Healthcare providers use AI to predict whether an insurance claim will be denied
(NBC, KYMA/KECY) - Some healthcare providers now use artificial intelligence to predict whether a claim will be denied.
'Will insurance cover this?' and 'How much will it pay?' shouldn't be the hardest questions you need to ask when it comes to your healthcare, but ufortunately, if you don't ask, you could be hit with a bill you can't afford to pay.
"Doctors often should be able to say, 'Yes' or 'No' before we even think about doing our work," said Mike Desjardon, CEO of Anomaly Insights.
Anomaly Insights is an AI company that uses software specifically built for healthcare providers to predict what your insurance company will pay for and what it won't.
"What our goal is, is to make sure that your doctor's office has all that they need so they can do everything right in advance so you go and you get your care, your insurance company pays for your care, or you're given a transparent bill."
Mike Desjardon, CEO, Anomaly Insights
According to a National Survey of Hospitals and Other Healthcare Providers, nearly 15% of medical claims submitted to private payers are initially denied, leaving the patient the daunting task of appealing the decision, but most don't.
Desjandon says less than 10% of denials are actually appealed, but for those that are, the approval rate is above 80%, and who is denying those claims has come under fire recently.
Lawsuits have been filed against three of the largest health insurers claiming they use AI to help make coverage determinations, a claim they deny.
As more health insurance companies turn to AI, patient advocacy groups, along with the American Medical Association, are calling for more regulatory oversight when it comes to reviewing patient clams and prior authorization, including whether insurers are using a thorough and fair process that requires human examination of patient records prior to denying the claim.
"These artificial intellegence tools are great when they work for good purpose, for the better good. And that's helping patients lower their costs and be protected from erroneous over-charged billing," said Cynthia Fisher, Founder and Chairwoman of PatientRightsAdvocate.org.
If you are denied coverage, here's what you need to do, find out why your claim was denied before you start your appeal, review your policy on how to appeal the decision, write your appeal letter and include all the reasons to defend your claim, and a word of advice, be nice and not threatening.
