Ai Is Helping Patients Fight Insurance Company Denials: 'it Is Wild'

Stephanie Nixdorf was astatine Disney World pinch her family successful December 2021 erstwhile she sewage nan call. A mysterious bump connected her elbow was melanoma, her expert said. Tests later showed it was Stage 4, pinch spots connected her lung and 2 tumors successful her brain.

Nixdorf, 51, a mother of 4 who lives pinch her husband, Jason, successful Davidson, North Carolina, began treatments immediately, and by January 2024 her crab was abating. The Premera Blue Cross wellness security offered by her husband’s employer had covered her crab care, but successful early 2024, erstwhile Stephanie’s doctors prescribed a supplier to conflict crippling arthritis induced by her immunotherapy treatments, nan denials began.

“I utilized to run, play tennis, beryllium active,” Nixdorf told NBC News. “Now I can’t moreover unfastened a yogurt aliases grip a steering instrumentality successful nan morning.”

Jason and Stephanie Nixdorf.NBC News

Premera Blue Cross, a not-for-profit licensee of nan Blue Cross Blue Shield Association successful Mountlake Terrace, Washington, is simply a starring wellness scheme successful nan Pacific Northwest, serving 2.5 cardinal people. For 9 months successful 2024, it denied repeated requests by Nixdorf’s doctors to screen infliximab, an inflammatory arthritis supplier they’d prescribed.

With his woman successful agony, Jason Nixdorf had a chance brushwood pinch Zach Veigulis, a erstwhile main information intelligence astatine nan Department of Veterans Affairs who was co-founding a institution to thief patients conflict security institution denials. That company, Claimable Inc., built an AI level that allows patients to make customized entreaty letters containing broad assessments of objective investigation connected a supplier aliases curen and different patients’ appeals history pinch it. The cost: astir $40.

When Nixdorf reached out, Claimable’s tract was not yet live, but its main executive and co-founder, Dr. Warris Bokhari, offered to thief constitute an entreaty missive for Stephanie utilizing they strategy they had developed.

In mid-September 2024, she sent that 23-page entreaty missive to Premera’s main executive and main ineligible counsel, arguing that 1 of its ain policies states it should screen infliximab, her records show. Her missive besides went to nan politician and lawyer wide of North Carolina, officials astatine nan Department of Health and Human Services, nan Consumer Financial Protection Bureau and nan Wage and Hour Division of nan Department of Labor.

Two days later, Premera approved nan drug. “I want to apologize that you person been waiting to person curen for 9 months,” nan support missive said.

Nixdorf is 1 of a increasing cohort of patients utilizing artificial intelligence to conflict wellness security denials. Several companies connection package programs that fto patients create broad entreaty letters comparatively quickly, pinch nan thief of AI. It scrapes nan net for each shred of grounds of supplier efficacy and past appeals occurrence successful a fraction of nan clip it would return a quality to do.

Courtney Wallace, a Premera spokeswoman, provided a connection to NBC News connected nan Nixdorf case.

“There was nary intent to contradict care,” she said. Rather, Premera made a “processing correction involving a misapplication of argumentation and duty to an incorrect expert specialist.”

Premera “fell short” successful this case, Wallace added.

Research shows nan arthritis Stephanie was experiencing, if untreated, tin origin irreversible associated harm and important disability.

Jason Nixdorf said he’s relieved that his woman was capable to person sum for a curen her doctors prescribed, but he besides feels angry complete nan ordeal and its consequences.

“Not only has nan hold caused Stephanie imperishable damage,” he said, “it will beryllium a lifelong point for her to woody pinch this arthritis. If we had gotten nan OK successful January, it could person been knocked retired and done then.”

'People springiness up'

As galore patients and their doctors know, trying to summation security sum for a supplier aliases curen tin beryllium a full-time and exasperating task. Comprehensive information connected security institution denials is unavailable, but a January 2025 study by KFF, a wellness argumentation research, polling and news organization, recovered that insurers participating successful alleged marketplace plans nether nan Affordable Care Act denied 19% of in-network claims successful 2023, nan astir caller twelvemonth for which information is available. Fewer than 1% of consumers appealed nan denials, nan investigation found, and erstwhile they did, complete half nan denials — 56% — were upheld.

In summation to nan effect security institution denials person connected patients’ health, they transportation a financial cost. In a 2023 KFF survey, 39% of consumers who were having problem paying their aesculapian bills said denied claims contributed to their problems.

Amid nan conflict complete Premera’s denials, nan Nixdorfs and their doctors many times tried to group up a lawsuit reappraisal by calling a toll-free number that was ne'er answered by a quality being, leaving messages that were not returned, faxing insubstantial documents astatine Premera’s request, and completing letters of aesculapian necessity.

Wallace, nan Premera spokeswoman, agreed location had been “a breakdown successful communication” successful nan Nixdorf case. “We’re focusing connected providing a amended acquisition for providers,” she added.

Nixdorf’s documents show Premera’s first denial came successful February erstwhile nan insurer said infliximab was “not medically necessary” to dainty her arthritis. A 2nd denial successful June characterized nan supplier arsenic “investigational aliases experimental,” moreover though it is recommended for inflammatory arthritis by nan National Comprehensive Cancer Network Drugs and Biologics Compendium, a book among oncologists. The 3rd denial, successful July, said infliximab was not Food and Drug Administration-approved.

“They group nan strategy up truthful group springiness up,” Jason said.

After nan 3rd denial, Jason requested Premera supply each nan records relating to its decision. He and his woman became moreover much troubled erstwhile they received nan materials, learning, for example, that nan expert utilized by Premera successful what’s known arsenic a peer-to-peer reappraisal of nan lawsuit was a master successful soul medicine pinch nary expertise successful crab aliases inflammatory arthritis.

They besides discovered nan institution contracted by Premera to do an independent reappraisal of their lawsuit — AllMed Healthcare Management — was led by Jeff Card, who had been head of objective reappraisal operations astatine Premera for 7 years until he joined AllMed successful 2021, his LinkedIn curriculum vitae says.

Having his wife’s lawsuit reviewed by a institution overseen by a erstwhile Premera executive presented a conflict of interest, Nixdorf told NBC News.

The Nixdorfs were amazed to study that nan institution contracted by Premera to do an independent reappraisal of their lawsuit — AllMed Healthcare Management — was led by a erstwhile Premera executive.NBC News

Premera’s spokeswoman declined to respond to this criticism, saying “AllMed is accredited by some nan National Committee for Quality Assurance and nan Utilization Review Accreditation Commission.” Premera’s business pinch AllMed is “subject to rigorous oversight, including quarterly reviews and audits” by nan insurer, Wallace said.

AllMed did not return an email and a telephone telephone seeking remark from nan institution and from Card.

Veigulis of Claimable said nan company’s 3 co-founders, including Alicia Graham, wanted to understand why group who person entree to wellness attraction don’t person it. Building their AI exemplary that went unrecorded past October, they began pinch rheumatology and migraine and now screen complete 50 life-changing treatments. Veigulis said astir 1,000 denials person been overturned by patients utilizing nan Claimable model.

“We spot truthful galore group who person met nan eligibility criteria who salary their premiums connected clip that still can’t entree their wellness care,” he said. “It is wild.”

'You person rights'

Tabitha Lee is simply a erstwhile paramedic moving successful rheumatology astatine Wilmington Health successful North Carolina. Since January, she has handled anterior authorization and security denials for nan astir 100 patients who travel successful each day.

Denials person ramped up recently, she said.

Jason and Stephanie Nixdorf.NBC News

“We’ve had a batch of patients connected medicine for years, unchangeable and well-controlled, and insurances were denying them,” Lee told NBC News. Instead, nan insurers would propose replacement narcotics that were connected their approved lists, aliases formularies, she said. This was causing problem for patients, Lee added, because “changing patients’ medications tin origin adverse reactions.”

Lee said she had tried filing entreaty letters for patients but it was time-consuming to compile nan technological and objective testing information connected each case. In February, astatine nan proposal of a rheumatologist and adjunct professor astatine nan Duke School of Medicine, she began filing appeals utilizing an AI-generated strategy created by Counterforce Health, a nonprofit founded by Neal K. Shah, a erstwhile hedge money head turned wellness attraction entrepreneur and advocate. Shah is besides main executive of CareYaya Health Technologies, a nonprofit that connects assemblage students pursuing wellness attraction degrees pinch families seeking attraction for aging relatives.

At nary charge, Counterforce generates customized entreaty letters based connected a patient’s security argumentation and nan existent grounds of successful appeals related to nan supplier aliases curen successful question. The letters besides spell to security regulators successful nan patients’ states to alert them to nan denials, which Shah said they whitethorn not beryllium alert of.

“Denials should beryllium appealed, but we observe astir group don’t entreaty because they are intimidated by full thing,” Shah said. His connection to patients: “When you get a no, please return nan adjacent measurement — you person rights.”

Lee said utilizing nan Counterforce package has helped her overturn denials. “I’ve gotten backmost approvals connected nan aforesaid time and nan time after,” Lee said. “It decidedly limits nan clip we person to walk formulating each denial missive and allows maine to activity much connected first anterior authorization and diligent assistance.”