If your health insurance denies a claim, this tool uses AI to help you fight back

Lexi Klomhaus was in the hospital when her health insurance changed—she’d just turned 26 and had been kicked off her parents’ plan. Despite endless calls to her new insurer, it took a week to get a response about her treatment, a mental health program. Then the insurer denied coverage for the care that her doctor said was necessary.

It’s a depressingly common situation: In one survey last year, nearly one in five Americans said their health insurance company had denied a claim over the past 12 months. Patients either end up with big bills or avoid healthcare that they need because they can’t afford it. The majority of patients don’t even know they have the right to appeal. Others often don’t attempt it because the insurance industry has made the process as complicated as possible. The appeal rate is miniscule. In plans purchased through Healthcare.gov in 2021, for example, less than 1% of patients appealed their denied claims.

But Klomhaus had happened to see a TikTok video talking about a new tool that uses AI to help patients quickly draft an appeal letter to their insurer.

“Though my [medical] provider cares, they do not have the time to truly get to bottom of this,” Klomhaus says. “I’ve learned through this process that your best advocate is yourself. Given the fact my provider was not able to effectively help me, and the exhaustion and confusion of navigating this process so far, the thought of drafting a letter was daunting. I felt I had no idea what I was doing or where to start.”

The new tool, called Fight Health Insurance, immediately helped. Within about eight minutes, she had a letter to send her insurer. With a few tweaks, and after asking her doctor to review it, she started the appeal process. When we spoke, the process was still underway.

Fight Health Insurance asks patients to upload their letter of denial, with a step that automatically removes personal information. Then it uses AI to begin drafting a response. “We’ll try to infer a bunch of things about the denial—we’ll use the AI system to guess what the procedure is, what the diagnosis might be, and why it’s medically necessary,” says Holden Karau, the software engineer who developed the tool. After patients review those details, the tool uses AI again to generate a few options for the appeal. “It’ll be like, ‘Hey, these are the different ways that we think you could appeal this decision—choose the one that you think matches your situation the best,’” Karau says.

Karau started working on the tool as a side project after dealing repeatedly with health insurance denials herself as a transgender woman. “When I was at a specific company, they didn’t want to cover certain procedures, and there was a fair amount of advocating for them to actually cover them,” she says. “In doing that, I met a bunch of other people who shared that problem, and that convinced me that it was pretty common.” She’d also dealt with denials for a motorcycle accident. Finally, when her pet insurance company denied a claim for anesthesia for her dog, she decided to do something to tackle the problem.

“I was at a data conference, and so my brain was in a different headspace,” she says. “I was like, ‘You know what, we could maybe use some of this for health insurance.” Later, at a hackathon, she built an early prototype, and when she realized it could work, kept refining the tool. It’s free to use, and Karau is continuing to refine and develop it in her spare time.

The tool helps patients get over the first barrier: not knowing where to begin. Often, because of limited time, their doctors can’t help. “I had no idea how to write an appeal—I had no clue what to include,” says Andrea Blitzer, whose health insurance refused to pay for IVF treatments. Using the tool, she quickly fired off an appeal, and has filed additional appeals as the company continues to refuse coverage. (Filing the appeal itself is often antiquated, with insurers requiring a fax or mailed letter. Fight Health Insurance hopes to eventually help with this step as well.)

There’s no guarantee, of course, that an appeal will work. But one set of data suggests that more than half the claims that are initially denied can eventually be overturned after appeals. (Fight Health Insurance doesn’t know the results of its tool so far; it’s not tracking data for privacy reasons, though it gives users the option to share their contact info, and will follow up for feedback when it’s been in use longer.)

It’s possible that the tool can begin to nudge the insurance industry to change. “I have the personal belief that a lot of the denials we get are kind of bogus, and other people share that belief as well,” Karau says. “Right now, when the health insurance company denies something, most of the time they don’t have to pay out anything—so that’s a win for them. But I think if most of the time when they did a denial, they had to pay it out and they also had to process some additional paperwork on top of it, they might not deny as much stuff.”