Make your health insurance company cry: One woman's fight to turn the tables

The application form is a site to behold:

https://fighthealthinsurance.com/scan

Specifically laying out what and how everything is stored. Hahah. Probably overwhelming to a non-dev, but Kudos either way!

The subheading of the article is "Using AI to fight insurance claim denials", and her site is here: https://fighthealthinsurance.com/

This is such a great example of the kind of disruptive impact we can expect from LLMs.

It exposes part of how the health insurance industry works:

"Out of roughly 40 denials, she won more than 90% of her appeals, she estimates"

Most people don't have the stamina to dig in when this happens, so my guess is the entire insurance industry is designed around the assumption that a lot of valid claims won't be paid out.

It's obviously disgusting that the industry has incorrect denials baked into their business model.

If we fix that with LLMs, what happens? It's going to have knock-on effects, since it could eliminate the profit margin these companies have right now.

Wow! Amazing job! I briefly met Holden at Kubecon. What an incredible engineer.

I see what's going on here. It's another example of externalization of costs. Doctors have no incentive to fight the denial of insurance. They should, but it's not important yet. If they have to sue you eventually for the billed cost, they will; or at least they'll sell the debt to a collection agency at some number of cents on the dollar. The Insurance company most definitely doesn't have an incentive. Once you're denied, they're off the hook. They kick it back to the provider, and ultimately to you through some debt collection agency. The only person that has an incentive is you. And now you're stuck with the cost; either in dollars or time, but what's the difference really? It's going to cost you either way. Maybe Holden Karau's approach is good and valid, but should it be converted to a paying service we're just back at square one where it's either time or money. Maybe there'll be a discount which makes it cheaper net/net, but who knows? The little person here is the patient. All the others, doctors and insurers, are the big persons. The little person absorbs the cost, whether they want to or not.

Single payer or not but I think everybody should agree that dealing with health insurance needs to be easier and more predictable. When I read the stories of how people won against them, it's always mind boggling to see the giant effort they had to put into it.

Hospitals and insurances should be fined if they have a high ratio of claims that get rejected first and reversed after appeal. Patients simply shouldn't have to go through this. The whole system is set up to profit from wearing down patients by attrition.

The insurance companies are already using AI to generate denials, might as well use it to appeal them too.

Kudos to her for making this open source and free to users!

The problem with fighting claims is that it's an asymmetric game. You, the patient, must MAKE time outside of your regular life, to argue on the phone with someone who is currently AT his full time job, and who feeds his family with YOUR premiums. It's a dirty game.

Disputing charges, small claims court or simply never paying bills is the better option because the good faith channels are rigged.

There are a large number of other industries where SOP is to make life difficult for customers in hopes that they give up on asserting their legal rights. Among other ones I can think of: insurance, debt collection, customer service disputes, privacy opt-outs, warranty work, property management, labor law.

It seems like these industries are ripe for AI-based startups whose job is basically to be an asshole to corporations on behalf of customers, the same way that corporations are assholes back. If anything, at least consumers will be able to say "Have your AIs talk to my AI."

Health insurance is such a weird thing. It shouldn't exist. You insure yourself against exceptional things. Yet we use insurance for our yearly flu-shot, hardly exceptional.

And insurance doesn't want to pay out, that is their business, which actually goes against the whole idea of healthcare. You need to spend money now to prevent higher cost later.

(on the other hand, car insurance weirdly doesn't penalize you for buying cheap tires, even though the difference between 4 cheap tires and 4 Michelin tires is less than the cost of a deductible for you when miss out on those 10 ft of breaking distance).

I'm about to switch healthcare plans and I'm already mentally preparing (i.e. stressing out) to file appeals for some medications I need that they will deny-by-default.

i'd love to fight my insurance, but it's so unnecessarily confusing.

instead of describing the process in plain language, everything is wrapped in so many layers of legalese that even the 'happy path' becomes impentrable.

i particularly hate the 'EOB' which they tell you 'this isn't a bill' but then they make it look as much like a bill as possible and don't really tell you what its for other than to show off that insurance is... around

I think the real answer here is to have bad behavior cost rather than trying to legislate it.

A company owes you something and doesn't promptly pay. If you prevail in the end and the original problem wasn't on your end what they owe gets a multiplier and then a high interest rate.

Several years ago I got totaled. The woman came up with a few bits of nonsense that clearly didn't match up with reality but the woman from the insurance company saw right through that and knew there was no possible way I contributed to it. Then they ghosted me until I filed a complaint with the insurance regulator.

Make that say 50% or 100% higher, then maybe a couple percent of interest from the date that they should have paid. This would make such tactics not in their interest because failure doesn't mean just doing what they should have anyway.

Health insurance and this anti health insurance product reminds me of the “time share” industry and time share exit companies. However, unlike the exit companies. This is actually useful.

Hope it ends up working out, and makes it sustainable. Although one thing about insurance companies is that they have made the rules of this game.

Some sources indicate there is some legal requirement or right granted to patients for these internal reviews. But I can’t find the exact law.

If this service takes off, I wouldn’t be surprised if the language of this law changes over the years to make it more difficult to file patient appeals (or make it outright impossible).

I fully expect a disruptive startup to leverage large context LLMs to offer a service which understands policies and automatically (as much as possible) appeals any and all insurance company shenanigans with all means available. (Need a large context window to get all the legal and policy texts into there.)

Also, not living in US, I wouldn't be surprised to learn that:

- any attempts to implement this will be met with weapons-grade lobbying on all levels to make it illegal

- it was attempted and litigated to hell and back and hence forced to shut down

- this business model is illegal already, neither lobbying nor litigation necessary

This is cool, it’s just unfortunate that it’s necessary.

It would be nice to see more research into the role of “payor harm” in patient outcomes.

> “Part of that is an unreasonable willingness to take things too far,” Karau said.

How many people lack that? And how many companies have the resources to take things even further? I wish there was another way to get this outcome. Baby steps, I guess; and this platform in particular sounds like a good step.

I have to say the worst health insurance company, that I consistently hear complaints about, is Aetna. Multiple parents have shared how difficult it was to get them to cover their labor and delivery costs even though it was clearly a part of their coverage. All of them had to spend hours on repeated phone calls over several months to get them to cover it. Once a claim is denied initially, Aetna’s appeals and reviews each take 30-60 business days for each step, and they usually have wait times of 1-2 hours. Exhausted mothers who should be enjoying their precious time with newborns are instead drowning under stress from being on the hook for five figure sums, and Aetna knows that they cannot be on the phone for hours. I suspect it’s all a purposeful strategy to frustrate people and prevent them from collecting on their claims.

In my opinion, if an insurance company ends up paying a claim that was denied, they should be forced to compensate the person for all the time spent, including wait times on hold, at 5x the equivalent hourly wage that person would have earned.

I wonder if someone made one for credit card disputes.

I don't think that's the way to go.

First, insurance and everything else (including your job) should be strictly decoupled.

Second, health-insurance and life-insurance companies should imho be required to be cooperatives. That makes it so that incentives are aligned.

That the instance company is denying certain claims (both wrongly and rightly) is perfectly fine. In fact, that is good. It's part of the core business to protect against abuse. The balance is important here and will reflect in the premiums.

Those two things should already fix most major issues in insurance in a working market with competition.