10 ms·

Using AI to fight insurance claim denials

203 points by jpmattia 2y ago

jpmattia 2y ago
The subheading of the article is "Using AI to fight insurance claim denials", and her site is here: https://fighthealthinsurance.com/ https://fighthealthinsurance.com/
- dang 2y ago
  Ok, we'll use that for the title above. Thanks!
rqtwteye 2y ago
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.
- WaxProlix 2y ago
  > Hospitals and insurances should be fined if they have a high ratio of claims that get rejected first and reversed after appeal They'd just invest more in not having to reverse on appeal. Handling these kinds of incentives with rules and strictures gets messy fast.
  - ryandrake 2y ago
    Well, write the law to address that, too. Too often, we throw our hands up and declare legislation impossible "because companies will just get around it in ways, X, Y, and Z". The solution is to write better laws that also remove X, Y, and Z as options. And also X0, X1, Y0, Y1, Y2, Z0, Z1, Z2, Z3, and Z4. The world is complex and regulation can be complex, too. You'll never fix things by giving up and saying "We can't write the perfect law--oh well, let's just let companies do whatever they want!"
    - dylan604 2y ago
      The concept of spirit of the law vs letter of the law infuriates me to no end. I think the letter of the law should stipulate the spirit of the law (almost a TL;DR right at the beginning) so that jurists can later take that into account when deciding if the law was broken.
      - 1-more 2y ago
        US Tax law is the only place where I can think of that the spirit is the most important part of the law. There isn't much of a hard and fast definition of a home based business, but if the vibe is "this is a hobby and I'm using the business only to claim deductions, not turn a profit someday" you can be in violation.
      - kredd 2y ago
        I agree in some sense, but spirit of the law also creates very uneven playground and leaves a lot of questions. The way I see the problem, it takes way too long for us to legislate anything. By the time something passes different levels of approval, whoever has any skin in the game might figure out a way around it. That happens a lot with finding loopholes in housing related legislations. If there is a proposal that would hurt investors, they lobby against it for a while, buying time to figure out an alternative method, and by the time it passes, they don’t really care because they’ve circumvented it anyways. I see why it would also suck if we fast tracked most of the legislations though.
        piva00 2y ago
        > I agree in some sense, but spirit of the law also creates very uneven playground and leaves a lot of questions. That happens anyway though, as much of law in Common Law systems is only settled by precedents, jurisprudence, etc. Even the US's Constitution interpretation is up to the courts when questions arise, that's the courts' job anyhow. At least working with the spirit of the law allows ways to prevent loopholes in a way that the letter of the law process only allows if new legislation is passed to cover those loopholes.
  - rqtwteye 2y ago
    “ They'd just invest more in not having to reverse on appeal” That would be the goal. Get it right first time around.
    - WaxProlix 2y ago
      "Invest" here doesn't necessarily mean monetary investment, they could for instance choose to degrade their arbitration and appeals process further, understaff it, or push regulatory boundaries in that direction. And that would possibly save them money, at least in the short term. And to the extent that costs do go up for appeals processes, there's no guarantee that the resulting setup has margins that incentivize doing right by customers at all.
      - rqtwteye 2y ago
        That could be solved by proper regulation. As far as I can tell they are already making the process as miserable as possible. I don’t think it would get worse.
- deleted 2y ago
  [deleted]
- aidenn0 2y ago
  Most of the time it's not too bad to appeal a claim for smaller amounts. People go through the hoops for the larger denials because they are so motivated. I got a $150k bill for emergency care for my daughter once; it wasn't too bad because they denied it as "uncovered elective procedure" which was trivial to show it wasn't, but it was still a tense month for me waiting. The punchline, of course, is that the insurance company and the provider agreed upon $30k. Doctors' offices can't tell you what a procedure will cost ahead of time, and the amount they bill you afterwards is completely fictitious (because if you don't have health insurance you probably can't pay 5x what the insurance companies pay, so will be bankrupted anyways).
  - rqtwteye 2y ago
    “ because if you don't have health insurance you probably can't pay 5x what the insurance companies pay, so will be bankrupted anyways” Or it could go the other way depending on arbitrary factors. Nobody knows.
  - dimal 2y ago
    “Most of the time” in my case, it has been bad. Because it wasn’t one big bill. It was dozens of bills for $200-500. Each submission could fail in unpredictable ways. “Lost” claims forms, database “errors”, “incomplete information”, etc. And trying to deal with this burden while being sick, was too much for me. I scraped back a few dollars, but had to give up and move forward with my life.
barryrandall 2y ago
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.
nostrademons 2y ago
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."
- rwmj 2y ago
  You correctly identify a problem then suggest a complicated technical solution. The simple solution is to make these practices illegal by passing laws.
  - ttymck 2y ago
    > passing laws. As if that's any less of a complicated technical solution.
    - mrguyorama 2y ago
      The law passing solution has been implemented in tens of states, so apparently it's not that difficult. Meanwhile, how often has a company in the US been reigned in by another company?
      - sirspacey 2y ago
        Often Disruptive services dramatically impact companies at scale The Credit Dispute industry radically lowered the aggressive dark patterns of credit score companies like Experian, as an example.
  - salawat 2y ago
    Because money laundering, wage theft, tax evasion, and labor violations never happen, right? Law being on the books does not resolve the central asymmetry here. Again, their full time job is bleeding you. You getting your rights asserted comes at the expense of your time. Hell, when was the last time you got to negotiate a EULA with $BigCorp's legal group? Odds are, never.
bojangleslover 2y ago
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.
- toomuchtodo 2y ago
  I help folks in r/sterilization who have obtained permanent birth control navigate and appeal their insurance. ACA compliant plans require this be covered at 100% as preventive care, so it’s building a workflow to check the boxes in the Rube Goldberg system to get to the outcome (full coverage per statue) insurance is constantly trying to avoid. This project is helpful and is going into the case management workflow right away. Fight slop with well crafted, guardrailed slop.
  - elevatortester 2y ago
    @toomuchtodo - you probably won't see this, but I'm very interested in this cause. If you happen to want an extra brain to help out, email is in my profile
    - deleted 2y ago
      [deleted]
  - pyuser583 2y ago
    Why the interest in sterilization? Because ACA makes it a very simple use case? Out of curiosity, does ACA require coverage if the doctor refuses?
    - toomuchtodo 2y ago
      Because it is the most aggressive way at almost no cost to empower someone’s reproductive rights in an adversarial socioeconomic system, while each avoided unwanted child is a net positive. Cost benefit ratio is enormous. ~40% of annual pregnancies (both US and international) are unintended, $330k cost 0-18 (2023 dollars), limited to no support for parents, etc. ACA coverage is for the procedure, doctors who won’t refuse can be found at https://childfreefriendlydoctors.com/ https://childfreefriendlydoctors.com/ If you want kids, Godspeed. If you don’t, I am building systems to radically empower that outcome. “Build something people want.” or something like that. Essentially a suffering reduction flywheel.
pj_mukh 2y ago
The application form is a site to behold: https://fighthealthinsurance.com/scan https://fighthealthinsurance.com/scan Specifically laying out what and how everything is stored. Hahah. Probably overwhelming to a non-dev, but Kudos either way!
- nondevux 2y ago
  I would even argue they should take all of those bits of text and replace them with an on-hover tooltip element, with the icons indicating the degree to which those things are stored externally. It's a bit more alarmist than it needs to be as is. However, it would mess with mobile?
secabeen 2y ago
The insurance companies are already using AI to generate denials, might as well use it to appeal them too.
- krolley 2y ago
  This is what I was thinking reading TFA. Doesn't it become an AI arms race, where insurance companies use AI to deny claims, and customers use AI to fight the denial ad infinitum?
OptionOfT 2y ago
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.
- josefresco 2y ago
  I get your point but Michelin is a global company, that manufacturers in over 60 countries. Maybe leave the "Chinese" part out and go with just "cheap tires".
  - efesfseegseg 2y ago
    [dead]
  - schmookeeg 2y ago
    I think those two are colloquially synonymous to most people. Particularly those with Amazon Prime accounts :)
  - dotancohen 2y ago
    I used to work at the Vehicle Engineering Lab at the Technion in Israel. China is the only place where large volume of tires are manufactured and distributed to worldwide retailers, which documents their tires using the DOT standard yet consistently fails all DOT tests when tested. As the DOT requires tires to be tested only after a certain number of failures, the DOT standard is meaningless when the factory can change owners and name on a whim. That consistently happens only in China.
- hervature 2y ago
parpfish 2y ago
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
peer2pay 2y ago
Kudos to her for making this open source and free to users!
kayo_20211030 2y ago
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.
baq 2y ago
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
xyst 2y ago
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).
SomaticPirate 2y ago
Wow! Amazing job! I briefly met Holden at Kubecon. What an incredible engineer.
thih9 2y ago
> “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.
valenterry 2y ago
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.
LorenPechtel 2y ago
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.
- ToucanLoucan 2y ago
  I've considered several times what a difference it would be if legal work by individuals was considered a billable expense in the event of the individuals winning. I think it would level the playing field at lease somewhat with regard to the inherent advantage any corporation has via having a legal division full of lawyers over a regular Joe trying to get justice. But yeah, if some farmer has to sue John Deere to be able to fix his tractor or whatever, that's going to take a ton of his valuable time to deal with. Why shouldn't he be compensated in the event he was correct?
- deleted 2y ago
  [deleted]
- joe_the_user 2y ago
  Uh, Fines are part of regulation. Fines are what makes regulations stick. Regulation is based on legislation. Of course, it's bad to have Legislation that tries to enforce things that regulators already have the tools to enforce (but aren't using). But broadly, if you want a hammer big enough that a profit-seeking corporation will avoid any tap with it, you want legislation. The usual schemes that imply companies will face costs without regulation being in effect (basically "let the market decide") won't work with individual consumers versus health providers or insurance companies.
blackeyeblitzar 2y ago
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.
simonw 2y ago
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.
- happymellon 2y ago
  They could all merge into one giant insurance agency, perhaps a National Health Insurance. Once they eliminate all competition the next target for optimisation is between the company and hospitals. They realise its cheaper, with better margins, to run primary care facilities rather than hospitals. The government see that they are a monopoly and force them to provide coverage for a minimal monthly cost. It seems like such a good idea that eventually the government agrees to give them a set amount each month for universal coverage of citizens. They rename themselves as the National Health Service.
bluedemon 2y ago
I wonder if someone made one for credit card disputes.

203 points by jpmattia 2y ago

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

dang 2y ago
Ok, we'll use that for the title above. Thanks!

rqtwteye 2y ago

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.

WaxProlix 2y ago
> Hospitals and insurances should be fined if they have a high ratio of claims that get rejected first and reversed after appeal They'd just invest more in not having to reverse on appeal. Handling these kinds of incentives with rules and strictures gets messy fast.
- ryandrake 2y ago
  Well, write the law to address that, too. Too often, we throw our hands up and declare legislation impossible "because companies will just get around it in ways, X, Y, and Z". The solution is to write better laws that also remove X, Y, and Z as options. And also X0, X1, Y0, Y1, Y2, Z0, Z1, Z2, Z3, and Z4. The world is complex and regulation can be complex, too. You'll never fix things by giving up and saying "We can't write the perfect law--oh well, let's just let companies do whatever they want!"
  - dylan604 2y ago
    The concept of spirit of the law vs letter of the law infuriates me to no end. I think the letter of the law should stipulate the spirit of the law (almost a TL;DR right at the beginning) so that jurists can later take that into account when deciding if the law was broken.
    - 1-more 2y ago
      US Tax law is the only place where I can think of that the spirit is the most important part of the law. There isn't much of a hard and fast definition of a home based business, but if the vibe is "this is a hobby and I'm using the business only to claim deductions, not turn a profit someday" you can be in violation.
    - kredd 2y ago
      I agree in some sense, but spirit of the law also creates very uneven playground and leaves a lot of questions. The way I see the problem, it takes way too long for us to legislate anything. By the time something passes different levels of approval, whoever has any skin in the game might figure out a way around it. That happens a lot with finding loopholes in housing related legislations. If there is a proposal that would hurt investors, they lobby against it for a while, buying time to figure out an alternative method, and by the time it passes, they don’t really care because they’ve circumvented it anyways. I see why it would also suck if we fast tracked most of the legislations though.
      - piva00 2y ago
        > I agree in some sense, but spirit of the law also creates very uneven playground and leaves a lot of questions. That happens anyway though, as much of law in Common Law systems is only settled by precedents, jurisprudence, etc. Even the US's Constitution interpretation is up to the courts when questions arise, that's the courts' job anyhow. At least working with the spirit of the law allows ways to prevent loopholes in a way that the letter of the law process only allows if new legislation is passed to cover those loopholes.
- rqtwteye 2y ago
  “ They'd just invest more in not having to reverse on appeal” That would be the goal. Get it right first time around.
  - WaxProlix 2y ago
    "Invest" here doesn't necessarily mean monetary investment, they could for instance choose to degrade their arbitration and appeals process further, understaff it, or push regulatory boundaries in that direction. And that would possibly save them money, at least in the short term. And to the extent that costs do go up for appeals processes, there's no guarantee that the resulting setup has margins that incentivize doing right by customers at all.
    - rqtwteye 2y ago
      That could be solved by proper regulation. As far as I can tell they are already making the process as miserable as possible. I don’t think it would get worse.
deleted 2y ago
[deleted]
aidenn0 2y ago
Most of the time it's not too bad to appeal a claim for smaller amounts. People go through the hoops for the larger denials because they are so motivated. I got a $150k bill for emergency care for my daughter once; it wasn't too bad because they denied it as "uncovered elective procedure" which was trivial to show it wasn't, but it was still a tense month for me waiting. The punchline, of course, is that the insurance company and the provider agreed upon $30k. Doctors' offices can't tell you what a procedure will cost ahead of time, and the amount they bill you afterwards is completely fictitious (because if you don't have health insurance you probably can't pay 5x what the insurance companies pay, so will be bankrupted anyways).
- rqtwteye 2y ago
  “ because if you don't have health insurance you probably can't pay 5x what the insurance companies pay, so will be bankrupted anyways” Or it could go the other way depending on arbitrary factors. Nobody knows.
- dimal 2y ago
  “Most of the time” in my case, it has been bad. Because it wasn’t one big bill. It was dozens of bills for $200-500. Each submission could fail in unpredictable ways. “Lost” claims forms, database “errors”, “incomplete information”, etc. And trying to deal with this burden while being sick, was too much for me. I scraped back a few dollars, but had to give up and move forward with my life.

barryrandall 2y ago

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.

nostrademons 2y ago

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."

rwmj 2y ago
You correctly identify a problem then suggest a complicated technical solution. The simple solution is to make these practices illegal by passing laws.
- ttymck 2y ago
  > passing laws. As if that's any less of a complicated technical solution.
  - mrguyorama 2y ago
    The law passing solution has been implemented in tens of states, so apparently it's not that difficult. Meanwhile, how often has a company in the US been reigned in by another company?
    - sirspacey 2y ago
      Often Disruptive services dramatically impact companies at scale The Credit Dispute industry radically lowered the aggressive dark patterns of credit score companies like Experian, as an example.
- salawat 2y ago
  Because money laundering, wage theft, tax evasion, and labor violations never happen, right? Law being on the books does not resolve the central asymmetry here. Again, their full time job is bleeding you. You getting your rights asserted comes at the expense of your time. Hell, when was the last time you got to negotiate a EULA with $BigCorp's legal group? Odds are, never.

bojangleslover 2y ago

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.

toomuchtodo 2y ago
I help folks in r/sterilization who have obtained permanent birth control navigate and appeal their insurance. ACA compliant plans require this be covered at 100% as preventive care, so it’s building a workflow to check the boxes in the Rube Goldberg system to get to the outcome (full coverage per statue) insurance is constantly trying to avoid. This project is helpful and is going into the case management workflow right away. Fight slop with well crafted, guardrailed slop.
- elevatortester 2y ago
  @toomuchtodo - you probably won't see this, but I'm very interested in this cause. If you happen to want an extra brain to help out, email is in my profile
  - deleted 2y ago
    [deleted]
- pyuser583 2y ago
  Why the interest in sterilization? Because ACA makes it a very simple use case? Out of curiosity, does ACA require coverage if the doctor refuses?
  - toomuchtodo 2y ago
    Because it is the most aggressive way at almost no cost to empower someone’s reproductive rights in an adversarial socioeconomic system, while each avoided unwanted child is a net positive. Cost benefit ratio is enormous. ~40% of annual pregnancies (both US and international) are unintended, $330k cost 0-18 (2023 dollars), limited to no support for parents, etc. ACA coverage is for the procedure, doctors who won’t refuse can be found at https://childfreefriendlydoctors.com/ https://childfreefriendlydoctors.com/ If you want kids, Godspeed. If you don’t, I am building systems to radically empower that outcome. “Build something people want.” or something like that. Essentially a suffering reduction flywheel.

pj_mukh 2y ago

The application form is a site to behold: https://fighthealthinsurance.com/scan https://fighthealthinsurance.com/scan Specifically laying out what and how everything is stored. Hahah. Probably overwhelming to a non-dev, but Kudos either way!

nondevux 2y ago
I would even argue they should take all of those bits of text and replace them with an on-hover tooltip element, with the icons indicating the degree to which those things are stored externally. It's a bit more alarmist than it needs to be as is. However, it would mess with mobile?

secabeen 2y ago

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

krolley 2y ago
This is what I was thinking reading TFA. Doesn't it become an AI arms race, where insurance companies use AI to deny claims, and customers use AI to fight the denial ad infinitum?

OptionOfT 2y ago

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.

josefresco 2y ago
I get your point but Michelin is a global company, that manufacturers in over 60 countries. Maybe leave the "Chinese" part out and go with just "cheap tires".
- efesfseegseg 2y ago
  [dead]
- schmookeeg 2y ago
  I think those two are colloquially synonymous to most people. Particularly those with Amazon Prime accounts :)
- dotancohen 2y ago
  I used to work at the Vehicle Engineering Lab at the Technion in Israel. China is the only place where large volume of tires are manufactured and distributed to worldwide retailers, which documents their tires using the DOT standard yet consistently fails all DOT tests when tested. As the DOT requires tires to be tested only after a certain number of failures, the DOT standard is meaningless when the factory can change owners and name on a whim. That consistently happens only in China.
hervature 2y ago

parpfish 2y ago

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

peer2pay 2y ago

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

kayo_20211030 2y ago

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.

baq 2y ago

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

xyst 2y ago

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).

SomaticPirate 2y ago

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

thih9 2y ago

> “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.

valenterry 2y ago

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.

LorenPechtel 2y ago

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.

ToucanLoucan 2y ago
I've considered several times what a difference it would be if legal work by individuals was considered a billable expense in the event of the individuals winning. I think it would level the playing field at lease somewhat with regard to the inherent advantage any corporation has via having a legal division full of lawyers over a regular Joe trying to get justice. But yeah, if some farmer has to sue John Deere to be able to fix his tractor or whatever, that's going to take a ton of his valuable time to deal with. Why shouldn't he be compensated in the event he was correct?
deleted 2y ago
[deleted]
joe_the_user 2y ago
Uh, Fines are part of regulation. Fines are what makes regulations stick. Regulation is based on legislation. Of course, it's bad to have Legislation that tries to enforce things that regulators already have the tools to enforce (but aren't using). But broadly, if you want a hammer big enough that a profit-seeking corporation will avoid any tap with it, you want legislation. The usual schemes that imply companies will face costs without regulation being in effect (basically "let the market decide") won't work with individual consumers versus health providers or insurance companies.

blackeyeblitzar 2y ago

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.

simonw 2y ago

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.

happymellon 2y ago
They could all merge into one giant insurance agency, perhaps a National Health Insurance. Once they eliminate all competition the next target for optimisation is between the company and hospitals. They realise its cheaper, with better margins, to run primary care facilities rather than hospitals. The government see that they are a monopoly and force them to provide coverage for a minimal monthly cost. It seems like such a good idea that eventually the government agrees to give them a set amount each month for universal coverage of citizens. They rename themselves as the National Health Service.

bluedemon 2y ago

I wonder if someone made one for credit card disputes.