Employee Survival Guide® - Mastering Health Insurance Claim Appeals: Harnessing AI to Overturn Denials

Episode Date: February 19, 2025

Comment on the Show by Sending Mark a Text Message.Unlock the secrets of successfully navigating the convoluted world of health insurance claim denials with insights from my extensive experience as an employment attorney. Imagine turning the tide on denied claims with a success rate of 80% using an AI-powered service. This episode dissects the complexities of ERISA, the federal statute governing health insurance claims, and highlights the urgency of resolving claims due to medical necessity. Drawing from a recent Wall Street Journal article, I outline crucial steps to take when your claim is denied, shining a light on the fiduciary duties of insurance representatives and the importance of understanding your plan documents.Explore the transformative potential of GetClaimable.com, an innovative tool that leverages AI to craft compelling appeal documents. With 850 million claims denied annually, it's shocking how few are appealed; yet, many appeals result in reversals. Discover how AI, bolstered by authoritative medical literature, is revolutionizing the appeal process, offering hope to those burdened by unjust denials. This episode offers practical guidance on gathering comprehensive documentation and evidence, illustrating a significant advancement in the intersection of AI and healthcare claims that empowers patients to challenge the insurance status quo effectively.Links Mentioned In Episode:Five Steps to Take if Your Health Insurance Claim is DeniedState Assistance ProgramsPatient Advocate FoundationMedicare Rights CenterSolace Health DollarFor.org (nonprofit helps with hospital bills)Health Insurers Deny 850 Million Claims a Year. The Few Who Appeal Often Win GetClaimable.comPaxosappeals.comFixMyClaim.com If you enjoyed this episode of the Employee Survival Guide please like us on Facebook, Twitter and LinkedIn. We would really appreciate if you could leave a review of this podcast on your favorite podcast player such as Apple Podcasts. Leaving a review will inform other listeners you found the content on this podcast is important in the area of employment law in the United States. For more information, please contact our employment attorneys at Carey & Associates, P.C. at 203-255-4150, www.capclaw.com.Disclaimer: For educational use only, not intended to be legal advice.

Hey, it's Mark here and welcome to the next edition of the Employee Survival Guide where I tell you, as always, what your employer does definitely not want you to know about and a lot more. It's Mark and welcome back to the Employee Survival Guide for yet another thrilling little episode. Now, seriously, I do these episodes based upon what I'm reading, what I'm hearing, et cetera, but today's episode is about something that's really novel and new. And if you have a health insurance claim and you're trying to get it covered by an insurance

carrier, I have some pretty wild news for you. So a little context here. I'm an employment attorney by trade and I've been doing this for too many years. I think it's 28. And along the way, I would have cases brought to me where the people have health insurance claims and they're denied anywhere from cancer or drugs or whatever it is. And part of my work is involving ERISA as a federal statute, E-R-I-S-A. And you've heard me talk about episodes about short-term and long-term disability claims, but Arissa also covers health insurance claims.

And for health insurance claims, there actually is more rigorous process that is required because health insurance claims have to be remedied very quickly. And so you've heard about the Affordable Care Act, and you probably heard about the politics recently and the Biden during his election, trying to get these claims approved in such ways.

So that's a context, the appealing denials of health insurance carriers. And there's a new sheriff in town, and it's not, well, it's not me, but sometimes I am, but I know a few sheriffs. But in reality, it's an AI sheriff. And I'll get to that in a second. So I'm going to tease you with that.

There's an AI product out there that has just caught my attention. And I'm going to share that in a little bit. But I'm going to share also how I came about this information related to this podcast. So as a little background approach, if you're denied a claim for any type of welfare benefit, including disability or health insurance benefits, there's an appeal process you have to go through. For health insurance, it's quicker because you have to get these claims approved because it's a medical necessity issue. You've heard that phrase before.

And you need to, in health, and your survival requires it to have a ready response to a health crisis that happens. So you want your insurance company to be quickly covering your claims. And also, think about the idea of new novel medical treatments or procedures that are on the fringe but are making their way. It's usually how medical science works. And insurance companies do this old dance of denying those types of new novel approaches or off-label usage of, let's say, IVIG,

which is an acronym for cancer treatment for basic cancer patients. And they use it in off-label ways, such as treating multiple sclerosis. So let me get into it. On February 12th, 2025, I was reading the Wall Street Journal as I do every morning when I'm having my breakfast. And I'm a big breakfast person.

Can't start the day without it. And so the story was five steps to take if your health insurance claim is denied. And they quote this quote, over 850 million healthcare claims are denied annually. That's a lot of claims. And so they provided some very quick steps in this one article. They issued an end to the article in the same day, but I'll get to the five steps. The first one is read the plan. And you've heard me talk about the plan before, the plan document, the summary plan description. It's required under ERISA to put forth that lengthy document that contains so much verbiage, it gets your eyes and head

spinning talking about what's covered, what's not. And it's in your employee portal, it should be, or it's not going to be in your employment manual, but you have to read the plan. The plan will tell you if you have a claim that's denied what to do. Typically it's an appeals process. That process usually is set forth at the very end of the plan documents. You can always go to the end

to find what your appeals rights are. But it's a very lengthy plan document that is written obviously by lawyers. Congress did intend that the summary plan description be written in such a way to be understood by, well, you. And I say that and I laugh because it's so verbose and so legally written that it's not comprehensible. And I've read plans for a long time, and I still have to do my... My concentration level has to go up when I read these plain documents because

they can get mind numbing and I that's for me. I'm an attorney and I I Live and breathe reading plain documents amongst other things. Don't ask why I got into it I got into it because I did disability work years and years ago and I helped people I won claims and It you know, it helped me gave me enthusiasm to do this work. One claim at a time. You just, you know, you kick ass one time, you want to do it again, you keep doing it, you do it. And you meet people who will also do the same thing and you get encouraged and then you

realize that the dark side, like Star Wars, the dark side is the insurance company. So they deny claims for profit. I'll get to that in a second. So I'd segue, sorry. Five steps to deal with, if your insurance company denies your claim. Read the plan document, because it tells you about your appeal process.

Number two, take notes of calls and collect paperwork. I can't emphasize how important this is. When you call an insurance company, take your phone out and record them, and just so you have the adequate and accurate notes of what's being said to you. And I also ask you to write down what these claims people are telling you. They are fiduciary responsibility holders to you as the plan participant under ERISA and under various federal and state law.

They, at least under ERISA, they are fiduciaries and they cannot misrepresent what the plan says. They can't play games with you. That's why you just take down everything they say to you. Ask them questions about the appeals process. All that information can be used at a later point in time to argue your appeal because what you don't know is a lot of insurance companies claims people said what claims management was notorious for doing this for years and I hope they clean their act up but we used to make sure that all their calls, well, they were recorded

on their end, and we asked for the records, and they produced it to us, and it's called Soap Notes. So they're recording you, so you record them because it matters, and you want to catch them in their lies. And so they will say things that are intended to mislead you. And that's really troubling because a federal law passed by Congress said, don't do that. And there's a claim called 50, I'm sorry, section 502A3, which is a fiduciary breach of duty claim. And it basically focuses on claims process like representations made by claims people.

So take notes of calls, write down verbatim what they said and ask a lot of questions. And then next is collect your paperwork. I mean, these cases are appeals are just basically a culmination of all of your paperwork, everything. We're talking the medical tests, get your doctors to write letters, you can write your own affidavit of facts

about what had happened, interacting with the claims people at the insurance company, everything you can do to perfect your claim. I'll get into later, but you wanna get into, I used to do this a lot where in prior years with fibromyalgia and other conditions like chronic fatigue syndrome, we used to get medical studies from various notable places,

NIH, National Institutes of Health, to support the claim itself. So you wanna get export medical science to support what you're doing, and I'll get to that in a second. The third step, sorry, I'm segwaying today, it's fight back, call your insurance company, ask why the claim was denied, and ask them how to file an appeal.

Now that sounds pretty straightforward, but it's really, really important. And I'm just repeating that section two takes a lot of notes of calls and asking about how to file a claim, but again, this transparency aspect that the claim person on the other side has to be transparent with you about all the steps.

We're not talking vagary, we're talking specific. Make them, have them stay on the phone until you're satisfied, you know exactly what to do next. Because they actually represent you and they can't misrepresent things to you. That's what a fiduciary is. Fourth, get help. Now, I'm gonna segue into something here,

and I'll put the show notes of these various links, but state assistance programs, this is according to the article, and non-profits including Patient Advocate Foundation and Medicare Rights Center can help craft appeals. A startup called Claimable, which I'll talk about in a second, is trying to use technology to smooth the process.

You can hire an advocate, me, an employment attorney, looking through the directory or a third-party company. There's a company called Salus Health, and then the article goes on to say, non-profit dollar for help, help dollar for helps with hospital bills, and you can also ask your doctor's office or hospital to appeal for you and try to ensure that they keep you in the loop on their communications.

Now, I have a comment about that. Getting doctors and hospital insurance, hospital companies to help you in your claims process, good luck because they're not all that, on the same page, they're busy or whatever, but you really have to be on top of them to make them do that. And maybe they're just too busy, too many cases.

I mean, these doctors now are large run facilities, multiple medical practices combined together in these healthcare plans. Number five, escalate after the denial of a claim by filing the administrative appeal. I talked about that in a second, but an administrative appeal contain, I call it the kitchen sink approach.

It's your affidavit, it's all the medical files you've collected, doctor's letters writing on your behalf, medical science research reports that were about the particular subject matter or the particular medicine that was being treated or used, anything you can support your case, including a written appeal document, like on a Word document, writing it out,

here's factually what has happened, here's a citation to the record, whatever that's gonna be, and your argument about why the claim should be medically necessary and approved. You're talking about a reversal of the denial. So that's an appeal process. So five steps, read the plan, take notes of calls, and collect paperwork.

Three, fight back, ask about appeals and how to file them, get help, and five, escalate the denial of a claim by filing an appeal. The Wall Street Journal came out with another article when they got into, it was titled, Health Insurers Deny 850 Million Claims a Year. The Few Who Appeal Often Win. And I'll put the article links in the show notes.

And I'll read a little bit here. Health insurance, health insurers process more than five billion payment claims annually. Federal figures show about 850 million are denied according to calculations by appeals company Claimable. And it's getclaimable.com is the name of the company I'll talk about in a second. Based on data from health policy nonprofit KFF

and the Centers for Medicare and Medicaid Services. Less than 1% of patients appeal. That's crazy, 1%. That means the insurance companies have figured out the odds of you appealing, and guess who's winning? Insurance companies. So keep that footnote in your head. The article further says, quote, few people realize how worthwhile those labors can be.

Up to three quarters of claim appeals are granted, studies show. Patients who fight, deny claims, must marshal evidence for medical studies, navigate dense paperwork, and spend hours on the phone during what is often one of the most difficult times of their lives. They debate insurers over whether a patient might ever recover from a stroke or whether an expensive new treatment holds real promise. The article goes on to say, quote, because a lot of people won't appeal, won't call, don't have the knowledge to sit on the phone, a lot of those go away, said Dr. Emanuel, an oncologist and medical ethicist at the University of Pennsylvania.

The article further states the sense of futility that keeps people from appealing denied claims is part of the current of anger against insurers that surged in December after the assassination of a United Health Care Chief Executive Officer, Brian Thompson. Insurers say that to remain solvent, they must determine which crisis merit reimbursement and which don't. I saw that and I was just shocked. It's almost as if they've just arbitrarily chosen which was more or better. Insurers across categories face similar issues over who and what they'll agree to cover in mid-rising costs, including home insurance companies that have canceled policies under

increasing risk from that natural disaster. The article is just going into the environment now for insurance companies. Like, we care. You operate an insurance company and take premium, you better insure, not walk away from the table after a fire. So, those are the articles that came out in the journal

that prompted me to start to think and then share this information with you. Now, there are, the first company I'm gonna talk about is called GetClaimable.com, so it's GetClaimable.com. This website attracted my attention the most, and I'm gonna talk about it. For 40 bucks, $40, you can upload documents and get a written appeal based on your case in minutes.

This company uses an AI-generated device to write your appeal document. They claim an 80% reversal rate on their website for denials for medical insurance claims that are denied. On their website, they say, claimables, AI-powered platform, craft custom appeals backed by clinical evidence, policy insights, and your unique health history. Each appeal delivers powerful arguments to boost your chances of overturning the denial. Now, let me just talk about this issue because if you can, for $40, send them uploads of documents,

I mean, I don't know how many documents you can upload, but when you have a medical insurance claim denial, you have a lot of medical records. And the first hurdle is getting those records in a PDF format and then to synthesize those records because that's what I normally will do. I'll basically stack I mean we're talking sometimes claims that are you know two three inches thick

and I have to you know put them in order and write a fact pattern based upon what happened. That's the only way you're gonna understand the case because you have to understand when you're writing an appeal, this is an appeal to firstly claims insurance company, okay, this is what Congress envisioned. And then you have to write the appeal eventually to a court. So when you write an appeal,

you're dealing with a version of the administrative law and you wanna understand that if it ain't in the bucket of the claim, like in terms of there's no documents or supporting information, you can't go outside anywhere and get it later on. It's just closed loop. So you have to front fill everything into your claim before you ever get to a court. God forbid you go that far. So think that in your head, and you can't put enough information, too much information, in a claim appeal. I actually always enjoy just gathering as much information

I could, I would reuse studies for various cases over and over again, and just throw them into a PDF maker and make it, and today's technology allows to do it very quickly. But I would, I'm explaining this for a reason because I'm going to tell you the answer. I would cull through, and we're talking hours of time of an attorney review of looking at all of the medical information and taking the best pieces out of whether it's an insurance soap note or a conversation with a client by a claims person and what the quote

was or what they said or what the doctor said or what the denial letter wrote because the denial letters when you get them from the insurance carriers they are required required to state specifically. Let's take a quick break. Hey, it's Mark and we have a new product for you. Let's take a quick break. It's Mark, and we have a new product for you. It's called the Employee Survival Guide or Employeesurvival.com. And it's a site that you can obtain PDF products that I created myself.

I was spending too many hours, way too many, researching and writing about, for example, the performance improvement plan or beating them. And the second one about negotiating severance negotiation agreements, two of the most important topics that we see in terms of the web traffic and podcast traffic we have. So check out Employeesurvival.com and see if this can try to help you and you don't need an attorney to use it. Thank you. Everything factually or why the claim was denied.

They just can't say it's not medically necessary and you can say go F yourself, okay? And you may get that feeling when you read one of these letters, because I certainly did. I had to deal with it for my wife's situation and yeah, I did the same thing I'm talking about. And you know, we appealed it and wealed it, and there was a medical thing, I can't really get into it, but it was denied not for medical necessity.

And it was a serious issue, so I'll just point that out. And lo and behold, the insurance company denied it. And I actually will say that I used a patient advocate. There's a patient advocate in Connecticut, in most states. They are the, I can't tell you, I'm an employment attorney and I know how to do this, but they are really good. And they're good because they will call

the insurance company directly and get on their case about why the claim should be approved. And I just can tell you, you need to engage patient advocates in these cases, and also an attorney if you need to. But the patient advocate I use, and I'm an employment attorney, I know how to do this, I still used one because I wanted to use every resource I could. So myself, the doctor, and also the patient advocate, we hounded the insurance company. We got the claim approved, because that's what I do, I get claims approved, but I found that resource really compelling and worthwhile,

and they were super nice, and they're free. I mean, tax dollars at work, I suppose. So, when I go through a process to write a fact pattern for an appeal, I'm telling you this story, I take all the information two inches thick, and I synthesize it down and it takes hours and I charge money for that process for a client because I'm able to do that

because I'm trying to build a case for the future potentially of a claim denial and I have to file an appeal to a federal district court. And what if the appeal is denied by the federal district court? Then I have to appeal to the Second Circuit Court of Appeals and I've done all of that. And guess what?

That claim record, I had to nail it down from the beginning before I even filed a lawsuit, and so I had to go through this process. So now I'm gonna tell you something. Claimable.com, their AI service, can do the hours of work that I was generating before in minutes. I mean, I've actually seen an example appeal

and they write factual arguments. I wouldn't say that they write legal arguments or not attorneys, the AI device is not. And they're using similar arguments that I would write, but they will take the fact pattern and the evidence in the fact pattern and synthesize it in the way that I would do it. And for $40, hell, that's a good purchase to buy.

If they claim that the rate of success on reversal is 80%, that's worth it. I mean, and we all have had our experience, if you have not yet, with AI devices where you upload documents into it for the synthesized something. So here, claimable.com or getclaimable.com is doing that to help the average person,

even if you don't have an attorney, to make an appeal of a claim that needs to be done quickly because you're in the middle of getting something, you know, treatment and you want to save a loved one's life or your own or whatever it is you're going through. Sometimes that really does help to push the balance over to get insurers to react to and pay claims. Now, that's a really huge development in the area of medical necessities and denials, which are obviously we now know,

there's 850 million claims a year of denials, and that's a lot. And so if you have this new feature of AI that's coming to the market, and for $40, you gotta use it. I mean, it's just silly not to do so. There are two other versions of different companies. One's called paxoappeals.com. So it's paxo appeals, I'm sorry,

I'm not even saying it right, paxos appeals, P-A-X-O-S-A appeals.com. And they claim a 90% reversal on previously denied claims and over $2 million in coverage obtained from patients. Again, I'm taking that from their website. It's not clear from this website whether they use an AI-generated outcome of written appeal or not.

You can't tell the type of costs associated with the service. They offer a free case review and then that's tier zero and then they have a tier one, two, and three reviewing and writing the appeal for you, but it does not appear if it's comprehensive in terms of argument writing or I can't tell after looking at the site whether it's any automated AI devices writing the appeal for you. I read in between the lines, looked like there were people actually doing it to help you. And the next company is called FixMyClaim.com. This company provides for support in dealing with medical behavior, health, and substance abuse challenges

claims, ensuring that they receive, people get the benefit they want. They say that their seasoned advocates deliver end-to-end solutions including billing, claims processing, pre-authorization, utilization review, verification of benefits, and writing appeals. I think that they kind of cover both angles of helping businesses, but also help writing appeals. I think that they kind of cover both angles of, you know, helping businesses but also help writing appeals for individual patients. Again, these are all focused at the area of health insurance claim denials. Again, FixMyClaims.com doesn't really have, and I'm not making, these are not advertisements for these, for these companies. This is just me telling you what they are. FixMyClaim.com does not have,

I can't see if there's any AI type of automation that's happening there. I will tell you that in reviewing the three different companies, they're essentially mimicking what ERISA case law, you know, what courts, you know, in their cases, decisions, there's typically tactics or arguments that courts and lawyers use to make arguments. And it's not clear from any of the three that they refer to a risk of case law at all. They do, claimable.com does refer to the Affordable Care Act,

and they do refer to state laws as well. But there's a thing about health insurance claim denials. It's governed by health law, both federal and also state, so then it has murky area. I won't get into the specifics of it, but from the getclaimable.com website, there's no angle of the lawyer writing the thing for you, the written appeal, that's what you need.

You have it done very quickly. So maybe it's a combination of solutions here of using a device like this, like GetClaimable, to generate the appeal document for you, and have that, you know, maybe you can afford an attorney, so maybe that's a very worthwhile purchase for you for $40, if you can manage to upload the correct information on their website, and, you know, try it.

And maybe you try it in try if you have an attorney, if you find an attorney, finding an Arisa attorney actually is difficult. I don't know if you know that, but when you look for an Arisa attorney, look for health insurance denials as kind of a search term, hopefully people doing their SEO marketing for you

on their websites, you can come across them. So it's a really gigantic development in the claims process for health insurance claims reviews because they have to be done so quickly, so quickly, and the insurance companies have to render decisions like within 10 days or less very quickly depending upon the context of each type of claim,

so that the person who's, the family who's getting the treatment has coverage. I mean, we all have heard the horror stories of people even filing bankruptcy because they have medical claims that are through the roof and not covered. And who's causing this? Health insurance companies denying 850 million claims a year.

That's insane. And it's all that greed and profit. And I gave you a little short vignette story about myself and how to deal with myself. I mean, I laughed when they denied the claim because of the issue for my wife's situation was relatively straightforward, but yet they just deny claims.

And I've had cases where clients have had serious medical problems and they deny claims outright because you just gotta understand one thing with insurance companies. They're gonna tell you no 10 times. And you have to respond with a hundred times saying You're better say yes because it is medically necessary and it's fighting the medical necessary type of Debate with insurance companies and if you ask yourself, what is medically necessary and you can look this up by the way

It's it's a vagary that's abused to the nth degree by insurance companies. They think they can outwit you. And one more point I should say, because I just remembered it, GetClaimable.com brings in through their AI device all of the medical information literature out there on the web, like from NIH, National Institutes of Health, or any area, and draws it into the appeal document for you. I thought that was the most incredible thing about it, that they were able to draw it in. So if you had some medical claim that was on a fringe or some coverage of drug treatment, whatever, it would draw all of that supporting medical evidence

into the claim appeal record for you automatically, quickly. That was the most astounding thing that I found because it takes a lot of research to do that manually. You have to find an attorney who's aware of the particular medical condition, if you're lucky to find the person, who's aware of all that current research study. I mean, there's a lot of research studies out there.

I mean, it's just overwhelming. But did you know that medical necessity is determined by what? All the medical research studies. It's kind of a closed-loop system of their own making. It's like, you know, and they cherry-pick stuff of what's supportive and what's not. And they actually produce their own studies, literally produce studies that favor insurance company denials. And I know that sounds insane, but that does happen, okay?

It's in the world we live in. So, Claimable with their AI service, again, captured my attention because it was able to draw out from the published material out there, like PubMed or something, where there are studies and synthesize that for you very quickly into your own individual style, written appeal just for you about your own case with that insurer, okay? So that's a big development. I can't emphasize how much.

I'll put all the notes or the citations and the links in the show notes, and you can click through that. But again, in summary, a lot of claims on IELTS, but now we have a new weapon, new sheriff in town, and that is, and remember this particular one, and it's not advertising, it's called getclaimable.com, and they will, if they do what they say,

they can't false advertise, but but $40, what a bargain. So this is another example of how AIs marching into the healthcare sector, into the employment sector, because people get their health insurance through their employers, and I've came across it myself, and was just dumbfounded, like, this is a huge development. So there you have it, AI in the medical necessity arena and claim denials, and you can read

about all the different links in the show notes. And that's what I do. I bring you what I'm looking at and I put it into a podcast for you. Thanks for listening, and don't forget to review review and I'll give you another stories and episode very soon. Thanks. If you like the Employee Survival Guide, I'd really encourage you to leave a review. We try really hard to produce information to you that's informative, that's timely,

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