Health insurance is a legal entitlement to payment or reimbursement for health care costs. At its core, health insurance is supposed to provide important financial protection for health care costs in case of accident or sickness in exchange for a monthly premium. It can also help people when they are not sick by covering routine check-ups and many preventative services.
Health insurance is especially important for society since health is a universal experience that all people will be impacted by. While some insurance plans, like car or homeowners, are there in case an accident or natural disaster occurs, health insurance is different because there aren’t rare occurrences that trigger the need for insurance. Instead, health insurance covers not just accidents or emergencies but also routine care that is meant to maintain health, enhance one’s quality of life, reduce the risk of developing serious diseases, and address any existing or new conditions.
When health insurance falls short the consequences are tragic. Those who have suffered an accident, injury, emergency, sickness, or disease are at risk of life-long financial debt. While health insurance is a business and it is expected for businesses to mitigate costs to be successful, certain strategies are causing significant consequences to those who have received medical care. For instance, health insurance companies will typically use an in-network and out-of-network plan for costs to be reduced. As long as a patient has access to the care they need, this strategy does not inherently create an unreasonable burden on the health insurance’s beneficiaries. Additionally, beneficiaries will receive descriptions of what the health insurance covers and what is excluded which depends on the plan. However, beneficiaries are at unnecessary risk of medical debt because health insurance holds all of the power in this relationship and abuses this power by deciding whether or not care is “medically necessary” after the patient has received the care which allows the company to refuse to cover any costs that it is designed to provide for.
Imagine someone who had a heart attack and to resuscitate them, the health care providers use a defibrillator, and then after they realize that the health insurance company has decided that the defibrillator was not medically necessary and will not be pay for it. A beneficiary should not have to decide upon whether or not to receive a life-saving measure nor should the beneficiary be stuck with medical bills that put them in life-long death just for surviving. Unfortunately, one wouldn’t have to use their imagination for this scenario as a survey showed “one in five Americans said their health insurance company had denied a claim over the past 12 months”. Health insurance companies have increasingly been using artificial intelligence (AI) to reduce costs by accelerating claims, coverage, and prior authorization decisions. However, the consequences are grave, an investigation found that in 2022, Cigna (a health insurance company) used an AI technology to deny or reject more than 300,000 claims for services or care that clinicians considered medically necessary. “Between 2022 and 2023, denials rose more than 20 percent for private, commercial claims and nearly 56 percent for MA [Medicare Advantage] claims.” The American Medical Association has called for regulatory guardrails against health insurance companies using AI in this way. However, without strict government regulations, health insurance companies will be continually motivated to deny claims by labeling them medically unnecessary so the company does not have to pay.
Until there are laws or government regulations to protect patients from these inappropriate denials of health care claims, patients must protect themselves. AI is not just for health care providers or health insurance companies but patients can use AI to help them fight the health insurance companies. While AI is contributing to an increased number of claim denials, a high number get overturned but that requires the beneficiary to go through an appeal process. Data suggests that more than half of the claims initially denied can eventually be overturned by appeals. However, this process is purposefully difficult. A new tool uses AI to help patients draft a letter for the appeal process using the letter of denial from the insurance company and the individual’s review. This tool helps people know how to appeal, what to include, and quickly draft the document. The company is hopeful this helps insurance companies change practices by increasing the amount of successful appeals but until the health insurance companies change, people who have suffered can fight back.