AI versus AI: The emerging arms race over health insurance denials

[Greenbeard]

Interesting look at a project from a software engineer who got fed up after having to fight UnitedHealthcare for physical therapy after getting hit by a car. As insurers experiment with using AI to make authorization decisions--including denials--startups like hers are looking at ways to balance the scales, using AI to appeal denials. It's a brave new world.

AI versus AI: The emerging arms race over health insurance denials

Karau’s company, FightHealthInsurance.com, is one of many upstart businesses seeking to harness the power of artificial intelligence to combat denials by health insurers that block access to medical services.

“There’s a lot of technology on the insurance side to automate denials,” Karau said. “I think it’s time to build the tools for patients and providers.”

Her company, and its companions in the market, are just getting off the ground. But they promise to help automate appeals for providers and patients, making it much faster and easier to contest denials that often go unchallenged. Evidence shows that tens of millions of denials issued annually by private health insurers are infrequently appealed by patients, even though the appeals are often successful. Both the extent of denials — and patients’ success at getting them overturned — vary by coverage type and insurer, but the difficulty of fighting back has created a widespread feeling of disempowerment, experts said.

In recent years, insurers have increased the use of algorithms and predictive software in the process of making coverage decisions. An investigative series by STAT found that UnitedHealth Group pressured its employees to follow the conclusions of an algorithm called nH Predict to cut off payment for the care of desperately ill older Americans with Medicare Advantage coverage. A subsequent U.S. Senate inquiry found the company’s denial rate for rehabilitative care jumped dramatically following adoption of the algorithm, reaching nearly 23 percent in 2022. The Senate report found that Humana and CVS/Aetna also relied heavily on algorithmic tools in issuing denials. Cigna has faced scrutiny over similar practices.

Meanwhile, advances in AI technology have created an opportunity to help patients push back.

A large handful of start-ups launched in the past couple of years are using generative AI and other forms of the technology to analyze clinical data and coverage requirements, and help draft appeal letters for doctors and patients. Nine companies have raised about $36 million from investors in recent years, according to Rock Health, which tracks investments in digital health companies. That is not a huge haul in the context of the billions of dollars raised by companies developing AI tools for use in health care. But it is becoming an increasingly active area of innovation, as providers and patients seek relief from denials and constant demands for more paperwork from insurers. The rise of these companies raises the spectre of an AI arms race between parties on opposites of health care transactions, with both sides relying on an imperfect and ever-changing technology to advocate for their positions.

 

[dmpi]

AI generated or human written, it's just a letter with a rationale. Matter of fact it's better if their approval policy is codified in software because then it will be uniformly applied and it won't be someone's judgement or discretion.