AI-powered platform helps patients fight denied insurance claims

The average American spends approximately $13,500 a year on health care, CMS.gov says, and as a share of the nation's GDP, health spending accounted for 17.3% – close to the same percentage of health care claims that are denied by insurance. At the intersection of health care and insurance stands Claimable, an AI-powered appeals platform that helps patients craft custom appeals in response to denied insurance claims. “We are trying to get everybody access to the health care that they need, deserve and ultimately pay for,” said Zach Veigulis, chief AI officer and co-founder of Claimable. “We feel that health care denials prevent patients from access to care, and access to health care is just as important as health care itself.”

Mr. Veigulis, until recently a lecturer at the University of Iowa Tippie College of Business and former chief data scientist for the U.S. Department of Veterans Affairs, launched Claimable with co-founders Alicia Graham, chief operating officer, and Warris Bokhari, chief executive officer, in October. The Sacramento-based company was named Startup Technology Company of the Year at the Technology Association of Iowa's 2024 Prometheus Awards, held this year in Des Moines, where Mr. Veigulis resides. “There's about five billion medical claims a year in the United States,” Mr. Veigulis said, and approximately 17% are denied. “That number ends up being about 850 million a year, and of those 850 million, only 1.7 million a year appeal,” he added. The phrase “not medically necessary” accounts for approximately 2% of denial explanations for in-network claims in the Affordable Care Act Marketplace. “It's not a clinical term, but it's a term that's used by insurance companies a lot to deny care,” said Mr. Veigulis, adding that it’s common for companies to even ignore the appeals of medical professionals, jeopardizing medical treatment for the patient. “That's where Claimable can come in at any time after this denial, and we're trying to change behavior to be the first line. That's ultimately what we want to do,” he said.

How it works

Training the AI model to generate an effective appeal was “a massive task that took several months,” Mr. Veigulis said. To accomplish this task, the team fed the model peer-reviewed, up-to-date scientific and legal literature, clinical research and appeal precedents over a six-month period. The result is a platform that generates appeals with an 87% success rate and a resolution of 10 days or less, he said. “You can come to our platform and leave in a half an hour or less with an incredibly compelling appeal that advocates for you using the highest scientific evidence, cases of precedent and the best legal protections, all for a small flat fee,” he said. The patient story is the most compelling component in crafting the appeal, Mr. Veigulis said. “We want insurance companies to see these patients as people, not as (a) member ID,” he said. “There is a person at the end of this that is often – majority – almost always incredibly impacted by this denial. It's life-altering.”

Navigating the website is fairly straight-forward. Customers create an account and click the “Start your appeal” button at the top of the home webpage, then follow a series of steps that include a brief overview of the medical condition being treated and the denied treatment, uploading a copy of the denial letter – which is optional – and personal insurance information. Generating the appeal takes 30-60 seconds, and the user can review the appeal before taking subsequent steps, with the option to send copies to three additional persons who may impact the outcome. “We call them influencers,” said Mr. Veigulis. “Those people can be plan executives, legislators, senators, reps, so on, within the state that are relevant to the patient's case; Department of Insurance, Department of Labor, CMS (Centers for Medicare and Medicaid Services), and even the (customer’s) employer.” The appeal is sent to the customer and the insurance company that denied the claim, as well as the optional three “influencers,” for a fee of approximately $40 – a modest sum when compared to the thousands of dollars some face in medical bills. Mr. Veigulis estimates the company has saved customers $3.5 to $4 million in health care costs for the claims they’ve processed so far, which number less than 100. “But we have plans to rapidly scale now that we do have a live platform that's open to the public,” he said.

HIPAA compliance

To keep sensitive medical information private, Claimable uses a HIPAA compliant cloud service that encrypts information that is transmitted.

“We take the security component incredibly seriously,” Mr. Veigulis said. “We never sell your data, for one – that's completely off the table for us. Your health care data, all of the infrastructure that we have is completely HIPAA secure. The AI models are completely protected. “Another thing that we've done a huge deal of, related to the same wheelhouse, is we've built this in a methodical way that doesn't require a human in the loop,” he continued. “Therefore, we can keep costs very low, while still ensuring quality,” adding that the process is designed to build appeals incrementally, a strategy aimed at minimizing the risk of errors or inaccurate information. Multiple models are deployed to evaluate the output of the letter before it’s presented to the customer, “which then becomes our final validation that everything is accurate,” he said.

What Claimable covers

Claimable currently facilitates appeals for 70 critical treatments, with a focus on frequently denied medications for individuals with autoimmune disorders and migraines – conditions that impact nearly 65 million Americans. The company noted that, aside from certain rare diseases, it only supports appeals for treatment-condition pairs approved by the FDA for the specific indication. The treatments encompass various drug formats, including subcutaneous injections, intravenous infusions, and other delivery methods. However, “we're rapidly expanding into other conditions and other types of services, like imaging and other medications and surgeries,” said Mr. Veigulis. “We hope to expand to 100 medication services in 2025.”

How it started

A former boss introduced Mr. Veigulis to Dr. Bokhari, who had been exploring how language models could support health care appeals. “(He’s) seen a lot of how the highest levels of technology intersects with health care,” Mr. Veigulis said, estimating that between himself and his co-founders, the three have approximately 50 years of health care and data science experience between them. Prior to launching the company, Dr. Bokhari led health care strategy and innovation at companies like GE, Apple Health, Anthem, and Amazon, while Ms. Graham led growth, product, and design for companies like Kaiser, CareFirst, Amgen, Disney, and Truepill. During his tenure at the Department of Veterans Affairs, Mr. Veigulis specialized in advanced analytics, creating machine learning models to predict diseases before they developed, uncovering new applications for existing medications and using data insights to broaden access to healthcare. “Those are the roles that are kind of distinct between each one of us, and the kind of team we needed to build in order to accomplish and build the product that we have," Mr. Veigulis said. As transformer models in generative AI like ChatGPT gained prominence, the trio saw an opportunity to apply similar technology to a new challenge: helping patients navigate health care appeals. “That's where the intersection of all of our skills came together,” he added. Claimable officially incorporated in July 2023 after closing their funding rounds, going full time in April 2024 before launching the product in October. “We ultimately want to see a health care system where every person has equitable access to health care,” Mr. Veigulis said. “We want to see providers (have) the ability to practice autonomously, so they don't burn out and leave the field. And we believe that providers and physicians are the most qualified individuals to work with a patient to get them what they need, and we don't believe insurance should have a role in dictating what a patient needs as far as healthcare goes." So, what’s the future of health care and insurance when faced with AI platforms like Claimable? “We believe the change in health care is going to be economically driven,” Mr. Veigulis said. “We also believe that there's a lot of work to be done on the policy and regulation side. Ultimately, we want to eliminate the ability for insurance companies to target individuals that they believe can't or won't appeal; to deny their claim and prevent them from access to health care…ultimately, getting patients access to the health care they need and deserve is our number one goal.”