Policy & oversight
Should software be able to deny your care?
A nonpartisan advisory commission told Congress this month that a person with the right expertise, not an algorithm alone, should be the one to sign off when a health plan denies coverage.
By the Goodsurance editorial teamJune 27, 2026
Prior authorization, the step where a health plan must approve a service before it is provided, increasingly runs through software. Algorithms and AI tools can sort routine requests quickly, which can cut paperwork and speed approvals. The worry is what happens at the other end, when the answer is no. In its June 2026 report to Congress, the Medicaid and CHIP Payment and Access Commission (MACPAC) devoted a chapter to automation in prior authorization and made a set of recommendations built around a simple line: a denial or a reduction in care should be reviewed and authorized by a qualified person, not by an automated tool acting alone. The Commission also urged more transparency, recommending that health plans disclose how and where they use automation, including how those tools are tested and overseen. MACPAC's recommendations address Medicaid, which matters to Medicare readers in two concrete ways. Millions of people are dually eligible, enrolled in both Medicare and Medicaid, so the rules for one program touch their care directly. And the broader direction of travel, that a human should own the decision to deny, lines up with the scrutiny prior authorization is getting across the whole system, including in Medicare Advantage. It is worth being precise about what this is and is not. A report to Congress is a recommendation, not a law; nothing here changes a plan's process on its own, and the Commission is careful to note that automation, used well, can genuinely help. The even-handed reading is that the technology is neither villain nor cure: it can make a slow system faster, and it can also turn a wrong call into a fast wrong call if no qualified person is checking the denials. On this page the useful takeaway is that you can always ask a plan whether a denial was reviewed by a person, and you always have the right to appeal.
A commission told Congress this month that a qualified person, not an algorithm alone, should sign off when a health plan denies your care.
In plain words
Before some care is covered, a health plan has to say yes first. More and more, a computer program helps decide. That can be fine for quick, easy approvals. The concern is when the answer is no. This month, a group that advises Congress said the rule should be clear: a real person with the right training, not a computer by itself, should be the one to deny care or cut it back. They also said plans should be open about when they use these tools. This is advice, not a law yet, and it is about Medicaid, but it matters for people who have both Medicare and Medicaid, and it fits a bigger push to keep a human in charge of the hardest calls. You can always ask if a person reviewed a denial, and you can always appeal.
Understand the basics first
Source: MACPAC
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