By Anna Claire Vollers, Stateline.org

As states strive to curb health insurers’ use of artificial intelligence, patients and doctors are arming themselves with AI tools to fight claims denials, prior authorizations and soaring medical bills.

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Several businesses and nonprofits have launched AI-powered tools to help patients get their insurance claims paid and navigate byzantine medical bills, creating a robotic tug-of-war over who gets care and who foots the bill for it.

Sheer Health, a three-year-old company that helps patients and providers navigate health insurance and billing, now has an app that allows consumers to connect their health insurance account, upload medical bills and claims, and ask questions about deductibles, copays and covered benefits.

“You would think there would be some sort of technology that could explain in real English why I’m getting a bill for $1,500,” said cofounder Jeff Witten. The program uses both AI and humans to provide the answers for free, he said. Patients who want extra support in challenging a denied claim or dealing with out-of-network reimbursements can pay Sheer Health to handle those for them.

In North Carolina, the nonprofit Counterforce Health designed an AI assistant to help patients appeal their denied health insurance claims and fight large medical bills. The free service uses AI models to analyze a patient’s denial letter, then look through the patient’s policy and outside medical research to draft a customized appeal letter.

Other consumer-focused services use AI to catch billing errors or parse medical jargon. Some patients are even turning to AI chatbots like Grok for help.

A quarter of adults under age 30 said they used an AI chatbot at least once a month for health information or advice, according to a poll the health care research nonprofit KFF published in August 2024. But most adults said they were not confident that the health information is accurate.

State legislators on both sides of the aisle, meanwhile, are scrambling to keep pace, passing new regulations that govern how insurers, physicians and others use AI in health care. Already this year, more than a dozen states have passed laws regulating AI in health care, according to Manatt, a consulting firm.

“It doesn’t feel like a satisfying outcome to just have two robots argue back and forth over whether a patient should access a particular type of care,” said Carmel Shachar, assistant clinical professor of law and the faculty director of the Health Law and Policy Clinic at Harvard Law School.

“We don’t want to get on an AI-enabled treadmill that just speeds up.”

A black box

Health care can feel like a black box. If your doctor says you need surgery, for example, the cost depends on a dizzying number of factors, including your health insurance provider, your specific health plan, its copayment requirements, your deductible, where you live, the facility where the surgery will be performed, whether that facility and your doctor are in-network and your specific diagnosis.

Some insurers may require prior authorization before a surgery is approved. That can entail extensive medical documentation. After a surgery, the resulting bill can be difficult to parse.

Witten, of Sheer Health, said his company has seen thousands of instances of patients whose doctors recommend a certain procedure, like surgery, and then a few days before the surgery the patient learns insurance didn’t approve it.

In recent years, as more health insurance companies have turned to AI to automate claims processing and prior authorizations, the share of denied claims has risen. This year, 41% of physicians and other providers said their claims are denied more than 10% of the time, up from 30% of providers who said that three years ago, according to a September report from credit reporting company Experian.

Insurers on Affordable Care Act marketplaces denied nearly 1 in 5 in-network claims in 2023, up from 17% in 2021, and more than a third of out-of-network claims, according to the most recently available data from KFF.

Insurance giant UnitedHealth Group has come under fire in the media and from federal lawmakers for using algorithms to systematically deny care to seniors, while Humana and other insurers face lawsuits and regulatory investigations that allege they’ve used sophisticated algorithms to block or deny coverage for medical procedures.

Insurers say AI tools can improve efficiency and reduce costs by automating tasks that can involve analyzing vast amounts of data. And companies say they’re monitoring their AI to identify potential problems. A UnitedHealth representative pointed Stateline to the company’s AI Review Board, a team of clinicians, scientists and other experts that reviews its AI models for accuracy and fairness.

“Health plans are committed to responsibly using artificial intelligence to create a more seamless, real-time customer experience and to make claims management faster and more effective for patients and providers,” a spokesperson for America’s Health Insurance Plans, the national trade group representing health insurers, told Stateline.

But states are stepping up oversight.

Arizona, Maryland, Nebraska and Texas, for example, have banned insurance companies from using AI as the sole decisionmaker in prior authorization or medical necessity denials.

Dr. Arvind Venkat is an emergency room physician in the Pittsburgh area. He’s also a Democratic Pennsylvania state representative and the lead sponsor of a bipartisan bill to regulate the use of AI in health care.

He’s seen new technologies reshape health care during his 25 years in medicine, but AI feels wholly different, he said. It’s an “active player” in people’s care in a way that other technologies haven’t been.

“If we’re able to harness this technology to improve the delivery and efficiency of clinical care, that is a huge win,” said Venkat. But he’s worried about AI use without guardrails.

His legislation would force insurers and health care providers in Pennsylvania to be more transparent about how they use AI; require a human to make the final decision any time AI is used; and mandate that they show evidence of minimizing bias in their use of AI.

“In health care, where it’s so personal and the stakes are so high, we need to make sure we’re mandating in every patient’s case that we’re applying artificial intelligence in a way that looks at the individual patient,” Venkat said.

Patient supervision

Historically, consumers rarely challenge denied claims: A KFF analysis found fewer than 1% of health coverage denials are appealed. And even when they are, patients lose more than half of those appeals.

New consumer-focused AI tools could shift that dynamic by making appeals easier to file and the process easier to understand. But there are limits; without human oversight, experts say, the AI is vulnerable to mistakes.

“It can be difficult for a layperson to understand when AI is doing good work and when it is hallucinating or giving something that isn’t quite accurate,” said Shachar, of Harvard Law School.

For example, an AI tool might draft an appeals letter that a patient thinks looks impressive. But because most patients aren’t medical experts, they may not recognize if the AI misstates medical information, derailing an appeal, she said.

“The challenge is, if the patient is the one driving the process, are they going to be able to properly supervise the AI?” she said.

Earlier this year, Mathew Evins learned just 48 hours before his scheduled back surgery that his insurer wouldn’t cover it. Evins, a 68-year-old public relations executive who lives in Florida, worked with his physician to appeal, but got nowhere. He used an AI chatbot to draft a letter to his insurer, but that failed, too.

On his son’s recommendation, Evins turned to Sheer Health. He said Sheer identified a coding error in his medical records and handled communications with his insurer. The surgery was approved about three weeks later.

“It’s unfortunate that the public health system is so broken that it needs a third party to intervene on the patient’s behalf,” Evins told Stateline. But he’s grateful the technology made it possible to get life-changing surgery.

“AI in and of itself isn’t an answer,” he said. “AI, when used by a professional that understands the issues and ramifications of a particular problem, that’s a different story. Then you’ve got an effective tool.”

Most experts and lawmakers agree a human is needed to keep the robots in check.

AI has made it possible for insurance companies to rapidly assess cases and make decisions about whether to authorize surgeries or cover certain medical care. But that ability to make lightning-fast determinations should be tempered with a human, Venkat said.

“It’s why we need government regulation and why we need to make sure we mandate an individualized assessment with a human decisionmaker.”

Witten said there are situations in which AI works well, such as when it sifts through an insurance policy — which is essentially a contract between the company and the consumer — and connects the dots between the policy’s coverage and a corresponding insurance claim.

But, he said, “there are complicated cases out there AI just can’t resolve.” That’s when a human is needed to review.

“I think there’s a huge opportunity for AI to improve the patient experience and overall provider experience,” Witten said. “Where I worry is when you have insurance companies or other players using AI to completely replace customer support and human interaction.”

Furthermore, a growing body of research has found AI can reinforce bias that’s found elsewhere in medicine, discriminating against women, ethnic and racial minorities, and those with public insurance.

“The conclusions from artificial intelligence can reinforce discriminatory patterns and violate privacy in ways that we have already legislated against,” Venkat said.

Stateline reporter Anna Claire Vollers can be reached at avollers@stateline.org.

©2025 States Newsroom. Visit at stateline.org. Distributed by Tribune Content Agency, LLC.

By Patti Nickell, Tribune News Service

FREDERICKSBURG, Texas — On my first night in Fredericksburg, I’m headed to one of my favorite dining spots, Hill & Vine Restaurant.

While I am salivating at the thought of its southern staples stamped with the flavors of the Texas Hill Country (think black-eyed pea hummus, chili-citrus brined pork chops and sweet cornbread), it’s the prospect of their wine list that has me really excited.

Hill & Vine’s owners are passionate about Texas wines, and on my first visit a few years ago, I became enthralled with a bold, rich Tempranillo marrying the flavors of red fruit with the smokiness of tobacco. On this occasion, two glasses of this Texas Tempranillo confirmed my belief that it is as good as any I have had in Spain’s Rioja Region.

Hill & Vine Restaurant offers the best of Texas food and wine. (Handout/Hill & Vine/TNS)

Fredericksburg, a small community halfway between Austin and San Antonio, is on Highway 290, better known in these parts as “the Wine Road.”

It has become the epicenter of Texas’s burgeoning wine industry with 75 of the more than 100 wineries along the route located in the town and its surrounding countryside.

Famous vineyards such as Signor, Grape Creek and the Texas Wine Collective attract some one million visitors annually. However, if you are looking for one of the region’s newest additions, head for Prochnow Vineyard at Crabapple Creek.

Enjoy a tasting on the expansive back porch where you can sample their Sangiovese Rose or Cabernet Sauvignon. If you’re lucky, owners Ross and Valerie Prochnow will join you and talk about how they are continuing the legacy began by Ross’s father, World War II flying ace Colonel Marvin Prochnow.

As significant as the wine industry is, it is but one factor in the enduring charm of Fredericksburg, which was settled by a group of German immigrants in 1847. Their leader, Baron Otfried Hans von Meusebach, was successful in his negotiations with the Penataka branch of the Comanche Indians, a group not usually known for negotiating with anyone.

One of the original Sunday Houses built by the Germans in the 19th century. (Trish Rawls/Trish Rawls/TNS)

Von Meusebach persuaded the tribe with his offer to share the land peacefully. His monetary gift of $3,000 doubtless didn’t hurt either. The treaty between the German immigrants and the Comanches was one of the few in American history that was never broken.

A bronze sculpture “Lasting Friendship” showing von Meusebach and Comanche chief Santanna sharing a peace pipe is located in the town’s Marktplatz.

It’s not surprising that the rich farmland proved so desirable to the German settlers who found they could grow almost anything in the fertile soil watered by the nearby Pedernales and Guadalupe Rivers.

Today’s visitors get a sense of this abundance at places such as Wildseed Farms and Fischer & Wieser’s Das Peach House.

Wildseed is the nation’s largest working wildflower farm (of course it is, it’s Texas y’all) with more than 200 acres devoted to Texas wildflowers.

Wildseeds Farm is the largest wildflower farm in the United States. (Handout/Wildseed Farms/TNS)

In peak season (spring through autumn), the farm looks like a multicolored carpet spread across the landscape. To better appreciate the beauty of Texas favorites such as bluebonnets, Indian Paintbrush, poppies, black-eyed Susans and coneflowers, take a stroll on the half-mile walking trail through the gardens, butterfly garden and vineyards.

Yes, they do make wine, and you can enjoy a tasting here, or opt for a cold beer in their Brewbonnet Biergarten.

Das Peach Haus is a rustic farmhouse overlooking a serene pond and surrounded by a grove of pine trees that suits the casual vibe of the Texas Hill Country.

Das Peach Haus, a Hill Country staple for nearly a century. (Hnadout/Das Peach Haus/TNS)

However, the modest structure belies the eclectic nature of the business it houses, Fischer & Wieser Specialty Foods, Inc., a Hill Country staple since 1928.

Yes, there is a peach orchard, the fruits of which you can taste in their award-winning jams and jellies, but also light bites and bakery items, cooking classes and wine tastings, dinner under the pines and on occasion, live music.

Their most recent addition is the Dietz Distillery, from which comes their Five Judges Gin, a London-style gin whose Lone Star spin honors the quintet of judges who have called the property home over the past century.

Plan to spend a day just wandering the compact downtown (either on foot or on the trolley tour) to see the surprising number of specialty shops and boutiques, museums, architectural gems, restaurants and bars for a town its size.

If you are a history or World War II buff, you won’t want to miss the Smithsonian-affiliated National Museum of the Pacific War, located here to honor a local boy, Chester W. Nimitz, who became Commander-in-Chief of Allied Forces in the Pacific theater.

If you are interested in architecture, you’ll love the famous Sunday Houses, built by German settlers as weekend residences when they came to town for supplies and church services, and unique to the Hill Country. Some of the original houses are available for overnight stays, while others such as The Gathering, where I stayed, are reproductions of the originals (although those originals didn’t boast the private courtyard hot tub and fire pit that my accommodation did).

Foodies won’t be disappointed either, as Fredericksburg has a surprisingly robust dining scene. If it’s authentic German you crave, Otto’s is the place to go for both schnitzel and sauerkraut and German and Austrian wines.

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If you just can’t leave Texas without brisket and all the trimmings, there’s the smokehouse at the Albert Hotel, and for the health-conscious who still love a good meal, book a table at the Hill Country Herb Garden. Order a glass of Texas wine or a craft cocktail, and while your meal is being prepared take a stroll through the property’s beautiful botanical garden.

For country music lovers, while you’re in the area make like Waylon, Willie and the Boys and take the short drive to Luckenbach, Texas.

Founded in the mid-19th century, it had a revival a century later when local legend “Hondo” Crouch purchased the “blink and you’ll miss it” town to preserve it as a shrine to country music.

In addition to Waylon and Willie with their iconic song, Jerry Jeff Walker recorded his album “Viva Terlingua” here.

Today, Luckenbach’s population may be in single digits (three at latest count), but visitors from around the globe flock here to have a picture taken in front of the 1886 post office that doubles as a general store and bar (don’t forget to show your appreciation by dropping a bill in the armadillo tip jar), and to see the dance hall, and listen to country music performers pick and sing during daily jams.

With all of its attractions, Fredericksburg’s greatest charm may lie in the potent combination of German spirit and Texas heart.

©2025 Tribune Content Agency, LLC.

There are 49 books in front of me, stacked like colorful bricks in a wall. These are the 49 books I didn’t include in the Chicago Tribune’s 10 Best Books of 2025. If you’re curious about the recipe for this list, here’s how I do it: I read all year long, and when I finish a book and loved it — a comic book, a mystery, a history, essay collection, novel — I set it aside. As months roll on, the stack climbs, teeters. It lives inside a closet. Occasionally, I hear a collapse when the stack gets too tall.

By July, the rumbling begins.

Then, sometime in November, when I can no longer read another thing and the deadline for this list approaches, I drag it all out of the closet and intuitively separate out the books I haven’t been able to shake. When I have 10, I have a list. I wish it were more thoughtful. I do shift books in and out of the top 10 pile until I feel certain: My favorites. But basically, that’s the process.

Then, afterwards, I feel terrible.

The first week of January I recall thinking, of course Adam Ross’s “Playworld,” a disturbing novel about a child actor and a much older woman, will make the top 10 in December. Nope. Was there a lovelier physical book this year than “Syme’s Letter Writer,” an ode to correspondence by the New Yorker’s Rachel Syme? Not really, and yet, that didn’t make the final 10, either. Alexis Okeowo’s “Blessings and Disasters,” a portrait of Alabama, deserved more readers. Same goes for “The Autobiography of H. Lan Thao Lam,” Lana Lin’s communing with the spirit of Gertrude Stein, via Naperville. And same for Kevin Nguyen’s irreverent, prescient “My Documents,” which pictures the U.S. government putting Vietnamese-Americans in camps. And Virginia Feito’s delightfully cold “Victorian Psycho.” And Jeff Chang’s great Bruce Lee biography, “Water Mirror Echo.”

All of those and about 40 others should be in this top 10, too.

Still … what’s here? I’m jealous of anyone reading these for the first time. In no order:

“Clam Down: A Metamorphosis” by Anelise Chen. Technically a memoir, though so hilarious and original, it’s impossible to read as genre at all but rather, a novelistic tale of a writer weathering a divorce who opens a typo-ridden email from her mother, imploring her to “clam down.” Surrounded by social media, buried in research, Chen decides to embrace the metaphor: Should she retreat into a hard shell? Or open up and trudge on?

“Red Scare: Blacklists, McCarthyism and the Making of Modern America” by Clay Risen. I can’t quite put my finger on why, but the year was agog in echoing histories of hypocritical censorship and political bullying that eventually left the nation is a different place. A powerfully patient narrative account that goes beyond the familiar images of Congressional hearings and Joe McCarthy to the everyday fear-mongering that created a network of repression — and the everyday courage that, one day, toppled the hysteria.

“The Gossip Columnist’s Daughter” by Peter Orner. The best Chicago novel in ages. Rooted in Orner’s real background as a Highland Park native with family connections, a mesh of obsession, broken friendships and the nagging persistence of family legends, bundled into a true crime that was never solved: the murder of Karyn “Cookie” Kupcinet.

“A Guardian and a Thief” by Megha Majumdar. Two tales and a clock. A mother’s passport is stolen just before she gets her son and father escape to Ann Arbor. A pickpocket will do anything to feed his family. An instant classic, set against societal collapse and the wrenching calculations and contradictions families make to survive.

“Sick and Dirty: Hollywood’s Gay Golden Age and the Making of Modern Queerness” by Michael Koresky. An uncommonly fun and sophisticated dark cultural history that will drive you back to film. Did you know the Hollywood production codes (1934-1968) that buried gay life started with a meeting at Loyola University? Do you know how gay filmmakers carried on nevertheless, with clandestine cleverness? An absorbing landmark of film criticism at a moment when the practice itself is fading out.

“Lost in the Dark, and Other Excursions” by John Langan. Not a household name, but someday. Langan, the most bracingly classical of the new horror writers, is swinging for greatness here, with dense nail-biters that draw on the erudite, swirling language of Shelley and Lovecraft but lean back into the character-driven snap of Stephen King. An author tracks the extras on a horror DVD to a bleak history. Notes to a review of a Frankenstein novel lead to a vast darkness. An essay on horror lit grows very nasty. Langan, never far from the past, yet fond of experiments, reads like the future.

“Do Admit! The Mitford Sisters and Me” by Mimi Pond. A sprawling, virtuosic group-biography of the six infamous sisters who escaped their country estate, then tumbled through a 20th century of scandals, fascist friends and journalistic triumphs. Page after page, Pond, one of our great underrated cartoonists, finds original paths through history.

“A Marriage at Sea: A True Story of Love, Obsession and Shipwreck,” by Sophie Elmhirst. A word-of-mouth smash over the summer with good reason: What begins as survival tale — an economical, riveting account of a couple in 1972 whose boat is struck by a whale, then spend months alone in the open ocean, starving and despondent — heads to surprising depths once they are found, and are uncomfortable with dry land, the way their story gets told and their own feelings about what exactly survived the disaster.

“King of Ashes” by S.A. Cosby. Proof that crime fiction isn’t always a churn of brand-name antiheroes. And yet Cosby’s star continues upward, reminding us again that broad appeal and comfortable beats doesn’t mean empty writing. His latest may be inspired by “The Godfather” — a son returns to his family crematory business and ailing patriarch, only to face a power grab and the blowback of revenge — but it deposits you in seriously Shakespearean territory. Blissfully pulpy and mournfully tragic, all at once.

“Murderland: Crime and Bloodlust in the Time of Serial Killers,” by Caroline Fraser. You know the feeling you’d follow some writers anywhere? I felt it with Fraser in “Prairie Fires: The American Dreams of Laura Ingalls Wilder,” her 2018 Pulitzer winner. The grip only tightens here, dragging you into a scary, thrillingly reckless patchwork of correlation. The premise, that ecological pollution in the Pacific Northwest of the ‘60s and ‘70s bred a generation of neurologically-singed human monsters, likely is not airtight, and yet, a great writer can root you. Part true crime, part corporate screed, part coming-of-age memoir, part Rachel Carson, part victim memorial, Fraser constructs an enormous mood board dense with villains and propulsive detail, crossing, crisscrossing.

A masterpiece, and the best book I read all year.

cborrelli@chicagotribune.com

By MEGAN JANETSKY and JULIA FRANKEL, Associated Press

JERUSALEM (AP) — Israeli police forcibly entered the compound of the United Nations agency for Palestinian refugees in east Jerusalem early Monday, escalating a campaign against the organization that has been banned from operating on Israeli territory.

The U.N. Relief and Works Agency for Palestinian Refugees, or UNRWA, said in a statement that “sizable numbers” of Israeli forces, including police on motorcycles, trucks and forklifts, entered the compound in the Palestinian neighborhood of Sheikh Jarrah.

“The unauthorized and forceful entry by Israeli security forces is an unacceptable violation of UNRWA’s privileges and immunities as a U.N. agency,” the statement said.

Meanwhile, officials said President Donald Trump will meet with Israeli Prime Minister Benjamin Netanyahu on Dec. 29 as U.S. officials meet with Netanyahu to move ahead with a U.S.-brokered plan on the future of Gaza. It was not immediately clear where the leaders will meet.

Israel’s long campaign against UNRWA

The raid was the latest in Israel’s campaign against the agency, which provides aid and services to some 2.5 million Palestinian refugees in Gaza, the occupied West Bank and east Jerusalem, as well as 3 million more refugees in Syria, Jordan and Lebanon.

Photos taken by an Associated Press photographer show police erecting an Israeli flag on the compound, and police cars on the street. Photos provided by UNRWA staff show a group of Israeli police officers in the compound.

Police said in a statement they entered for a “debt-collection procedure” initiated by Jerusalem’s municipal government, which did not immediately respond to a request for comment.

The agency was established to help the estimated 700,000 Palestinians who fled or were driven out of what is now Israel during the 1948 war surrounding the creation of the Israeli state. UNRWA supporters say Israel hopes to erase the Palestinian refugee issue by dismantling the agency. Israel says the refugees should be permanently resettled outside its borders.

For months following the start of the Israel-Hamas war began on Oct. 7, 2023, UNRWA was the main lifeline for Gaza’s population during Israel’s offensive there.

Throughout the war, Israel has accused the agency of being infiltrated by Hamas, using its facilities and taking aid — claims for which it has provided little evidence. The U.N. has denied it. Israel also has claimed that hundreds of Palestinian fighters work for UNRWA. UNRWA has denied knowingly aiding armed groups and says it acts quickly to purge any suspected fighters.

After months of attacks from Netanyahu and his far-right allies, Israel banned it from operating on its territory in January. The U.S., formerly the largest donor to UNRWA, halted funding to the agency in early 2024.

UNRWA has since struggled to continue its work in Gaza, with other U.N. agencies, including the World Food Program and UNICEF, stepping in. Tamara Alrifai, UNRWA’s director of external relations and communications, said UNRWA has been excluded from ceasefire talks.

“If you squeeze UNRWA out, what other agency can fill that void?” Alrifai said.

US officials meet Netanyahu

Netanyahu met with the U.S. ambassador to the U.N., Mike Waltz, and other officials on Monday in a visit the Trump administration said was aimed at pushing forward the U.S.-drafted 20-point plan for Gaza that includes the current ceasefire and following stages.

Israel’s government later said Trump and Netanyahu would meet on Dec. 29 to “discuss the future steps and phases and the international stabilization force of the ceasefire plan.”

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With the remains of one hostage in Gaza yet to be handed over to Israel, Arab and Western officials have said they expect an international governing body in Gaza to be announced in the coming weeks. A search was underway on Monday for the hostage’s remains, Hamas said.

On Sunday, a senior Hamas official told the AP the group is ready to discuss “freezing or storing or laying down” its arsenal of weapons as part of the ceasefire, offering a possible formula to resolve one of the thorniest issues in the U.S.-brokered agreement.

The war started when Hamas-led fighters attacked southern Israel, leaving around 1,200 people dead and abducting 251 others.

Israel’s retaliatory offensive has killed at least 70,360 Palestinians, according to Gaza’s Health Ministry, which operates under the Hamas-run government. The ministry does not differentiate between civilians and combatants, but says nearly half the dead have been women and children. The ministry’s numbers are considered reliable by the U.N. and other international bodies.

The ministry also says over 370 Palestinians have been killed in Israeli strikes since the ceasefire took effect.

Violence has also risen in the Israeli-occupied West Bank, where Israel’s military shot and killed one man Sunday night. Officials said he was throwing rocks at soldiers with two others, one of whom was arrested. Palestinian health officials said the third man was wounded. The military said no soldiers were injured.

Palestinian authorities identified the man killed as a 19-year-old from the northern city of Qalqilya.

Construction of barrier along Israel-Jordan border

Israel began construction of a 50-mile (80-kilometer) barrier along its border with Jordan, Israel’s defense minister said Monday.

Israel Katz said the construction was aimed at preventing “efforts of Iran and its proxies to establish an eastern front against the state of Israel.”

The final project will include increased security along 310 miles (500 kilometers) of border areas in eastern Israel, and would cost the government around $1.7 billion, according to Israeli government figures.

Associated Press writer Josef Federman in Doha, Qatar, contributed to this report.