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As states continue to curb health insurers\u2019 use of artificial intelligence, patients and doctors are arming themselves with AI tools to fight claims denials, prior authorizations and soaring medical bills. (Photo by Anna Claire Vollers\/Stateline)<\/p>\n
As states strive to curb health insurers\u2019 use of artificial intelligence, patients and doctors are arming themselves with AI tools to fight claims denials, prior authorizations and soaring medical bills.<\/p>\n
Several businesses and nonprofits have launched AI-powered tools to help patients get their insurance claims paid and navigate byzantine medical bills, creating a robotic tug-of-war over who gets care and who foots the bill for it.<\/p>\n
Sheer Health, a three-year-old company that helps patients and providers navigate health insurance and billing, now has an app that allows consumers to connect their health insurance account, upload medical bills and claims, and ask questions about deductibles, copays and covered benefits.<\/p>\n
\u201cYou would think there would be some sort of technology that could explain in real English why I\u2019m getting a bill for $1,500,\u201d said cofounder Jeff Witten. The program uses both AI and humans to provide the answers for free, he said. Patients who want extra support in challenging a denied claim or dealing with out-of-network reimbursements can pay Sheer Health to handle those for them.<\/p>\n
In North Carolina, the nonprofit Counterforce Health<\/a> designed an AI assistant to help patients appeal their denied health insurance claims and fight large medical bills. The free service uses AI models to analyze a patient\u2019s denial letter, then look through the patient\u2019s policy and outside medical research to draft a customized appeal letter.<\/p>\n Other consumer-focused services use AI to catch billing errors<\/a> or parse medical jargon<\/a>. Some patients are even turning to AI chatbots like Grok<\/a> for help.<\/p>\n A quarter of adults under age 30 said they used an AI chatbot at least once a month for health information or advice, according to a poll<\/a> the health care research nonprofit KFF published in August 2024. But most adults<\/a> said they were not confident that the health information is accurate.<\/p>\n State legislators on both sides of the aisle, meanwhile, are scrambling to keep pace, passing new regulations that govern how insurers, physicians and others use AI in health care. Already this year, more than a dozen states<\/a> have passed laws regulating AI in health care, according to Manatt, a consulting firm.<\/p>\n \u201cIt doesn\u2019t feel like a satisfying outcome to just have two robots argue back and forth over whether a patient should access a particular type of care,\u201d said Carmel Shachar, assistant clinical professor of law and the faculty director of the Health Law and Policy Clinic at Harvard Law School.<\/p>\n \u201cWe don\u2019t want to get on an AI-enabled treadmill that just speeds up.\u201d<\/p>\n <\/strong><\/p>\n \t<\/p>\n Health care can feel like a black box. If your doctor says you need surgery, for example, the cost depends on a dizzying number of factors, including your health insurance provider, your specific health plan, its copayment requirements, your deductible, where you live, the facility where the surgery will be performed, whether that facility and your doctor are in-network and your specific diagnosis.<\/p>\n Some insurers may require prior authorization before a surgery is approved. That can entail extensive medical documentation. After a surgery, the resulting bill<\/a> can be difficult to parse.<\/p>\n Witten, of Sheer Health, said his company has seen thousands of instances of patients whose doctors recommend a certain procedure, like surgery, and then a few days before the surgery the patient learns insurance didn\u2019t approve it.<\/p>\n You would think there would be some sort of technology that could explain in real English why I\u2019m getting a bill for $1,500.<\/p>\n<\/div>\n \u2013 Sheer Health co-founder Jeff Witten <\/b><\/p>\n<\/div>\n<\/div>\n In recent years, as more health insurance companies have turned to AI<\/a> to automate claims processing and prior authorizations, the share of denied claims has risen. This year, 41% of physicians and other providers said their claims are denied more than 10% of the time, up from 30% of providers who said that three years ago, according to a September report<\/a> from credit reporting company Experian.<\/p>\n Insurers on Affordable Care Act marketplaces denied nearly 1 in 5 in-network claims<\/a> in 2023, up from 17% in 2021<\/a>, and more than a third of out-of-network claims, according to the most recently available data from KFF.<\/p>\n Insurance giant UnitedHealth Group has come under fire in the media<\/a> and from federal<\/a> lawmakers for using algorithms to systematically deny care to seniors, while Humana<\/a> and other insurers face lawsuits<\/a> and regulatory investigations<\/a> that allege they\u2019ve used sophisticated algorithms to block or deny coverage for medical procedures.<\/p>\n Insurers say AI tools can improve efficiency and reduce costs by automating tasks that can involve analyzing vast amounts of data. And companies say they\u2019re monitoring their AI to identify potential problems. A UnitedHealth representative pointed Stateline to the company\u2019s AI Review Board, a team of clinicians, scientists and other experts that reviews its AI models for accuracy and fairness.<\/p>\n \u201cHealth plans are committed to responsibly using artificial intelligence to create a more seamless, real-time customer experience and to make claims management faster and more effective for patients and providers,\u201d a spokesperson for America\u2019s Health Insurance Plans, the national trade group representing health insurers, told Stateline.<\/p>\n But states are stepping up oversight.<\/p>\n Arizona<\/a>, Maryland<\/a>, Nebraska<\/a> and Texas<\/a>, for example, have banned insurance companies from using AI as the sole decisionmaker in prior authorization or medical necessity denials.<\/p>\n Dr. Arvind Venkat is an emergency room physician in the Pittsburgh area. He\u2019s also a Democratic Pennsylvania state representative and the lead sponsor of a bipartisan bill<\/a> to regulate the use of AI in health care.<\/p>\n He\u2019s seen new technologies reshape health care during his 25 years in medicine, but AI feels wholly different, he said. It\u2019s an \u201cactive player\u201d in people\u2019s care in a way that other technologies haven\u2019t been.<\/p>\n \u201cIf we\u2019re able to harness this technology to improve the delivery and efficiency of clinical care, that is a huge win,\u201d said Venkat. But he\u2019s worried about AI use without guardrails.<\/p>\n His legislation would force insurers and health care providers in Pennsylvania to be more transparent about how they use AI; require a human to make the final decision any time AI is used; and mandate that they show evidence of minimizing bias in their use of AI.<\/p>\n \u201cIn health care, where it\u2019s so personal and the stakes are so high, we need to make sure we\u2019re mandating in every patient\u2019s case that we\u2019re applying artificial intelligence in a way that looks at the individual patient,\u201d Venkat said.<\/p>\n <\/strong><\/p>\n \t<\/p>\n Historically, consumers rarely challenge denied claims: A KFF analysis found fewer than 1% of health coverage denials are appealed. And even when they are, patients lose more than half of those appeals<\/a>.<\/p>\n New consumer-focused AI tools could shift that dynamic by making appeals easier to file and the process easier to understand. But there are limits; without human oversight, experts say, the AI is vulnerable to mistakes.<\/p>\n \u201cIt can be difficult for a layperson to understand when AI is doing good work and when it is hallucinating or giving something that isn\u2019t quite accurate,\u201d said Shachar, of Harvard Law School.<\/p>\n For example, an AI tool might draft an appeals letter that a patient thinks looks impressive. But because most patients aren\u2019t medical experts, they may not recognize if the AI misstates medical information, derailing an appeal, she said.<\/p>\n \u201cThe challenge is, if the patient is the one driving the process, are they going to be able to properly supervise the AI?\u201d she said.<\/p>\n Earlier this year, Mathew Evins learned just 48 hours before his scheduled back surgery that his insurer wouldn\u2019t cover it. Evins, a 68-year-old public relations executive who lives in Florida, worked with his physician to appeal, but got nowhere. He used an AI chatbot to draft a letter to his insurer, but that failed, too.<\/p>\n On his son\u2019s recommendation, Evins turned to Sheer Health. He said Sheer identified a coding error in his medical records and handled communications with his insurer. The surgery was approved about three weeks later.<\/p>\n \u201cIt\u2019s unfortunate that the public health system is so broken that it needs a third party to intervene on the patient\u2019s behalf,\u201d Evins told Stateline. But he\u2019s grateful the technology made it possible to get life-changing surgery.<\/p>\n \u201cAI in and of itself isn\u2019t an answer,\u201d he said. \u201cAI, when used by a professional that understands the issues and ramifications of a particular problem, that\u2019s a different story. Then you\u2019ve got an effective tool.\u201d<\/p>\n Most experts and lawmakers agree a human is needed to keep the robots in check.<\/p>\n AI has made it possible for insurance companies to rapidly assess cases and make decisions about whether to authorize surgeries or cover certain medical care. But that ability to make lightning-fast determinations should be tempered with a human, Venkat said.<\/p>\n \u201cIt\u2019s why we need government regulation and why we need to make sure we mandate an individualized assessment with a human decisionmaker.\u201d<\/p>\n Witten said there are situations in which AI works well, such as when it sifts through an insurance policy \u2014 which is essentially a contract between the company and the consumer \u2014 and connects the dots between the policy\u2019s coverage and a corresponding insurance claim.<\/p>\n But, he said, \u201cthere are complicated cases out there AI just can\u2019t resolve.\u201d That\u2019s when a human is needed to review.<\/p>\n \u201cI think there\u2019s a huge opportunity for AI to improve the patient experience and overall provider experience,\u201d Witten said. \u201cWhere I worry is when you have insurance companies or other players using AI to completely replace customer support and human interaction.\u201d<\/p>\n Furthermore, a growing body of research has found AI can reinforce bias that\u2019s found elsewhere in medicine, discriminating against<\/a> women, ethnic and racial minorities, and those with public insurance.<\/p>\n \u201cThe conclusions from artificial intelligence can reinforce discriminatory patterns and violate privacy in ways that we have already legislated against,\u201d Venkat said.<\/p>\n Stateline reporter Anna Claire Vollers can be reached at <\/em>avollers@stateline.org<\/em><\/a>.<\/em><\/p>\nA black box<\/h4>\n
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