You Can’t Automate Judgment Out of Healthcare

Automation is good at following rules. Judgment is what's left when the rules run out.

A prior auth where every field maps cleanly to the payer's criteria doesn't need a person. Neither does a claim that matches the policy line for line. Automate those all day. That's the easy 80%.

The other 20% is where healthcare actually lives. The note that technically satisfies the requirement but wouldn't survive a medical director's read. The repeat authorization that clears every criterion because the codes match, for a therapy this patient has already failed twice. The exception the policy never anticipated. None of those are solved by rules. They're judgment calls: someone weighing an ambiguous situation and deciding what it actually is.

Here's what most AI implementations miss. You can't remove those calls from the workflow. They don't disappear when you automate. They just stop being made on purpose.

The system still resolves the ambiguous case. It has to produce an output. But it resolves by defaulting, not deciding, picking the most probable pattern and moving on, with no one aware a judgment was even required. The call still got made. Nobody made it.

That's the quiet cost of "automating judgment away." You don't eliminate the judgment. You relocate it to a model that can't know it's exercising it, or to a downstream person who inherits the consequence without the context.

You can't automate judgment out of healthcare. You can only decide who exercises it. Someone accountable for the call, or a system that doesn't know it's making one.

Where in your operation is a judgment call being made by default right now, and would anyone know if it were?