A Silicon Valley software engineer is leveraging her technological expertise to help patients use AI to fight back against health insurance claim denials — some of which may have been driven by AI themselves.
Holden Karau built FightHealthInsurance.com, a free website that helps patients draft appeals for denied insurance claims, following her own experiences dealing with claim denials.
“I would say experiencing the American health care system as a trans person, you get to experience a lot of health insurance denials,” Karau told Quartz, adding that she also suffered injuries when she was struck by a car. “That gave me a motivation to think about this problem.”
Karau, originally from Canada, has working with data and machine learning at some of the world’s biggest tech companies — including Amazon (AMZN+0.01%), Google (GOOGL-0.79%), Apple (AAPL+0.20%), and Netflix (NFLX-0.48%) — for over 10 years. During a conversation with a colleague, she came up with the idea of using the tools she works with every day “to make access to healthcare better.”
Although Karau says she loves paperwork, she’s seen how it can been used to deny people care, which inspired her to use generative AI to make appealing denials easier for patients.
The platform has been gaining increased attention in recent weeks after the fatal shooting of UnitedHealthcare (UNH+2.00%) CEO Brian Thompson in December put a renewed spotlight on health insurers and their business practices. Public scrutiny has especially been focused on the companies’ alleged use of AI in evaluating claims.
Karau hopes her website can level the playing field. She highlights that insurers have a major advantage over patients — and even doctors — because they have access to vast amounts of data, which allows them to harness powerful AI tools.
“Imagine that you’re going up against someone that’s allowed to use computers, and you’re only allowed to use typewriters,” Karau said. “Of course, the person who has computers is going to be able to just bury you in paperwork.”
Recent lawsuits and government reports have shed some light on the ways health insurers are using AI to evaluate claims.
In October, a report from the U.S. Senate Permanent Subcommittee on Investigations showed that the nation’s insurers have been using AI-powered tools to deny some claims from Medicare Advantage plan subscribers.
The report found that UnitedHealthcare’s denial rate for post-acute care — health care needed to transition people out of hospitals and back into their homes — for people with Medicare Advantage plans rose to 22.7% in 2022, from 10.9% in 2020.
The rise coincided with UnitedHealthcare’s implementation of an AI model called nH Predict, originally developed by naviHealth, a subsidiary of UnitedHealth Group that has since rebranded.
Algorithms like nH Predict can analyze millions of data points to generate predictions and recommendations by comparing patients to others with apparently similar characteristics, according to a study published last year. However, the study cautions that claims of enhanced accuracy through advanced computational methods are often exaggerated.
Both UnitedHealth and Humana are currently facing lawsuits over their use of nH Predict. The suits allege that insurers pressured case managers to follow the algorithm’s length-of-stay recommendations, even when clinicians and families objected. One lawsuit filed last year against UnitedHealth claims that 90% of the algorithm’s recommendations are reversed on appeal.
Fight Health Insurance was designed to simplify the process of appealing claim denials.
Users can visit the platform and upload their insurance denial. Once the denial is processed, the system analyzes the information and identifies the procedure that was denied and the reason given by the insurance company, asking users to confirm or correct any errors.
After verifying various details, users can also upload supporting documents like health records or insurance plan documents, though the system can operate without them. Once the process is complete, the platform generates multiple appeal drafts, allowing users to select the one that best fits their needs and make additional edits if needed.
Appeals can then be printed and mailed by the user or faxed directly through the platform for a $5 fee, a feature introduced in response to feedback from users lacking access to printers or fax machines. Karau also has plans to develop a future version tailored for doctors and other medical professionals.
Karau says she’s heard from many patients who have been able to use the platform successfully. “Most recently, I remember a woman who rides motorcycles. She was able to get her back surgery approved after it was initially denied, and she’ll probably be able to start riding again later this year,” Karau said.
Karau hopes that ventures like hers can bring about improvements in the U.S. healthcare system. She said she believes meaningful change is possible if health insurance companies face real consequences for unjustifiably denying patient care.
“I think that there could be some significant changes if we can make it more expensive for them to deny care,” Karau said. “One of the ways is appealing these denials.”
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