This is no small problem. Patients often face denials from health insurance companies for prescribed medications or services. According to statistics from the company Claimable, 850 million out of 5 billion U.S. health claims are denied annually, with 60% of affected patients experiencing care delays that can contribute to worsening health.
A typical reason is the lack of medical necessity. If the insurance company believes that the prescribed medication or treatment isn't medically necessary based on the patient’s diagnosis or doesn’t align with standard treatment guidelines, it may deny coverage. Or If a patient seeks treatment from a provider who isn’t in the insurance company’s network, the insurer might deny or reduce coverage. This is common for specialist consultations or procedures done at non-partner facilities.
Despite having legal rights to appeal, many patients do not pursue these options. Only 10% of denials in Medicare Advantage plans are appealed, with a high success rate for those that are. In ACA plans, less than 0.2% of denials are appealed.
Claimable is a new startup that aims to empower US patients against insurance denials (Figure 1). The company uses Generative AI, combined with medical and legal knowledge, to write appeal letters. Their goal is to “empower patients to swiftly challenge unjust denials, helping them access vital treatments, reduce financial burdens, and prevent critical care delays.”
To initiate the appeal process, patients upload their insurance claim denial letters and answer some questions. The Claimable system uses ChatGPT to craft the appeal letters which take advantage of a library of medical, legal, and policy resources (i.e. additional documents that are fed into the ChatGPT). Claimable asserts that unlike traditional form-based tools, the platform provides a personalized experience, adapting to responses in real time and crafting appeals with fact-based, patient-centered narratives.
Appeals are submitted via fax or mail, with an option for urgent 72-hour reviews. Claimable charges $39.95 per appeal, plus shipping fees. The platform is available nationwide, accepting denials from all major insurance providers, including Medicare, Medicaid, United Healthcare, Anthem, Aetna, Cigna, and BCBS. Currently, Claimable supports appeals for 60 critical treatments, particularly targeting commonly denied medications for autoimmune and migraine patients, conditions impacting about 65 million Americans. By early 2025, they want to expand support to over 100 treatments. Thus, it is likely most patients' appeals cannot be supported by Claimable, unless they were denied one of the 60 treatments covered by the company.
In terms of success rate, Claimable offers the following statistics obtained during testing:
- 80% success rate in appeals, which is 1.6 times higher than the industry average.
- Most cases are resolved within 10 days, three times faster than the average processing time.
- Appeals can be generated and submitted within minutes, significantly faster than traditional methods.
- Nearly $3 million has been recovered for patients, demonstrating the platform’s impact.
Since their recent launching, they have filed fewer than 100 appeals.
In summary, Claimable is a good example of AI being used to help patients directly as opposed to the multitude of AI applications that assist doctors and the medical community administering healthcare. It is a service that has an associated cost (~$40 per appeal), but the financial (and health-related) benefit from having a denial overturned is likely to far exceed that amount. The CEO of Claimable states that the platform is positioned as a solution to give patients a voice in a system often dominated by insurers.
Figure 1. The company Claimable uses ChatGPT to help patients appeal health insurance denials (https://www.getclaimable.com/).
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