AI denial risk is now a number the board risk committee asks for.
Tokto gives the health plan's risk and compliance officer one record that ties every AI denial, every clinical review, and every PHI flow to a member, a plan, and an authorization, ready for CMS, OCR, the state DOI, the audit committee, and the board risk committee.
A federal court orders disclosure of the AI tool behind post-acute denials. CMS asks about the program-audit posture. The board risk committee asks the CRO for the AI denial reversal rate and the control that requires clinical review. The risk function has a model inventory and a RAG status, but no per-member record of whether a human ever reviewed a denial.
What you get with Tokto
- Every AI denial scored and recorded against a member, a plan, a clinician, an authorization, and a denial code.
- A single evidence layer that CMS, OCR, the state DOI, the HIPAA auditor, and the board risk committee read against the same record.
- Policy enforced at the prompt: no AI denial without clinical review, no PHI to a vendor without a contract.
- AI risk that is measured by reversal rate, controlled at the prompt, and attestable to the board.
How it works
Tokto turns AI utilization management into a measured, controlled risk. Every UM co-pilot, every ambient scribe, every prior-auth triage model becomes a scored record at the moment of output, tied to the member, the plan, the clinician, and the review that did or did not happen. The risk function can finally put a number on AI denial exposure.
When a court orders algorithmic disclosure, when CMS runs a program audit, when the board risk committee asks whether AI denials are within appetite, the answer is one query against the system of record. The CRO reports AI denial risk the way every other reserve-driving risk is reported.
What goes wrong without it
- AI denial risk is never quantified. The first number is a 90 percent reversal rate in a class certification.
- An ambient scribe records patients without consent. The control gap opens CIPA exposure.
- A vendor with PHI access has no current BAA. The risk register never flagged the lapse.
- The board risk committee asks if AI denials are within appetite. The CRO has a heat map, not a record.
In March 2026, a federal judge in the District of Minnesota ordered UnitedHealth to disclose internal documents and source materials behind nH Predict, the AI tool used to manage Medicare Advantage post-acute care claims. Plaintiffs in the related Estate of Lokken class action cite a 90 percent reversal rate on appealed denials, with only 0.2 percent of patients ever appealing. The Lokken class was certified in February 2025.
See how Tokto makes enterprise AI visible, governed, and accountable for Regulatory / Risk in Healthcare.
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