AI Brings New Hope to Patients Battling Denied Health Insurance Claims

If your health insurance company has ever refused to cover a claim, you’re not alone. Nearly 20% of in-network claims are denied every year. Consumers appeal fewer than 1% of them.

Now, a growing number of tools can help, using the power of artificial intelligence (AI). One startup company, Claimable, said it can generate custom appeals in under 30 minutes, helping cut the red tape that often discourages people from challenging coverage decisions.

How AI Appeals Work

Tools like Claimable and Fight Health Insurance use AI to guide people through the insurance appeals process and generate appeal letters to contest denials. Claimable asks you to take a 25-minute survey about your case, then supplements your story with peer-reviewed evidence and relevant state and federal laws to generate a letter. 

Zach Veigulis, co-founder and chief AI officer for Claimable, compares it to having insurance, medical, and legal experts helping you with your appeal.

“What would take someone 30 to 50 hours, even if they were educated in writing an appeal, we’ve reduced that down to 30 minutes,” Veigulis said.

Claimable charges a flat fee of $39.95–win or lose–plus the cost of shipping the letters to your insurance company and other relevant parties, which could include the state insurance department, the federal Department of Labor, your employer, and even local politicians.

Claimable doesn’t cover everything. It files appeals for 75 medications across more than a dozen conditions. But Veigulis said the company aims to handle appeals for all conditions.

Fight Health Insurance, a free alternative, asks you to upload your denial and other relevant documents to generate an appeal letter with the help of a chatbot. Alternatively, you can use a general-purpose chatbot like ChatGPT or Google Gemini to help draft an appeal letter, but they aren’t trained specifically for this purpose.

What to Watch For

Patient Advocate Foundation (PAF) helps people with chronic and life-threatening illnesses navigate the health insurance system. Caitlin Donovan, a spokeswoman for the foundation, said writing a letter is a big hurdle for many patients. But if you use an AI service, Donovan recommended at least having a human review it for inconsistencies. 

“Obviously, having a really skilled person who knows how to work the system, and what levers to pull at the right times, is going to be better for you than an AI-generated Word document,” Donovan said. But, she said, not everyone has access to these services. “Something is better than nothing. The underlying cause of this is that our system is so complicated and so biased against the patient that we’ll take all the help we can get.”

Donovan recommended that patients use PAF’s guide to appealing denials to help.

A Growing Problem for Patients

Many health care providers say denials are increasing. And they may be becoming more complicated. Donovan said 10 years ago, PAF case managers would typically spend 22 calls resolving a case. Today, it’s up to 30. 

In many cases, Veigulis said, insurers issue denials that go against their own medical policies. Or their medical policies are stricter than accepted clinical guidelines. 

In some cases, insurance companies make decisions for non-medical reasons. For example, on July 1, CVS Caremark removed weight-loss drug Zepbound from its formulary to “balance access and affordability.” It changed its preferred obesity treatment to Wegovy. Claimable has created an appeals strategy for the patients who could be affected, Veigulis said.

The Bottom Line

Health insurers deny millions of claims each year, but few are appealed. Companies like Claimable are stepping in to help with AI tools and creating customized appeal letters for a flat fee. But experts say you should have a human review these letters for accuracy. As denials rise, AI tools may offer an easy first step in challenging health insurance decisions.