Meet the entrepreneurs using AI to fight health insurance claim denials

The intersection of artificial intelligence and healthcare insurance has created a new battleground where patients are leveraging AI tools to challenge insurance claim denials.

Current landscape: UnitedHealthcare’s high denial rates and the tragic murder of its CEO have brought renewed attention to the issue of AI-driven insurance claim denials.

• Data from ValuePenguin indicates UnitedHealthcare has the highest claim denial rate among major providers, rejecting approximately one-third of claims
• The company faces multiple lawsuits, including one alleging their AI model had a “90% error rate” in Medicare Advantage claim denials
• A Senate Subcommittee investigation revealed the company knowingly used algorithms that increased denial rates

Emerging solutions: New AI-powered tools are being developed to help patients fight back against automated claim denials.

• FightHealthInsurance.com, created by software engineer Holden Karau, offers free AI-generated appeals based on user-provided information about denials and medical history
• Claimable, a startup launched in October, charges $39.95 to help patients challenge denials using advanced language models like GPT-4
• These tools analyze patient health histories and treatment guidelines to create compelling appeals for insurers

Market dynamics: The scale of insurance claim denials reveals a significant gap between rejections and patient appeals.

• HealthCare.gov insurers denied 17% of claims in 2021, according to KFF research
• Less than 0.2% of denied in-network claims are appealed by patients
• Claimable reports an 85% success rate in challenging denied claims

Expert insights: Healthcare industry veterans are highlighting systemic issues in the claims process.

• Warris Bokhari, Claimable’s CEO and former executive at major healthcare companies, describes appeals as the best way to ensure human review of claims
• Industry insiders note that automated denials often go unchallenged, leading patients to abandon necessary care
• Experts suggest that regulatory changes could help address the imbalance, though some worry that cost-cutting measures might increase denial rates

Looking ahead: While AI tools offer promise for patients fighting claim denials, the healthcare insurance landscape remains complex and challenging for consumers.

• Claimable plans to expand its coverage to over 100 medical conditions in 2025
• The balance between cost management and patient care continues to be a critical industry issue
• The development of AI tools for patients may help level the playing field, though broader systemic changes may be necessary for lasting improvement

Future implications: The emergence of AI tools to challenge insurance denials represents a significant shift in patient advocacy, though questions remain about the long-term impact on healthcare access and insurance industry practices. The success of these tools could prompt insurers to reassess their automated denial systems, potentially leading to more balanced claim evaluation processes.