Healthcare providers use AI to predict whether an insurance claim will be denied

(NBC, KYMA/KECY) – Some health care providers are now using artificial intelligence to predict whether a claim will be denied.

“Is this covered by my insurance?” and “How much will I get reimbursed?” shouldn’t be the hardest questions to ask when it comes to your healthcare, but unfortunately, if you don’t ask, you could end up with a bill you can’t pay.

“Physicians should be able to say ‘yes’ or ‘no’ often before they even start their work,” said Mike Desjardon, CEO of Anomaly Insights.

Anomaly Insights is an AI company that uses software specifically designed for healthcare providers to predict what your insurance company will and won’t cover.

“Our goal is to make sure that your doctor’s office has everything he or she needs, so that everything can be arranged well in advance. That way, you can go to the office and get your care, your insurance company will pay for your care, or you will get a transparent bill.”

Mike Desjardon, CEO, Anomaly Insights

According to a national survey of hospitals and other health care providers, nearly 15 percent of medical claims submitted to private insurers are initially denied. Patients are then required to appeal the decision, but most do not.

According to Desjandon, less than 10% of cases are actually appealed, but for those applications where this does happen, the approval rate is above 80%. In addition, there has been a lot of criticism recently about who rejects these applications.

Lawsuits have been filed against three of the largest health insurers, alleging that they use AI to determine coverage, a claim they deny.

As more health insurers turn to AI, patient advocacy groups and the American Medical Association are calling for greater oversight of patient claims review and prior authorization, including whether insurers are conducting a thorough and fair process that involves human review of patient records before denying claims.

“These artificial intelligence tools are great when they’re working for a good cause, for the greater good, and that’s helping patients reduce their costs and be protected from unfair, overbilling,” said Cynthia Fisher, founder and president of PatientRightsAdvocate.org.

If your coverage is denied, here’s what you should do: Find out why your claim was denied before you appeal. Check your policy to see how you can appeal the decision. Write your appeal letter, giving all the reasons you need to defend your claim. Also, give this advice: be nice and non-threatening.