review organizations (IRO) and utilization review organizations (URO) can expect to work with new care guidelines when assessing coverage standards.

Senate Bill (SB) 855 is one of several pieces of legislation to appear in recent months aimed at improving mental health coverage and addressing perceived disparities in the breadth and extent of coverage. Similar laws, including Illinois House Bill 2595, require that health insurers adhere to standards of care developed by nonprofit organizations, rather than the more traditional commercial standards.

The Illinois bill, for instance, requires that “an insurer shall exclusively apply the criteria and guidelines set forth in the most recent versions of the treatment criteria developed by the nonprofit professional association for the relevant clinical specialty.”

With voters in five states passing ballot measures to approve the use of medical or recreational marijuana, the 2020 election cycle shows that the trend of relaxing laws surrounding cannabis continues to gain traction.

 

Fair IDR: The Way Forward To Protect Patients & Resolve Surprise Medical Bill Disputes

Protecting patients from surprise medical bills is a national concern.¹ The stories of financial hardship placed on patients from surprise medical bills, whether due to lack of coordination in our health care delivery system or misaligned billing practices of health care organizations, are well told. In fact, over 57% of American adults have received at least one surprise medical bill.²

Independent medical peer review services are a fundamental part of the U.S. health care system, providing valuable, evidence-based decisions on medical claims.

However, there is an emerging trend that is pushing for faster medical review determinations, particularly in the event of non-acute and non-emergent situations. This trend can potentially compromise the quality of independent review services for the intended beneficiary – the enrollees.

The act of surprise billing – when a patient receives an unexpected medical bill, sometimes for thousands of dollars or more – is a common occurrence within the American health care system. Studies show that roughly 20% of surgical patients receive a surprise bill, at an average of $2,000 in non-covered fees.

Though states are responding differently to the COVID-19 public health emergency (PHE), current stay at home orders in many regions and the hesitation for companies and employees to return to the office have brought attention to a previously under-the-radar element of business continuity. Namely, the potential for operational disruptions brought on by situations where your workforce cannot attend the office, or where your office is forced to close.

Accreditation and certification organizations have varying requirements to respond to the disruption of normal business, whether it is called business continuity, as in the case of URAC, PCI, or HITRUST; Disaster Management (NCQA); or Business Continuity Management (ISO). Emergency situations that can trigger a WFH business continuity model might be anything from the current PHE to prolonged power outages, severe weather, earthquake damage or other disruptive situations.

ALBANY, NY – February 28, 2020, – The National Association of Independent Review Organizations (NAIRO), the nation’s leading voice of independent medical peer review, is pleased to announce its annual Educational Symposium on April 28-30, 2020 at the Kiawah Island Golf Resort in South Carolina.

The NAIRO Symposium offers two days of networking and in-depth education, with sessions focusing on a range of topics relevant to the independent review of healthcare claims.  The event’s 2020 theme is “Protecting Review Integrity During Healthcare and Regulatory Evolution,” and will highlight changes in the healthcare and regulatory environment and their subsequent impact on Independent Review Organizations, Workers’ Compensation Organizations and Health Utilization Management Organizations.

We are very excited to present the all-new NAIRO website and association management platform! This website will help with the work of keeping our membership connected. With social networking support, simple tools for staying in touch, space for sharing documents and photos and resources to support committees, we can use it to help market our association and highlight great work being done.

In addition, NAIRO.org is going to be the workhorse that will collect member dues and support event registration and payment.