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AI in US Healthcare: Your Rights as a Patient When Algorithms Influence Your Care
US hospitals and insurers use AI for prior authorisation, diagnosis, risk stratification, and treatment planning. Patients have rights under HIPAA, the ACA, and emerging state laws when AI influences clinical and coverage decisions.
Key Takeaways
Health insurers increasingly use AI for prior authorisation. A 2023 Senate investigation found that UnitedHealth's nH Predict AI denied claims at a rate far higher than human reviewers — leading to DOJ investigation and class action lawsuits.
Under HIPAA, you have the right to access your health information including data used in AI-assisted coverage decisions, and to request amendment of inaccurate health information that may affect AI assessments.
The ACA requires insurers to provide written explanation of coverage denials and to have internal and external appeals processes. These rights apply to AI-generated denials — 'our system denied it' is not a compliant explanation.
The FDA regulates AI as a medical device when used for diagnosis or treatment recommendations. Before deployment, diagnostic AI should have FDA 510(k) clearance or De Novo approval — verifiable through the FDA device database at accessdata.fda.gov.
At least 8 states have enacted or are advancing laws specifically regulating AI in health insurance decisions — requiring human review, disclosure, and enhanced appeals. California, Colorado, and New York have the most developed frameworks.
If your AI-generated insurance denial was incorrect: file an internal appeal; file an external appeal with your state insurance commissioner; file a complaint with CMS for Medicare/Medicaid; and consult a patient advocate for complex cases.
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How AI is used in US healthcare
AI is now used across the US healthcare system in ways that directly affect patient care: prior authorisation AI determines whether insurers will cover treatments before they occur; diagnostic AI assists radiologists and pathologists in interpreting medical images; risk stratification AI identifies patients at high risk of deterioration; and administrative AI manages scheduling, billing coding, and documentation. The prior authorisation context has attracted the most scrutiny. A 2023 Senate investigation found that UnitedHealth Group's nH Predict AI model denied claims at over 90% in some categories, overriding individual clinical presentations in favour of statistical averages. Class action litigation and a DOJ investigation followed.
HIPAA rights
HIPAA gives you the right to access your protected health information (PHI), including information used in coverage decisions and AI-assisted clinical assessments. Submit a written access request to the covered entity — they must respond within 30 days. You also have the right to request amendment of health information you believe is incorrect. Inaccurate health information can affect AI assessments — correcting it is an important first step in challenging AI-influenced decisions.
Insurance denial rights under the ACA
The ACA requires insurers to provide: written notice of coverage denial with specific reasons; an internal appeals process; and an external review process by an independent organisation. These rights apply equally to AI-generated denials. The notice must explain the specific reason — including the clinical criteria used. If an AI system denied your claim, the insurer must explain what criteria led to the denial, not simply state that an automated system reached that conclusion.
State-level AI healthcare laws
California's SB 1120 (effective 2025) requires insurance coverage determinations involving AI to be made or reviewed by a licensed clinician. Colorado's SB 21-169 (2021) requires health insurers to test AI systems and algorithms for unfair discrimination against protected classes and take corrective action where bias is found. New York has proposed legislation requiring human review of AI-generated prior authorisation denials for urgent care. Check your state insurance commissioner's website for applicable AI insurance requirements and file complaints there if an insurer appears to violate them.