These entrepreneurs are using AI to combat medical insurance claim denials

Health insurers use AI to approve or deny claims. Now patients have access to AI-powered tools to fight back.

UnitedHealthcare, The company, which got here into the highlight after the assassination of its CEO Brian Thompson, has one in every of the very best claims denial rates and, in some cases, uses AI to disclaim patient care.

But business owners at the moment are using AI to fight back against these claim denials. Holden Karau, a software developer from the San Francisco Bay Area, recently released a free tool called “ FightHealthInsurance.com that uses AI to appeal rejections. You provide some basic details about your denial, your insurance plan, and your medical history, and the tool asks just a few additional questions after which offers three different pre-written appeals to pick from.

“I want to increase the number of appeals because I think there are too many rejections and it is important that we create a level playing field for AI,” Karau said. “People are being hurt by insurance companies’ use of AI.”

UnitedHealthcare’s insurance denials have sparked a national conversation since Thompson was fatally shot last week. On Monday, Luigi Mangione, a University of Pennsylvania graduate whose Reddit account reveals a history of back pain, was arrested and charged with murder.

“This has come into focus because of national events…” But the issue has been under the surface for a really very long time.”

Data from insurance research firm ValuePenguin showed that UnitedHealthcare’s claims rate was the very best of any major provider, with a few third of claims denied. (ValuePenguin posted on its website that an insurer contacted the corporate on Dec. 5, the day after the shooting, to dispute the denial rate. However, ValuePenguin researchers didn’t update the denial numbers.)

The company faces several lawsuits over its denials. Last November, the estates of two deceased Medicare Advantage patients were recorded sued UHC claimed that their claims for care were rejected using an AI model with a “90% error rate.” (UnitedHealth had argued that the lawsuit needs to be dismissed since the patients haven’t accomplished their appeals.) In October 2024, the Senate Investigations Subcommittee decided published a report The company found that the corporate used algorithms to disclaim claims and “knew from testing that at least one of these automation technologies resulted in an increase in the percentage of denied claims.”

“This has come into focus because of national events…” But the issue has been under the surface for a really very long time,” said Warris Bokhari, co-founder and CEO of Claimable, a startup that uses AI tools to combat denials. Launched in October, Claimable initially focused on helping rheumatology patients whose expensive medications generally is a red flag to insurers, and has since expanded to incorporate migraines and the childhood brain disorders generally known as PANS and PANDAS, which cause sudden onset result in psychiatric symptoms. Claimable, which charges consumers a flat fee of $39.95, hopes so as to add greater than 100 terms in 2025.

Bokhari, a senior physician who worked at Amazon, Apple and Anthem (now Elevance Health), founded the corporate after realizing that giant language models like GPT-4 might be used to supply details about a patient’s medical history and treatment guidelines analyze Create a compelling story for an insurer to approve payment.

HealthCare.gov According to a, issuers rejected a complete of 17% of claims in 2021 2023 report from the health researcher KFF based on data published by the federal Centers for Medicare and Medicaid Services. Yet most patients never appeal. The same KFF study also found this HealthCare.gov Consumers appealed lower than 0.2% of denied in-network claims.

“What happens to the remaining claims? They remain unchallenged. Therefore, patients end up leaving care,” Bokhari said.

Claimable has filed a whole lot of lawsuits to this point, with a hit rate of greater than 85%, he said. “Insurers are using AI to fight faster and faster, and patients have no voice,” he explained. Appeal is the very best method to ensure an individual, not software, is reviewing your claim, he said, calling it the industry’s “dirty little secret.”

“We’re not going to fix health insurance with AI, but I think we can make it more accessible with AI.”

Claimable’s Bokhari said he hopes there can be regulatory changes to assist patients struggling to get coverage for needed treatments, but he fears denials will increase as the brand new Trump administration tries to to cut back costs. “I think denials are going to increase,” he said. “I think it will be bad for Medicare and I worry it will be bad for veterans depending on what they do with the VA.”

Karau, who’s transgender, said her project grew out of private experiences struggling to get insurance coverage for each gender-affirming surgery and physical therapy after she was hit by a automobile in 2019. “I literally couldn’t walk,” she said. “There were a lot of arguments about my physical therapy.”

This experience led her to advocate for friends after which found the FightHealthInsurance.com Tool. “This will help insurance companies stay honest,” she said, adding, “We’re not going to fix health insurance with AI, but I think we can make it more accessible with AI.”

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