How to Beat the House: The AI Arms Race in Healthcare Claims

In healthcare, the house always wins. And right now, the house is UnitedHealthcare (UNH) and its AI-driven denial system, nH Predict. This isn’t some conspiracy theory. It’s a cold, calculated fact. The biggest health insurance company in the world has a model designed not just to process claims, but to deny them. And if you’re a provider, it’s like playing blackjack against a dealer who’s counting cards — you’re going to lose, unless you fight back with your own tech.

Let’s break down how the game works.

The Algorithm That Plays Defense

nH Predict was developed by NaviHealth, now part of UnitedHealth Group. It’s a predictive algorithm that crunches data on

• patient diagnoses,
• ages,
• mobility levels,
• and even home environments.

It compares each patient to a database of thousands of similar profiles. From there, it decides what care you should get, how long you should stay in the hospital, and when you’re ready to go home.

The problem? This AI isn’t some benevolent oracle. It’s a cost-cutting machine. If the algorithm decides you’re “done” — no matter what your doctor says — your claim can be denied. And it’s happening a lot. In 2020, UnitedHealthcare’s post-acute care denial rate was 10.9%. By 2022, it had jumped to 22.7%. That’s not efficiency. That’s playing defense on payouts.

The Ripple Effect of Denials

Claim denials don’t just hurt the bottom line; they create chaos. Hospitals and health systems spend $19.7 billion per year fighting denied claims. Nearly 15% of all claims to private payers are denied initially. Among those, 54% are eventually overturned — but not before multiple, costly rounds of appeals.

The average cost of fighting a single claim? $44. Add in clinical labor and it rises to $57 for an inpatient stay and $95 for inpatient surgery.

Staff get tied up in paperwork, payments are delayed and patients lose faith in the system. It’s like a blackjack table where every hand you play bleeds chips and morale.

The Hidden Game of Inputs and Outputs

Here’s the twist: AI models like nH Predict live and die by their inputs. The data you feed them determines their outputs. So if you’re a provider, every claim you submit — approved or denied — is a data point in the AI’s brain. And over tens of thousands of claims, a pattern emerges. A blueprint of the denial model begins to take shape.

This is where Agentic AI comes in.

Agentic AI: The Card Counter for Claims

Imagine an AI system on your side — one that tracks every claim you submit, every piece of documentation, every denial reason. Over time, it learns how the nH Predict model thinks. It spots the weak spots in your claims before UnitedHealthcare does. It flags the codes, the documentation gaps, the tiny errors that nH Predict loves to exploit.

And it doesn’t just stop there. Agentic AI can automate appeals, prioritize the highest-value claims, and even predict when a denial is coming before you hit “submit.” You’re not just reacting to denials anymore. You’re preempting them.

In short, you’re playing offense. You’re counting cards at the claims table.

Reengineering the Denial Game

Over thousands of claims, Agentic AI can reverse-engineer the denial model. You start to see the patterns:

• Which diagnoses are most likely to be flagged?
• What documentation tends to trigger a denial?
• How do patient profiles influence outcomes?

With this intelligence, you can reengineer your submissions. You can optimize claims so they slip past the AI’s net. You can clean up your processes, train your staff, and — most importantly — get the approvals your patients need.

The Arms Race Has Begun

Healthcare providers are in an arms race they didn’t sign up for. The good news? The technology to fight back exists. The AI that’s denying claims is not invincible. It can be outsmarted, outmaneuvered, and outplayed.

But you need to know the game. And you need the right tools.

Want to learn how to beat the house in the AI claims war? Reach out to Action is the Antidote team for a deeper dive. We and our partners are building systems to help providers turn the tables.

Subscribe to Action is the Antidote for more insights on leveraging AI to win the battles that matter. The house may have the odds — but you’ve got the playbook.