Healthcare providers routinely use artificial intelligence to write exam notes, summarize lab results, and identify risk factors in patient charts. Now, the New York Times reports, they’re starting to use it to challenge coverage denials.
“For a growing number of doctors,” the Times wrote in a July 10 article, “AI chatbots—which can draft letters to insurers in seconds—are opening up a new front in the battle to approve costly claims, accomplishing in minutes what years of advocacy and attempts at health care reform have not.”
Dr. Azlan Tariq, a rehabilitation specialist cited in the article, turned to AI after burning dozens of hours on unsuccessful appeal letters and prior-authorization requests. Tariq’s patients included “a 45-year-old man who spent five months in a wheelchair while his insurer denied appeal after appeal for a prosthetic leg.”
Sound familiar?
Tariq told the Times that AI not only halved the time he spends on insurance filings but also improved his approval rate on prior authorizations from 10 percent to 90 percent. He uses a tool called Doximity GPT, which is a HIPAA-approved version of ChatGPT, the most widely used generative AI tool at the moment. Doximity GPT draws information directly from the patient’s chart, medical/scientific literature, and the insurer’s own policy language, so its correspondence is patient-specific, evidence-supported, and tightly focused on the actionable details of each individual case.
According to a survey by the American Medical Association, doctors and their staff spend an average of 12 hours a week preparing and submitting insurance paperwork. The same research showed that medical offices routinely drop winnable challenges because the paperwork burden is simply too high. Insurers use that to their advantage, deliberately drawing out cases until doctors and patients give up from sheer exhaustion.
The same dynamic surely exists among prosthetists. Although we couldn’t find a formal survey with hard evidence to document this trend, there’s strong anecdotal evidence that prosthetists spend gobs of time on insurance filings—and that they (and their patients) regularly settle for suboptimal prosthetic solutions rather than committing to round after round of claims, appeals, counterappeals, and so on. “Fighting with the insurance companies has taken its toll on practitioners,” veteran prosthetist Mac McClellan told Amplitude last year. “They now have tons more paperwork that takes them away from taking care of patients.”
Could generative AI serve prosthetists and amputees in the same way it’s benefiting doctors and their patients? It could—and it already is.
“I’ve used ChatGPT to craft letters of medical necessity,” we were told by one prosthetist, who would only discuss their clinic’s internal business practices on condition of anonymity. “I’ve used it to craft L-Code justifications to argue why each code that we’re trying to get covered is medically necessary for that patient. It has saved me tons and tons of time writing these, and often the chatbot is more articulate than I would be. Sometimes I’ll use a chatbot as a jumping-off point and then personalize it after the fact, which still saves 30 minutes of my time.” The prosthetist added that they have seen more approvals and fewer denials since they started using ChatGPT.
This practitioner did not want their name published for an interesting reason: The clinic manager wishes to avoid scrutiny from insurers. Because while there’s nothing unethical or illegal about filing claims with AI support, insurers might view it as a provocation in what the Times article refers to as “the AI arms race.” The insurers have their own AI bots, which are programmed to review claims in bulk and write responses. And just as our source is getting better at using AI to justify coverage, insurers are continuously getting better at using AI to deny claims. As one doctor told the Times: “Their AI will deny our AI, and we’ll go back and forth.”
There’s no telling where it all ends. But in the near term, if you’re working on an insurance appeal, it might be worth taking a shot with ChatGPT, which is an open-source program that you can use for free. Or it might be worth asking your clinic if they’d consider using AI to beef up an initial claim.
And if you’re a prosthetist or patient who’s already using AI to get the best coverage you can, let us hear from you: editor@livingwithamplitude.com.
