AI Arms Race: Patients Deploy Artificial Intelligence to Combat Insurance Claim Denials
The use of artificial intelligence by health insurance companies to automate claim processing, including denials, has sparked a growing controversy, culminating in public outrage following the tragic death of UnitedHealthcare CEO Brian Thompson. While the circumstances surrounding Thompson’s murder remain under investigation, the incident has cast a harsh spotlight on UnitedHealthcare’s high claim denial rates, allegedly fueled by AI-driven processes. This has, in turn, spurred the development of AI-powered tools designed to help patients fight back against what many perceive as unfair and opaque denial practices.
UnitedHealthcare, already facing multiple lawsuits over its claim denial practices, has come under intense scrutiny. Data from ValuePenguin suggests the company boasts the highest claim denial rate amongst major providers, rejecting roughly one-third of all claims. While the company has contested these figures, the public outcry and ongoing legal battles paint a picture of an industry grappling with the ethical and practical implications of AI in healthcare decisions. Lawsuits allege that UnitedHealthcare used AI models with high error rates to deny care, even leading to patient deaths in some cases. A Senate subcommittee report further revealed that the company knowingly used algorithms that increased denial rates.
Amidst this controversy, innovative entrepreneurs are leveraging AI’s power not to deny claims, but to challenge denials. Holden Karau, a software engineer, developed FightHealthInsurance.com, a free tool utilizing AI to generate appeal letters for patients. By inputting basic information about the denial, insurance plan, and medical history, patients can access pre-written appeals tailored to their specific situations. Karau’s motivation stems from a belief that insurance companies are leveraging AI to their advantage, leaving patients at a disadvantage. FightHealthInsurance.com aims to level the playing field, empowering patients to fight back against what she perceives as unjust denials.
Another notable player in this emerging field is Claimable, a startup founded by physician-executive Warris Bokhari. Claimable utilizes advanced language models like GPT-4 to analyze patient data and generate comprehensive appeals, focusing initially on complex conditions like rheumatology and migraines, where expensive medications often trigger denials. Bokhari, who has a background with major companies like Amazon, Apple, and Anthem (now Elevance Health), argues that AI’s ability to process vast amounts of medical information and treatment guidelines creates compelling arguments for insurers to reconsider denials. Claimable boasts a high success rate, exceeding 85%, demonstrating the potential of AI-driven appeals to overturn initial denials.
The underlying issue exacerbating this conflict is the startlingly low rate of patient appeals. A KFF report revealed that only a minuscule fraction of denied in-network claims are appealed, suggesting that many patients simply abandon seeking necessary care. This highlights the critical need for tools like FightHealthInsurance.com and Claimable, which empower patients to navigate the complex appeals process. These tools not only automate the often daunting task of writing appeals but also provide access to information and resources that can increase the likelihood of a successful outcome.
Looking ahead, concerns loom about the potential for increased claim denials, particularly in light of anticipated cost-cutting measures under the incoming Trump administration. Bokhari anticipates that denials will rise, potentially impacting Medicare and veterans’ healthcare. He advocates for regulatory changes to protect patients and ensure access to essential treatments. Karau, driven by personal experiences with insurance denials, believes AI can play a crucial role in improving accessibility within the healthcare system. While both acknowledge that AI alone cannot solve the complex issues plaguing the healthcare insurance landscape, they are optimistic about its potential to empower patients and hold insurance companies accountable. This nascent “AI arms race” underscores the growing influence of artificial intelligence in healthcare and the urgent need for ethical guidelines and regulations to ensure equitable access to care.
