Relating to the use of certain automated systems in, and certain adverse determinations made in connection with, the health benefit claims process.
If passed, SB815 would significantly alter the current practices within the insurance industry regarding how health claim evaluations are conducted. The law mandates that whenever adverse determinations are made, they must be supported by clear clinical bases and must involve human oversight rather than being fully automated. The proposed changes are expected to enhance transparency in the decision-making process, thereby empowering patients to understand the reasons behind adverse evaluations and ensuring they are well-informed about their rights to appeal such decisions. This could lead to an increase in trust between patients and insurers as the process is subjected to greater scrutiny.
Senate Bill 815 addresses the use of automated systems in the health benefit claims process, specifically focusing on how such systems can impact adverse determinations made by insurance companies. The bill introduces definitions for pertinent terms such as 'algorithm', 'artificial intelligence system', and 'automated decision system', and it explicitly prohibits the use of these automated systems for making adverse determinations regarding the medical necessity of health care services. This legislation aims to ensure that decisions about healthcare are made by qualified professionals rather than relying on algorithms, which may not consider the complexities of individual patient needs.
The sentiment surrounding SB815 is largely supportive among patient advocacy groups and healthcare professionals who argue that human judgment should remain central in medical decision-making. Opponents, primarily from the insurance industry, may express concerns over the potential increase in administrative burdens and delays in the claims process due to the stricter regulations on automated decision-making. The discussions on the bill have emphasized the balance between innovation in technology and the necessity of maintaining a human touch in healthcare assessments.
Despite general support for the objectives of SB815, there are notable contentions, particularly regarding implementation timelines and potential regulatory burdens. Critics argue that the bill's provisions may complicate the utilization review process, leading to delays in necessary health care approvals. Additionally, there are concerns about how this regulation may impact the efficiency of operations within insurance companies, which could eventually affect cost savings that such automated systems typically provide. Stakeholders will need to address these practical implications to ensure the bill's goals do not inadvertently hinder patient access to timely medical care.