Recently I wrote about the Conversation I had at my Rotary Club on the subject of AI and jobs. It seems now every time we sit for lunch, one of the conversation topics is ALWAYS AI. In the last few blogs, we have been not only talking about the speed AI is moving, in what we called AI Years ™ that are way shorter than earth years. We also talked about the Adoption of AI by the big players in healthcare, insurance companies, hospitals and providers. Frankly the 1st one is moving the fastest and with the most capital. I have been criticized for saying the “best equipped people in healthcare are insurance companies”. Why? Because they have ALL THE DATA.
We are going to refer in this blog to just one article from the Wall Street Journal (WSJ) the same paper that told us earlier this year that Americans have over 850,000,000 medical claims denied yearly. Now in the article (link below) dated May 5, 2025, we have the headline “UnitedHealth [UNH] Now Has 1,000 AI Use Cases, Including in Claims”. Now in full disclosure I have had a contract with dozens of payors in my career, never one with UNH. So, I actually know them only as a former member and from what I read, but I know more than the average consumer about healthcare and how insurance companies work. I still have an active Florida Life and Health License. To be fair, UNH says “But artificial intelligence on its own will never deny a claim, assures the insurer’s chief digital and technology officer”. From what I know. both statements could be true.
WSJ says that UNH is using these AI tools to reduce administrative burdens, improve customer experience and aid in medical diagnosis. Nice public relations position but recall that in America we have about 850 million annual medical visits and interestingly 850 million denials of claim for everything from consultations, procedures to medications. If you are an American with employer medical coverage or in a Medicare Advantage plan and you are over 50, probably 80% of you have experience something your doctor has prescribed have been either changed or denied. It has happened to every single member of my family over 30 years old.
UNH says these AI tools are there to “guide their human workers”. UNH claims that AI plays a role in evaluating the claim, “but it will never be allowed to deny claim”. They also say they process over 5 billion medical claims annually. The WSJ highlights that “More than 90% of the claims UnitedHealth processes every year are auto-adjudicated—meaning that software automates a decision based on the information provided.” The missing 10% of claims can’t be auto adjudicated because they have missing information. Who do you believe? Go back and read “5 billion medical claims”, and all denials are human?
UNH said they “had rolled out an AI-powered chatbot that helps customers find doctors. If users write “stomach pain,” the chatbot directs them to gastroenterologists. The tool aided in 18 million searches during the first quarter of 2025.”
UNH and Medicare Advantage
Earlier this year, WSJ also reported that UNH was under investigation by the U.S. Justice Department, for practices that focused on recording diagnosis that trigger extra payments, including from physicians group it owns.
An AI Arms Race is Underway.
In the last blog we noted the 1,000s of projects trying to use AI to improve care, reduce cost and even make the lives of provider better. As of my last research there are today over 100 mostly Venture Capital funded companies trying to help doctors with not taking notes. The industry focus is called Ambient AI Transcription. The goal is that the AI is listening to the conversation between the provider and the patient and it takes notes, that then the provider can review, edit, delete or replace. Some doctors love it and some hate it. The reading and editing take time, more time in many cases than just typing it in the first instance. There are also issues on privacy and security someone else can discuss. We tried it in part with Dragon Medical (Nuance) and though it was a while back it was not worth it. Most of these companies will not make it, suspect 99% will fail. Epic the largest Hospital based EHR Company in the world has partnered with Nuance and ChatGPT to provide this Ambient Documentation in their best EHR product.
The Consumer Needs Help. The Combatants?
In a world where AI is being used by insurance companies to review and as accused deny claims, and where hospitals are using it to increase efficiency that includes higher utilization, and where their doctor is Consumer’s only line of defense against those 850 million claims denial; the Consumer needs to be their own advocate. AI can help.
The Consumer in most cases is the product and has the least to say in how they are treated. They/We, need help in taking control of their own medical records, then use AI to advise and inform them/us. The Consumer needs to fend for themselves and file contestation of denial of services. We think that out of the box-out of the system view is only possible today because of technology and AI.
About HealthScoreAI ™
Healthcare is at a tipping point, and HealthScoreAI (HSAI) is positioning to revolutionize the industry by giving Consumers control over their health data and unlocking its immense value. U.S. healthcare annual spending has exceeded $5 trillion with little improvement in outcomes. Despite advances, technology has failed to reduce costs or improve care. Meanwhile, 3,000 exabytes of Consumer health data remain trapped in fragmented USA system of 500 EHRs, leaving Consumers and doctors without a complete picture of care.
HealthScoreAI seeks to provide a unique solution, acting as a data surrogate for Consumers and offering an unbiased holistic view of their health. With over 850 million medical claims denied annually in the U.S., HSAI intends on giving Consumers practical tools to respond to denial of care by insurers. We aim to bridge the gaps in healthcare access and outcomes. By monetizing de-identified data, HealthScoreAI seeks to share revenue with Consumers, potentially creating a new $100 billion market value opportunity. With near-universal EHR adoption in the USA, and advances in technology, now is the perfect time to capitalize on the data available, practical use of AI and the empowering of Consumers, in particular the 13,000 tech savvy baby boomers turning 65 every single day and entering the Medicare system for the first time. Our team, with deep healthcare and tech expertise, holds U.S. patents and a proven track record of scaling companies and leading them to IPO.
Noel J. Guillama-Alvarez
https://www.linkedin.com/in/nguillama/
+1-561-904-9477, Ext 355
https://www.wsj.com/articles/unitedhealth-now-has-1-000-ai-use-cases-including-in-claims-f3387ca3