Insurance CEOs vs. Congress: AI Denials, Prior Auth & The Healthcare Affordability Crisis

Introduction (00:01):
Welcome to Health Law Talk presented by Chehardy Sherman Williams. Health law broken down through expert discussion, real client issues, and real life experiences. Breaking barriers to understanding complex healthcare issues is our job.

Conrad Meyer (00:22):
Good morning, good afternoon. Wherever you are listening to another episode of Health Law Talk, we’re back in the city. I’m Conrad Meyer.

Rory Bellina (00:28):
Rory Belina.

Conrad Meyer (00:30):
And Rory, I don’t know if our listeners have been following the news this week, but I got to tell you, it was wild on Washington yesterday. I think it was January 22nd. What was going on?

Rory Bellina (00:42):
Yeah. So yesterday, I think you mentioned we were talking about this before this show, but five of the big health insurance CEOs had to go before Congress. They kind of had these back to back stage hearings. So we had United Health, CVS, Elevance, Cigna, and Ascendium. So they were all in Washington going through some congressional meetings and hearings from both sides.

Conrad Meyer (01:04):
It looked like from what we saw, it looked like both parties were grilling the CEOs on various issues. It looks like they were talking about PBMs, which we have not really done a show on, but we really need to.

Introduction (01:20):
Sure.

Conrad Meyer (01:22):
Because I find that topic very interesting. Most people don’t even understand what a PBM is. Talking about ACA and the exploration of the subsidies, so the premium increases and then talking about AI and everyone seemed to be mad. Absolutely. I think there was one time I saw both parties, everyone was mad at the CEOs. Yeah.

Rory Bellina (01:44):
I think that like you mentioned, from both sides, they are getting a lot of pressure from their constituents back home and then from other people in Washington. Things aren’t going great with healthcare on a national level. We’ve got kind of the roll off of these subsidies under ACA that we’re going to talk about. So I think that’s a concern. The PBM and the consolidation of these PBMs with these big health insurance companies and how they are forcing out these smaller independent pharmacies. I know we’re going to have a future episode exactly on that topic. It might take a couple of episodes to fully cover and explain what’s going on, but those are the two things. So we’ve got these major, I would consider them Fortune 500, Fortune 100 health insurance companies that are basically running the market. And there’s real concerns about, there really is a monopoly, but how costs are only going up and it’s ultimately affecting the taxpayer.

Conrad Meyer (02:42):
We don’t want to forget about the AI driven denials. I mean, we’re hearing about AI and everything lately. Sure. And so now we’re hearing about insurers using AI on denials. So we’re going to talk about that. We’re going to break it all down for everyone today and see how this affects your practice, you and individually, and how we’re going to get through this. So let’s get right to it. So yesterday before the House Energy and Commerce in Ways and Means, the five CEOs, you got Steven Hemsley, David Joyner, Steve was United, David’s with CVS, Gail Boudreau from Elevance, David Cordani with Cigna and Paul Markovich with Ascendium all were on the hot seats. What was very interesting and I could see it from watching, but I saw AOC yelling at people. I saw Republicans yelling. So it seemed everybody was on the front line battling the CEOs.

(03:41):
So I never seen it. Finally, we have some bipartisan agreement on something.

Rory Bellina (03:45):
Yeah. And the timing’s interesting because I know that there’s been a lot of criminal hearings on the federal level from the United Healthcare shooting that occurred back, geez, that was now, I guess, December of 24 when that occurred. There’s a lot of

Conrad Meyer (03:59):
Anger for that.

Rory Bellina (03:59):
Yeah. It’s horrible what happened, but it really, I think, did open up the eyes to a lot of these Washington politicians on health insurance and how detrimental it can be to families, the costs that are incurred. The costs that are incurred on the employer side, if you’re listening and you own a business, the cost that you have to incur to insure your employees under ACA or just to have an employment staff because all of your competitors are doing it as well. So I think that Congress is obviously concerned about this and another big segment is this ACA subsidy expiration that we’re going to talk about that people may or may not even know about what’s going on with it.

Conrad Meyer (04:40):
Yeah. And I think we’re going to go into the prior authorization and the AI claim denials and then which I think really, really is going to get interesting. And then finally the PBM issue. So let’s start with the premiums. Sure. So what happened with ACA tax credits or the subsidies, whatever you want to call it, what’s the story behind that? I know they ended in December of last year. I mean, just economically, what does that mean for premiums?

Rory Bellina (05:11):
On a very high level basis, essentially what occurred is that those enhanced ACA tax credits expired at the end of 2025. So that’s going to cause an increase in premiums for millions of Americans, unfortunately. House Ways and Means Chair, Jason Smith out of Missouri, he opened up by saying that his staff put in a report that the average family insurance plan now costs over $27,000 a year. So when you break that down, roughly you’re a little over 2,000 a month. If you consider the average family has four point something members, I think is the latest census data, that’s where the costs are. So you’re talking about a major expense of over $2,000 a month on average for families and that’s just for the coverage.That doesn’t even address the deductibles portion, which have continued to increase. So the other part about this is that the marketplace, it’s not just a problem with the ACA marketplace.

(06:10):
On the employer sponsored insurance side, they’re also seeing very large premium creases, especially if you would compare to 15 years from now and I believe there was a stat listed yesterday from the Urban Institute that 7.3 million fewer Americans will have subsidized coverage

Conrad Meyer (06:30):
This year. Yeah, but that follows through with what happens. So the subsidies expire, it gets more expensive. Like you said, it doesn’t just go with ACA policies, right? I mean talking about employer based policies and let me ask, when have we ever in a given year seen an insurance company come back on an employer based and premium and say, “Oh, we’re going to have. We’re going to have a decrease this year.” Never happens. Never happens.

Rory Bellina (06:54):
The Affordable Care Act or Obamacare, depending on how you refer to it, it should be a case study on how you have a plan in mind or how the government and the federal government has a plan in mind, how that plan gets implemented and then how it ultimately fails because I think we’re starting to see the failure of ACA. I think that if you were to say, if I asked you to summarize what was ACA put in place for, what are you going to tell me?

Conrad Meyer (07:21):
I’m going to tell you that was largely meant to cover uninsured by using a mandated premium for young people to offset the cost for covering the uninsured. Yeah.

Rory Bellina (07:34):
That’s a very good summary of what it was. The goal when President Obama was in office was that there were millions of Americans that were not insured or underinsured and they wanted to put into place a mandate and it got challenged all the way up to the Supreme Court, but a mandate that every American needed to have some form of insurance because the Medicare and Medicaid system just couldn’t sustain it.

Conrad Meyer (07:55):
That’s right.

Rory Bellina (07:55):
So they did the best that they could. I think that they had a good goal in mind, but then so the insurance companies took a punch on the nose when they were all said, “You all have to participate in this. You have to offer this coverage to now millions of Americans that before were probably considered uninsurable.”

Conrad Meyer (08:17):
And remember, once you’re in, there’s no

Rory Bellina (08:18):
Preexisting closing,

Conrad Meyer (08:20):
Right? So that

Rory Bellina (08:20):
Risk pool- Cancer is-

Conrad Meyer (08:23):
No

Rory Bellina (08:23):
Preexisting

Conrad Meyer (08:24):
Denial. You’re in the pool.

Rory Bellina (08:27):
So you’re in. And the health insurance companies had to do it. They were mandated to do it. Now I think the health insurance companies are starting to slowly recoup their losses and get back to-

Conrad Meyer (08:39):
But wait, hold on a second. I’m going to call you out on this. Do they really have losses? I mean, did you see some of the profit margins from some of these folks? That’s fair. So wait, and then I understood that now we’re getting a litle bit off here. The medical loss ratio regulations were required to have a, what, 90% or something like that of the premium goes directly to healthcare. I thought the stop gap to sort of keep the insurance companies honest and say, if you’re not spending 90% of the premium on healthcare related services that you need to cut it down, but it still goes up.

Rory Bellina (09:10):
I think-

Conrad Meyer (09:11):
It still goes up.

Rory Bellina (09:12):
I don’t

Conrad Meyer (09:12):
Get it.

Rory Bellina (09:13):
Yeah, that’s correct. You’re fair to call me out on that. I think loss is the wrong word. There was a loss in their revenue, not a loss to the insurance companies. If they were making $100 million when the ACA-

Conrad Meyer (09:26):
I get

Rory Bellina (09:26):
It. When ACA came into effect, now they’re making 80 million. They want to get back to the hundred.

Conrad Meyer (09:31):
Yeah, but their delta is still hot. They

Rory Bellina (09:32):
Still have a positive number. It’s more than

Conrad Meyer (09:34):
80 million.

Rory Bellina (09:35):
There’s

Conrad Meyer (09:35):
Looking billions of

Rory Bellina (09:37):
Dollars here. Right. I was just using that as a

Conrad Meyer (09:39):
Crude example. I

Rory Bellina (09:39):
Get it. I get it. There’s still a positive number. They want that number to be more positive. So I think that’s where we are. So what was interesting, I know you want to talk about it, what was your thought on some of the responses yesterday?

Conrad Meyer (09:53):
I watched Steven Hemsley from United testify that insurers are completely compete aggressively to keep premiums affordable. I could promise you the American people will look at that and say, “Really? Are you kidding? Do you do that? ” And then I think he shifted the blame to say, “Well,” and I have my notes here saying that really the premiums are determined largely by a broader healthcare system. What does that mean?

Rory Bellina (10:20):
What in

Conrad Meyer (10:21):
The world does that mean?

Rory Bellina (10:22):
I think he and the other CEOs all kind of backed each other up and said, “We need to look at hospital costs. We’re not the bad guys. It’s these hospitals. We need to look at prescription drug prices, which is a slippery slope because a lot of these insurance companies own PBMs and what they called healthcare inflation.” I don’t think the members of Congress are buying that though. Not

Conrad Meyer (10:43):
Only do they not buy it, but I think, again, to your point, are we going to be honest here? Because now you’ve got insurance companies owning PBMs. They set the rates, they set the prices, right? Now you have insurance companies also on the front lines owning primary care clinics.

Rory Bellina (10:58):
And demanding or requiring that you have to use a brand name drug versus generic. Absolutely.

Conrad Meyer (11:03):
Correct, correct. So I find it to be a little bit disingenuous to go in front of a committee and say, “Oh, we’re doing the hard work here. We’re doing it hard. We’re being so tough.” And yet what they don’t tell you is, “Well, we also own the PBMs. Oh, we also own the clinics. We also are the gatekeepers of the care.” So yeah, we’re all that, but we’re not going to tell you

Rory Bellina (11:24):
That. Right.

Conrad Meyer (11:26):
Wow.

Rory Bellina (11:27):
What did they say about prior auth? I remember that came up from my notes from the members from both sides were talking about prior auth.

Conrad Meyer (11:35):
This statistic really says it all. So you’ve got one in five medical claims are denied. 20%.

Rory Bellina (11:42):
I

Conrad Meyer (11:43):
Thought

Rory Bellina (11:43):
It’d higher than that,

Conrad Meyer (11:44):
Honestly. I was a litle higher than, but still, wait, here’s the kicker. Ready for this? 82% of Medicare Advantage denials are overturned on appeal. 82%. I mean, that tells you that there’s something wrong with the system.

Rory Bellina (11:58):
That it’s an automatic denial

Conrad Meyer (12:00):
Most

Rory Bellina (12:00):
Likely

Conrad Meyer (12:01):
At the- Correct. So let’s just do a frontline automatic denial. Hopefully no one will appeal. We’ll save some money that way and you know what? The people don’t get the care they need. That to me is unconscionable. That’s unconscionable. I’m sorry.

Rory Bellina (12:15):
One of the members brought up yesterday some AMA survey data that 61% of physicians believe insures use of AI is increasing prior auth. I

Conrad Meyer (12:25):
Guarantee you that.

Rory Bellina (12:26):
I guarantee that. Yeah. I think that’s absolutely occurring because there’s no way that anyone is looking at these. I think it’s- Can

Conrad Meyer (12:32):
Someone answer this question for me and I’ve asked this question a lot, Rory and myself and my practice over the years. How is it that the use of authorization or denials, how is that not the practice of medicine?

Rory Bellina (12:45):
We’re going to get to that. I actually have a note that I want to talk about that. Oh, you do? Okay. Yeah. Yeah. I wanted to talk about

Conrad Meyer (12:49):
That. That’s just nuts to me.

Rory Bellina (12:50):
Yeah. All right. I had in my notes that I wanted to ask you, what were your thoughts on the PBM issues? I know AOC brought this up and she got very upset about it in regards to the consolidation of PBMs with these healthcare insurers.

Conrad Meyer (13:08):
Well, it’s kind of like what you’re saying in other businesses. I mean, you’ve got these massive companies buying up and controlling PBMs and even payers that are controlling PBMs. And what people don’t understand are PBMs were supposed to be like they were a false-

Rory Bellina (13:22):
The system advocate for you. Advocate

Conrad Meyer (13:23):
For the individual, right? And instead what they’re using, I call them like the hidden mafia, the prescription mafia.

Rory Bellina (13:29):
The middleman, as they like to be known.

Conrad Meyer (13:31):
And they’re controlling all of the rates, all of the prices. So to me, when I read earlier, was it last week I read that our HHS secretary, he mentioned about Kennedy, right? Is it

Rory Bellina (13:49):
Robert?

Conrad Meyer (13:50):
Robert.

Rory Bellina (13:51):
Yeah,

Conrad Meyer (13:51):
RFK. Yes. Okay. He mentioned that now we have a most favored nation’s pricing for Medicare for prescription drugs, which I thought was interesting. So I can see the fight. You’ve got these companies now controlling the middlemen. They’re controlling the access. They’re controlling everything. So I find it very disingenuous. You see Hemsley in front of a committee saying, “We’re trying to be aggressive,” but yet, and I don’t think the committee members understand that the breadth of this and how depth and the inner workings of this, because there’s a lot of control, especially

Rory Bellina (14:22):
At

Conrad Meyer (14:22):
The PBM level.

Rory Bellina (14:25):
What I thought was interesting was a comment that I believe that it was brought up, I think AOC, I was actually quoted saying it yesterday on the record that her analysis is that CVS Caremark manages 30% of all prescriptions. That’s nuts. So you’ve got one health insurance. One health insurance,

Conrad Meyer (14:40):
30%.

Rory Bellina (14:41):
CVS CareMark, yes, and managing one. So you’ve got one PBM that has the largest chain of pharmacies. How is that not

Conrad Meyer (14:49):
Antitrust? I don’t get that.

Rory Bellina (14:50):
Managing

Conrad Meyer (14:51):
That. I’m surprised FTC … Now I’m not an antitrust lawyer, but I could …

Rory Bellina (14:56):
Well, because see a lot of people, I’m sure our listeners know this, but CVS also owns health insurance companies. That’s right. So you’ve got this complete vertical integration. You’ve got United with Optum. And you’re

Conrad Meyer (15:07):
Telling me there’s no Chinese walls in there that there’s sort of conflict of interest. I mean, you’re telling me they don’t build. I guarantee you they’re sharing information with each other, guarantee you.

Rory Bellina (15:17):
And the goal is to keep you within their own system so the money stays there. And ultimately it’s hurting, I think, the patients and these independent pharmacies. No

Conrad Meyer (15:25):
Competition.

Rory Bellina (15:26):
Yeah. There’s none. No

Conrad Meyer (15:27):
Competition.

Rory Bellina (15:28):
And the CEO’s response is that, well, by doing this by Cigna owning Express Scripts, CVS owning Aetna Caremark, and then obviously United owns Optum, that creates efficiencies. I don’t know if that’s … I think that’s a very politically correct answer that CEOs are going to say. They’re on the hot seat. But what happens when your health insurance company is now telling your PBM, who now employs your physician at a clinic that is owned by the health insurance company, you need the brand. You can’t have the generic. So you have to pay a higher deductible, your insurance is going to get billed more, your premiums are going to go up, but ultimately we get more. And on the PBM side, which we’re going to go into, because it’s a popular topic, is the discounts and the reimbursements on the PBM side. That’s right. The savings never go to the patient.

(16:17):
The savings go up.

Conrad Meyer (16:18):
They pocket the delta.

Rory Bellina (16:19):
Absolutely.

Conrad Meyer (16:21):
So now the PBM becomes a moneymaker.

Rory Bellina (16:22):
Yeah. Oh, absolutely. Absolutely. Why would these insurance companies want to get into pharmacy? Oh, because

Conrad Meyer (16:27):
They could control it.

Rory Bellina (16:28):
They know that there’s so much money on the pharmacy side, especially as we’re getting a aging United States population.

Conrad Meyer (16:35):
Well, and one thing I want to tell you, and that goes back to what I was saying, the vertical integration of these companies, whether it’s these payer companies into the care market, meaning the PBM and the primary care. I find it creates a complete conflict of interest, total conflict of interest. And so I’m very interested to see what the future holds for that in terms of legislation. Are we going to legislate this at the federal level? Do we even understand the depth of how far it goes? I don’t know. I don’t

Rory Bellina (17:06):
Know either. I don’t

Conrad Meyer (17:07):
Know. All

Rory Bellina (17:09):
Right. So let’s jump back to what happened with these subsidies.

Conrad Meyer (17:13):
Got it.

Rory Bellina (17:14):
So again, they expired, the enhanced subsidies, I’ll say expired 12, 31,

Conrad Meyer (17:19):

2025. So

Rory Bellina (17:20):
They’re

Conrad Meyer (17:20):
Gone. They’re

Rory Bellina (17:21):
Gone

Conrad Meyer (17:21):
Now. So now premiums are skyrocketing. What’s the average I

Rory Bellina (17:24):
Think? Average family employer plan 27,000 per year was cited yesterday, out of pocket maximum on average 20,000 per year.

Conrad Meyer (17:34):
That’s staggering.

Rory Bellina (17:35):
Yeah. Prior auth, like we said, to summarize, one in five claims are being denied, 82% are being overturned on appeal. So it’s an issue. Congress is aware of it. What are they going to do with it? I don’t know if anything, because I think the insurance companies, like we said, they want to get that delta back to be even a bigger delta for them and here’s how they’re doing it. They’re scooping up these pharmacies and buying these PBMs.

Conrad Meyer (18:03):
So one of the things when you talk about claim denials and I think it was very interesting yesterday and you’re looking at the data that we just talked about

Rory Bellina (18:10):
Too,

Conrad Meyer (18:11):
Is AI and healthcare. Which brings up to our next part that we’re going to go talk to our listeners is the new Medicare AI pilot program.

Rory Bellina (18:21):
Wiser. Wiser.That’s right. What a great name. I love acronyms. Who

Conrad Meyer (18:23):
Comes up with that? That’s pretty good.

Rory Bellina (18:25):
Congressional staffers have to because there’s always a great acronym for a new program. So the WISER program, what is that?

Conrad Meyer (18:32):
No, I think this is very important because I don’t think enough providers even have this on their radar right now about what’s happening. So CMS launched what they call the Wiser Program. Let me spell it out for you. It means wasteful and inappropriate service reduction. Now it starts literally just a few weeks ago. Few weeks ago. Yeah. January 1st, 2026. It’s going to run for six years in six states. Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. Now here’s the great thing. Louisiana isn’t part of it yet, but providers need to pay attention because this could expand nationally. And if you’re a provider in Louisiana that does work in Texas, okay, right next door, you might need to be aware of what’s going on.

Rory Bellina (19:12):
Interesting. I’m curious how they pick these states, but-

Conrad Meyer (19:15):
Maybe at a jar.

Rory Bellina (19:16):
We’ve got some big ajar. Yeah. There’s really no … We’ve got some big states, we’ve got some small states, some blue states, some red states.

Conrad Meyer (19:25):
But the interesting thing, the companies that are doing these AI reviews get paid on the savings. CMS is really big on reimbursing for savings because they’re trying to keep cost down. But think about that for the incentive, like the savings. What does that mean? So are we going to deny more care and just reap the savings?

Rory Bellina (19:46):
Well, I think to summarize what wiser is, it’s Medicare’s goal to apply AI and machine learning to prior auth decisions for traditional Medicare. So not an advantage, but your traditional beneficiary, they’re saying that there’s safeguards in place. CMS is saying that a qualified human clinician, I don’t know what a human clinician is.

Conrad Meyer (20:08):
And what does that mean? Is that like an LPN

Rory Bellina (20:10):
Or what is that? Who is considered a clinician? Are they like a

Conrad Meyer (20:14):
Doctor?

Rory Bellina (20:14):
Do we know? I’m going to make a note to get more information on that. Must review any denial before it’s final and the vendors can’t have compensation arraignments directly tied to denial rates.

Conrad Meyer (20:26):
Okay. Let me stop you right there. Okay. Because you know what I found interesting is these denials and it’s unbelievable. I know you’ve seen this in your practice.

Rory Bellina (20:34):
Oh yeah. The

Conrad Meyer (20:34):
Insurance company-

Rory Bellina (20:35):
I know what you’re going to say before you say it. The insurance

Conrad Meyer (20:37):
Company is putting these doctors … Now sometimes they’re doctors, right? They’re supposed to be peer to peer.

Rory Bellina (20:43):
They’re going to sit in a room like us with a stack of paper to the ceiling or a computer.

Conrad Meyer (20:48):
But here’s my question. If I’m an orthopedic and I’m going to go, I need to do X, Y, Z for a patient, let’s say it’s a back surgery. Say I do orthopedic back and spine and I go and I get a denial and then I’m going peer to peer with like say a payer with their doctor and you ask that doctor, “Well doctor, what specialty are you? ” Family medicine. I’m a pathologist. Right,

Rory Bellina (21:09):
Right.

Conrad Meyer (21:09):
So wait, you’ve never done surgery in your life and you’re making a call about a denial for a back spine issue? Well, yeah. I mean, wouldn’t you be outraged?

Rory Bellina (21:19):
Yeah, absolutely.

Conrad Meyer (21:20):
So if you’re going to have those denials, I think they need to be true

Rory Bellina (21:26):
Peer

Conrad Meyer (21:26):
To peer.

Rory Bellina (21:27):
Absolutely.

Conrad Meyer (21:28):
Peer to peer, because it’s much more difficult to look at another orthopedic surgeon in the face and say, “Yeah, we’re going to deny that.

Rory Bellina (21:34):
” And you’ve also hired a employee. I mean, they’re an employee. You’ve hired an employee physician to review denials. It’s not going to look good if you overturn all the denials that your boss essentially is trying to say these shouldn’t be paid. You need to kind of tow the … They’re going to be expected to tow the company line. And so when they get all of these denials, I think they’re going to continue to say it’s still denied. So don’t have

Conrad Meyer (22:04):
Compensation tied to savings. Don’t have comp tied to denials, right?

Rory Bellina (22:08):
Correct. It shouldn’t be. It shouldn’t be. But your job is to review the denials. I always am curious about what’s the moral boundaries of that physician who’s reviewing the denials. Is he truly-

Conrad Meyer (22:24):
Or is it really a physician? I mean, do you see that the Senate 2024 committee report found that AI tools have been linked to denial claims that are rate 16 times higher than decisions without AI? Yeah. And so I want to know is who is programming or prompting for the AI, right?

Rory Bellina (22:42):
Well, states are starting to get involved in that. So I know Texas, they have a great acronym for this one. Traga? Triaga?

Conrad Meyer (22:51):
Not to be confused with Traeger.

Rory Bellina (22:52):
Right, not the grill. It was a responsible AI, Texas Responsible AI Governance Act. So I’ll call it TREGA. That went into effect a few weeks ago. California has an act. I don’t know if it’s been signed yet by the governor, but those are regulations that require the disclosure when AI is used in diagnostic or treatment decisions. So states are realizing that this is an issue and they’re doing what they can. Under TREGA as well, if you’re a Texas practitioner, you must provide patients with “conspicuous written disclosure of AI use before or at the time of interaction in emergencies as soon as reasonably practical.”

Conrad Meyer (23:35):
What about California?

Rory Bellina (23:36):
California prohibits, this is AB 489 if anyone wants to look it up that prohibits AI systems from using terms or phrases that imply care is being provided by a licensed human professional when it’s not. I think that’s more of a licensure standpoint as far as is this practicing medicine or not. I think that the goal behind California. So states are aware that AI is heavily involved in this. Everyone is using it. It makes sense that the government and CMS is going to use it because they get so many claims on a daily basis. And another topic while we’re talking about future topics is I think you and I will summarize this the same, but the CMS Medicare system, it’s a honesty based system. Absolutely

Conrad Meyer (24:26):
It is.

Rory Bellina (24:26):
You provide a service, you submit the bill.

Conrad Meyer (24:28):
We pay it.

Rory Bellina (24:29):
And it gets paid and then maybe we’ll audit it, maybe we’ll look at it, but it’s very much like an honesty based system. That’s right. I think of course CMS is starting to is going to use AI. Why wouldn’t they to see are there bad providers out there that are taking advantage

Conrad Meyer (24:43):
Of it? I think the problem is though who’s prompting that, right? Because AI in itself is not self-aware, at least not yet, right? Right. But who’s prompting it and how is that being prompted and who’s reviewing the prompt and who’s teaching it to review the claim and how? What’s the process? An agent or whatever they’re using to review the claim and deny it, how does that process look? Because I could tell you, I’m skeptical now. Now look, look, right now Louisiana has none of this. None of this. Like I said before, if you’re practicing in Texas, if you’re going across state lines, if you’re a Louisiana doc and you’re doing telemed or you’re in both states and back and forth, you need to be aware of

Rory Bellina (25:23):
This. Yeah, make sure. So like you mentioned, Louisiana, the concern for Louisiana, if we’re going to focus here on a couple of things briefly before we wind down is that this ACA subsidy, it’s definitely affecting Louisiana hard. There’s estimates that over 200,000 residents were enrolled in the ACA marketplace plan. So they’re going to see those premiums unfortunately double, triple.

Conrad Meyer (25:48):
Now look, here’s the problem.

Rory Bellina (25:50):
What happens if you can’t afford that?

Conrad Meyer (25:52):
That’s another problem. So in typical, right? We have our charity care. Everyone will go back to the ER just like it was before. Then you got DISPRO. So you have DISH payments, right? So you’re back to uncompensated care where the hospitals are going to have to seek reimbursement for that through some sort of a subsidy or a dish payment. And

Rory Bellina (26:13):
So now you’re going now- Right

Conrad Meyer (26:14):
Back to the old system.

Rory Bellina (26:15):
Back to the old model of ER

Conrad Meyer (26:18):
Visits.

Rory Bellina (26:18):
Five hour waits.

Conrad Meyer (26:19):
That’s right.

Rory Bellina (26:20):
Horrible. Not always, but unfortunately a lot of horrible outcomes or outcomes that could have been prevented because it’s underinsured. Despite

Conrad Meyer (26:27):
The fact that we have an urgent care at every corner, it’s almost like a Wendy’s,

Rory Bellina (26:30):
Right?

Conrad Meyer (26:31):
Right. Or like whatever fast food, you look at, there’s an urgent care, there’s another one, like the Starbucks, urgent care everywhere.

Rory Bellina (26:36):
Yeah. Yeah. And in our neighborhood, there are more urgent cares I would say than any other business if you had to look at it. It’s incredible. So are you aware of anything on the Louisiana level for transparency requirements for AI here yet? I don’t think that there’s anything.

Conrad Meyer (26:55):
And you know what? I hate to say it as much as I love our medical board. I think- They’re going to have to get

Rory Bellina (26:59):
All of this.

Conrad Meyer (27:00):
They’re going to have to jump in and get involved. I can promise you right now- They’re talking about it. They’re talking about it. And I also think that it’s very interesting. I remember when Epic came out, a lot of docs were using Epic templates to kind of get their records done right. And we always counsel them, be very careful about doing that because it could bite you later. So now I have yet and I need to get more on top of this. I want to see how has Epic used AI to integrate? Have they used AI? And I’m sure they have, they got to. And I need to do some research on that because I’d love to know what they’re doing from an AI standpoint. So here’s another problem. What are we going to do about telling patients about this? I mean, do patients need to know that the doctor they’re seeing is using some form of AI tool?

Rory Bellina (27:54):
I think that as of right now, and I’ve experienced this from personal experiences that I know different one big health system here in Louisiana uses an AI transcribing service and the patients are made aware of it when the doctor walks in the room that there’s an AI dictation transcribing software that takes the encounter, uses AI and machine learning and puts it in the note in Epic in a draft format and then the doctor’s supposed to obviously go through and make changes and so forth. So I think that that’s an efficiency thing, that it’s patients were probably recording their interactions regardless. So now the doctor is doing it. I think that’s for an efficiency thing to get things done a little bit quicker. I also think it could enhance reimbursements because a lot of times when a doctor after their encounter, they have to go in the note, they have to put in there their charges and the scribe looks at or the biller and coder looks at and decides what to bill and code.

(28:48):
Well, if this AI is now programmed to listen to this and to pick up key words, I think these bills are going to get bigger and bigger. I think it’s- Oh, I

Conrad Meyer (28:57):
Guarantee they’re going to get

Rory Bellina (28:58):
Better, but

Conrad Meyer (28:58):
Then the question

Rory Bellina (28:58):
Is- It’s listening for words that are CPT codes, essentially.

Conrad Meyer (29:03):
Okay. So let me throw this at you. So tell me this shouldn’t be on DOJ’s radar, right or OIG’s radar. So up coding, you’re telling me that AI and using AI to prompt … In other words, if I’m a UR person and I’m going through on a record and trying to figure out how do we maximize reimbursement on an E&M code from a level one to a level five, right? And I’m looking, okay, so I’m going to say, tell Jarvis, you’re going to need to look at this, this, this, this, this and this. And then when you assess the note, you can decide if it’s properly coded as a level three, a level four, level five, I promise you.

Rory Bellina (29:42):
Or feed, or you’re going to give it if someone is going to develop a large language model learning system where it could very much say, look at this patient record, listen to this patient- We should do that. We should make it up, right? Let’s go off air so no one steals our idea. But Yeah. In all seriousness, I’m sure that there’s LLMs that are designed to listen to a full record with the prompt in mind of upcode this as much as you can because we are going to listen to everything. And if the doctor mentions this, oh, let’s run that lab. Let’s run that

Conrad Meyer (30:17):
Panel. I can promise you this, he’s not going to give two cents about AI doing it. They’re going to say, you know what? If it wasn’t actually done or this note was modified, you’re on the hook. I don’t care if Jarvis did it. So I’m sorry to all the Jarvis fans because I do like Jarvis. But I think honestly, you know what else is going to be interesting using AI from a UR standpoint for peer review, for peer review. So imagine your quality assurance committees, your quacks. And if you’ve got a peer review issue, they’re going to be using AI to assess competency. That’s true. Or if you’re going to have AI driven for M&M conferences on your mortality mobility rate. That’s

Rory Bellina (31:05):
A good point.

Conrad Meyer (31:05):
So I could see AI coming in all aspects of healthcare that have not been infiltrated yet. Interesting. So in the end, where are we, Rory, on the takeaways here? I think we covered a lot here for the listeners. And so what should we take away? I

Rory Bellina (31:24):
Think that the key is that doctors and providers, they’re going to face this uphill battle with fighting prior auth and prior auth denials. The key there is going to be the documentation in your record and really staying diligent for that. Unfortunately, I think that’s a big theme of what we see going on and having to fight these with AI because you have to presume now that there’s AI on the other side of every bill or prior auth request that’s reviewing it and trying to find a way to deny it. Unfortunately most or fortunately I should say, statistically, most denials are overturned on appeal. It’s burdensome. It takes a lot of staff time, but if you don’t appeal, your practice is leaving money on the table and you’ve got patient harm issues as well.

Conrad Meyer (32:15):
And look, I mean, I guess when we’re talking about appeals, just like we saw on the Medicare Advantage, the 82% are overturned. And here’s another thing when you talk to physicians about this, they can’t stand the red tape and the paperwork, but you have no choice.

Rory Bellina (32:30):
Yeah.

Conrad Meyer (32:31):
You have no choice. Someone’s got to be working those claims and usually they have medical billing providers, but again, that takes money off the table. So I could see leaving … If you don’t appeal and you don’t fight this, you’ll leave your money on the table.

Rory Bellina (32:45):
Yeah. I think that’s a good summary of everything and we just have to wait and see what’s going on. The one big beautiful bill that Congress is still kind of working through, I expect there’s going to be healthcare updates in there as well.

Conrad Meyer (32:58):
Yep. Yep. And I think for hospital administrators, medical staff, look at AI policies and see how AI is integrated in your facility. And also for physician practice, how are your practices using AI and how are you documenting the quality checks for that? So I think that’s the main thing. And lastly, I think to wrap it up, I think watch for the legislation and watch for the regulation. I can’t imagine the state board of medical examiners here in Louisiana’s not going to put their hands on this. Now whether the legislature does, that’s a whole different story because I think, I don’t know how in the weeds they are, but I guarantee you, I think the state board of medical has to. And not just them, but all providers. So the board of psychology, anyone who is board of counselors, I mean, anyone who does direct patient care on a board level in this state needs to be looking at this, I think.

(33:52):
So I think right now we got a lot of material coming on. This is going to be a really, really good year. And I want to thank everyone today for listening. Rory, any final comments before we wrap it up?

Rory Bellina (34:04):
No, just stay tuned. We’ll continue to update it. I like this topic. I like it on the national level, so stay tuned.

Conrad Meyer (34:10):
Yeah, we’ll stay tuned for some more AI topics, PBM topics. And again, drop us a line if you have anything to say. Reach out to us. Rory and Conrad always listening to you guys. Leave us that five star rating. Thank you for listening. Have a great day and look forward to our next episode. See you.

Introduction (34:26):
Thanks for listening to this episode of Health Law Talk presented by Chehardy Sherman Williams. Please be sure to subscribe to our channel. Make sure to give us that five star rating and share with your friends. Chehardy Sherman Williams is providing this podcast as a public service. This podcast is for educational purposes only. This podcast does not constitute legal advice, nor does this podcast establish an attorney-client relationship. Reference to any specific product or entity does not count as an endorsement or recommendation by Chehardy Sherman Williams. The views expressed by guests on the show are their own and their appearance does not imply an endorsement of them or their entity that they represent. Remember, please consult an attorney for your specific legal issues.