It’s happened too often for San Francisco primary care physician Dr. Paul Abramson: an email or screeching fax denies insurance coverage for a medication or service he firmly believes a patient needs.
Appealing the decision can sometimes require hours of wading through medical records and crafting the precise language to persuade the insurance company to reconsider. It’s a process intended to induce exhaustion.
“What they count on is physicians and patients giving up in frustration,” said Abramson.
Many do. Insurers reject about 1 in 7 claims for treatment, according to some estimates, while doctors and patients appeal less than 1% of those denials. However, when they do, they’re successful in an overwhelming majority of cases.
Recently, Abramson has been testing a tool to help him stave off surrender: an AI product that generates appeal letters. In a few months of experimentation, he’s found that it saves time and energy and leads to more approvals for his patients. It’s also a satisfying middle finger to an intentionally adversarial system.
“It feels like an arms race,” he said. “They’re using technology to delay and deny care, and now we’re mustering technology to respond and produce more documentation in retaliation.”
The product, Fight Paperwork, is a professionalized version of Fight Health Insurance, a patient-focused appeals platform that San Francisco engineer Holden Karau launched last summer. Karau quit her job at Netflix this year to focus on empowering people to stand up to insurance companies. With her new tool, she said, she’s helping physicians “bite back” and “get care covered.”
“The system is so fucking broken,” said Dr. Leah Spieler, a primary care physician in Emeryville. She says Fight Paperwork — and other AI tools like Open Evidence, which can generate prior authorization letters — save her many hours a week of tedious work. They also preserve her brainspace to benefit her patients. “I didn’t go to medical school to spend my time figuring out the exact words that will get insurance companies to give my patients the medication that they need,” she said.
Since its launch in May, Fight Paperwork has helped doctors speed through the coverage denials their patients receive — more than a dozen each day in one case — and reduce insurance charges — from $1,000 to $20 in another. The company charges users on a monthly basis.
The platform has generated more than 6,000 appeals, and Karau and her cofounder are in marketing mode to reach more providers. Last week, the duo showed up outside a conference for therapists in downtown San Francisco, donning branded lab coats and furry hand puppets as a gimmick, raising both eyebrows and awareness of their tool.
“Mental health providers tend to be more solo practitioners, so they have even less time and support” for writing appeals, Karau said, noting that they’re among the biggest customers.
While AI tools help therapists, doctors, and patients “fight back,” as Spieler put it, the battle is hardly fair given the outsize resources of insurance companies, according to Dr. Harley Schultz, a retired physician in the Bay Area.
“I think an ‘arms race’ is optimistic, because it would imply that there are equal sides. It’s more of a mosquito bite that may cause them some inconvenience,” he said. “The whole system is unequal and skewed.”
Schultz said time-saving tools for doctors are a positive development, and perhaps if enough people start appealing denials, the “itch” on insurance companies will become noticeable. But, more likely, the firms will fight automation with automation — “their robot basically wrestles with your robot.”
“If the motivation was actually to get people the best care at the lowest cost, things would be done differently,” he said. In a better tech-driven world, insurance companies would use AI to flag anomalous care requests to review, instead of issuing what he describes as blanket denials.
Though Abramson appreciates the tool, he believes the problem of insurance denials must be solved by regulation. “There are no consequences to the insurance companies for wasting everyone’s time,” he said. “When there are more consequences, they will stop playing the game.”
California has proposed legislation that would force more transparency on pharmacy benefits managers, a middleman in the healthcare industry accused of driving up prices.
“It’s hard to find time to go to Sacramento to talk to legislators,” Abramson said. Fight Paperwork, meanwhile, is a small but manageable way to put his “time and energy into advocating for change.”