AI denial is now a reserve assumption.
Tokto gives the health-plan CFO one record that ties every AI denial, every clinical review, every ambient capture, and every PHI flow to a member, a plan, and an authorization, ready for ERISA, CMS, HIPAA, and state DOI obligations on the same evidence.
All three of the largest Medicare Advantage insurers are past motion to dismiss on AI denial. The CFO has to update the loss-reserve disclosure, answer the actuary on AI-related run-off exposure, and answer outside counsel on the per-member trail in the same quarter. The model file is in three different vendor systems.
- Every prompt tied to a member, a plan, a clinician, an authorization, and a denial code.
- A complete record for OIG, CMS, the state DOI, the ERISA plaintiff, the appellate panel, and the HIPAA auditor.
- Policy applied at the prompt: no AI denial without clinical review, no PHI to a vendor without contract.
- Defensibility under class certification, ERISA scrutiny, CIPA wiretap claim, and HIPAA audit at once.
- An AI denial reaches a 90-percent reversal-on-appeal pattern. Reserve disclosure has to be restated under class certification.
- An ambient clinical scribe captures patient audio without consent. CIPA, CMIA, and Federal Wiretap Act all open. D&O carrier reprices.
- A vendor with PHI access has no current BAA. HIPAA breach disclosure follows. Investor relations gets the call.
- A federal court orders algorithmic disclosure. The plan and its model vendor produce inconsistent answers. Outside auditor flags an internal-control finding.
Tokto governs the AI surface across the plan from the CFO's seat. Utilization-management co-pilots, ambient clinical scribes, prior-authorization triage, and vendor APIs flow through one record. Loss reserves, disclosure language, and CMS Medicare Advantage program-audit responses all read off the same trail.
When the District of Minnesota orders algorithmic disclosure, when ERISA appellate panels ask how a denial was reviewed, when a state AG opens a CIPA inquiry on an ambient scribe, the CFO answers reserves, disclosures, and program audits out of one query.