Can I use AI to Appeal Medical Claim Denial?
Short answer is yes. Over 20% of medical claims are denied (ACA marketplace denial rate is ~19% (CMS). 73 million in-network claims in 2023 were denied. And less that 1 percent appealed.
Insurers increase margins through claim-denial workflows. We are being diplomatic.
AI in healthcare medical claims is very lightly regulated. Generally there is supposed to be real person reviewer and evaluate but how often do they simply sign off on the AI denial.
Some insurer AI systems evaluate likelihood of patient follow-through, raising fairness concerns. Again, diplomatically said.
Are there online companies that use AI to help me fight AI?
Yes, several online companies now use AI to help individuals appeal denied medical claims, making the process faster and more accessible than traditional methods. These services typically generate personalized appeal letters using your specific situation, policy details, and medical records, saving you hours of research and drafting.
Leading AI Medical Claim Appeal Services
- Fight Health Insurance offers a free, AI-based tool where you can upload your denial letter and relevant documents. The system then generates a comprehensive appeal letter tailored to your requirements.
- Claimable is another service that focuses on AI-generated, personalized appeals. Their process involves a detailed questionnaire and yields evidence-backed letters for a flat fee of about $40 per appeal. This platform specializes in medication-related denials but is expanding its coverage.
- Counterforce Health is a nonprofit platform that provides free, AI-based appeal letters for a variety of health claim denials. It can also automate follow-up calls with insurers to reduce the administrative burden for patients.
- PenguinAI and Aegis Health are geared more towards clinics and healthcare providers but use similar AI-driven technology to automate the appeal and denial management process.
What to Expect
- These platforms ask you to upload your denial letter and any supporting documents.
- Their AI reviews your case, matches evidence from medical literature and policy regulations, and crafts a multi-page appeal letter.
- Some, like Counterforce Health, also use AI to make automated follow-up calls to insurance companies.
- Experts generally recommend having a human review the AI-generated letter before submitting, to ensure accuracy and completeness.
This new generation of AI-powered services can be an effective first step in contesting denied claims, saving you time and increasing your chances of success.
What is the Cost?
The cost of AI-powered medical claim appeal services varies depending on the company:
- Claimable charges a flat fee of about $40 per appeal, regardless of the outcome. There may be additional charges for shipping the letter if you want them to send it directly to your insurer or regulators.
- Counterforce Health provides its AI appeal service completely free to patients, made possible through grants and nonprofit backing.
- Fight Health Insurance also offers a free tool where users upload their denial and receive a personalized appeal letter.
- Some platforms offer the ability to print or fax appeals for a small fee (for example, $5 for direct faxing or document mailing).
What About Next Steps and Insurer Reply/Rebuttal?
Most paid services charge a simple per-appeal flat fee rather than ongoing subscriptions or percentages of recovered amounts. Free options are expanding, offering significant value for patients needing help with the appeals process.
Most AI-powered appeal services do not typically handle direct, ongoing conversations with your insurer once you have submitted the appeal. Their main service is generating and preparing your initial appeal letter; after that, you are responsible for sending it in and managing the responses.
However, one notable exception is Counterforce Health, which introduces an AI assistant called Maxwell. Maxwell can make follow-up phone calls to insurance companies, request updates, check the status of appeals, and document responses. This reduces the patient’s need to repeatedly call or navigate phone systems. Still, this level of automated follow-up is unique to Counterforce Health, and most other services focus strictly on document generation rather than real-time communication or negotiation with insurers.
In summary, if you want a service that helps automate insurer follow-up and status calls—not just generating appeal letters—Counterforce Health is currently your best bet among AI-powered platforms.
Frequently Asked Questions
Can I use AI to appeal a denied medical claim?
Yes. Several AI platforms can generate personalized appeal letters based on your denial letter, policy details, and medical documentation. These tools simplify the appeal process and often increase the chances of success.
Are AI-generated appeal letters effective?
They can be very effective, especially when the denial is tied to policy wording or incomplete documentation. Experts still recommend having a human review the AI-generated letter for accuracy before submitting.
Is it legal to use AI to fight insurance denials?
Yes. Patients are legally allowed to create their own appeal letters, whether written manually or produced with AI. These tools do not replace legal advice—they simply help organize and draft needed documentation.
How much do AI appeal services cost?
Prices vary: Claimable charges around $40 per appeal, Counterforce Health offers a free nonprofit option, and Fight Health Insurance also provides a free AI tool. Some services may add small fees for mailing or faxing.
Do AI services submit the appeal for me?
Most services only generate the letter; the patient submits it. Counterforce Health is an exception—their AI assistant “Maxwell” can place follow-up calls to insurers and monitor status.
Do AI tools help with follow-up after the appeal is submitted?
Most tools do not offer follow-up. Counterforce Health is currently the only platform providing automated insurer phone-call follow-up.
Do I need to upload my denial letter?
Yes. All major AI appeal platforms require your denial letter so they can analyze the insurer’s rationale and reference the correct policy language.
Are AI appeal tools safe to use with medical information?
Reputable services follow HIPAA-compliant data handling practices, but patients should always review the platform’s privacy policy before uploading sensitive documents.
Can AI help with prior authorization denials?
Most tools can handle both claim denials and prior authorization denials. Some services, such as Claimable, specialize in medication-related issues.
