The biosimilar did not work well for him. His symptoms worsened, he had urgent and unpredictable bowel movements, and he got kidney stones twice, ending up in the hospital, he says. His doctor’s office appealed the coverage denial after his bad side effects, he says, but the company upheld it and he could not get the medication he wanted.
Whitehead found Warris Bokhari, the founder of Claimable, an AI tool that helps people appeal insurance denials for medication and other treatments. Claimable drafted a letter for him and told him to send it to. With his input, Claimable outlined his experience with the biosimilar drug, detailed how he’d missed work because of his symptoms, and cited federal statutes that, the AI argued, meant that his insurer had to cover this “medically necessary drug.”
Health insurers are increasingly using AI to evaluate requests for coverage of drugs and medical procedures. But patients, too, are using AI to fight back against denials. Services like Claimable, Fight Health Insurance, Mediloop, and Billyze help people understand their medical bills and push back against what could be improper billing or wrongful denials.
People often don’t appeal insurance denials for several reasons; it can be intimidating to know what paperwork to file, and the bills can start to pile up, says Sara R. Collins, a senior scholar at the Commonwealth Fund and one of the authors of the report. In the survey, some people who appealed their denial said that their provider had threatened to send their overdue bills to collections while they awaited word from their insurer.
Often, patients feel helpless when they receive a medical bill or prior authorization denial, says Collins. They don’t know who to contact or what to do. Though their provider can sometimes help with next steps, that isn’t always the case. AI tools have emerged to offer guidance, usually for a fee.
“I realized that if you could invert and and actually give patients the ability to argue articulately against the insurer, you might actually change someone’s life,” says Bokhari, the CEO and co-founder of Claimable.
“That’s when the models got good enough that it was like, yeah, we can actually do this, let’s make it available for people to use,” she says.
For instance, if an insurance company said that a patient needs to get an X-ray before they get an MRI, and a regulator in California overturned that decision, the AI model could use the language the state regulator used to overturn that denial in its appeal letter.
Bokhari says he hopes that someday, his AI tool won’t need to exist. If it starts getting more expensive for insurers to deny care than to just pay for it, maybe they’ll approve more claims, he says.
Similarly, Warrick says that she wishes that Fight Health Insurance weren’t needed. “We would prefer that this went down a path where nobody used it anymore,” she says, “because health care was no longer so hard to actually access.”
He’d tried to make that case on his own to his insurer, unsuccessfully. He’d needed AI to persuade them instead.
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