Insurance Companies are Using AI to Block Claims
Revolutionizing Patient Care: The Power of Pre-Qualification with AI
This article was recently published by Propublica.org.
It is unfortunate, but health insurance companies have been heavily relying on artificial intelligence (AI) for at least the past five years. You can debate the why and get muddied down in how it’s not right that they are rejecting claims every 1.2 seconds, but knowing how they work and having your own AI on your side can make a significant difference.
There is a Disconnect
The problem lies in the fact that health insurers and the doctors that work for them are disconnected from the well-being of their insured patients.
In a quote from a Cigna executive, they stated, “Why not just deny them all and see which ones come back on appeal? From a cost perspective, it makes sense.”
This attitude not only blocks access to needed medical treatment but also creates physician burnout, medical staff dissatisfaction, and significantly impacts medical device sales across the surgical marketplace. Cigna knows that over half of all rejections are never appealed. That blocks care.
Fighting the Denial is a Losing Proposition
If you are a surgeon or a key decision maker in the medical device industry, having a mitigation strategy in place to address this issue is essential. While it may be tempting to set up seminars with surgeons to teach them how to fight and appeal denials, this technique only works in 41% of cases. A better solution is to start the process with a better patient that is easier to move through the prior authorization process. Here is data from the Kaiser Family Foundation showing that denied claims are rarely appealed and insurers across the industry uphold 59% of all denials.
Better Strategies are Needed
Two-thirds of surgeons and staff in the post-COVID era are overworked and are not going to tolerate constant arguing with insurance companies.
Appeal strategies that start at the end of the process create situations where surgeons do not want to do the case.
The case becomes simply too hard to approve regardless if it is the most innovative option for their patients. That hurts patient access to innovation, surgical case volumes, and it is costing medical device billions of dollars in lost revenue.
Solutions That Work
In 2017, I founded Nemedic with the goal of revolutionizing the healthcare industry by putting patients first. Our mission is to improve the lives of patients by creating a seamless and efficient healthcare experience that not only prioritizes their needs but also ensures that they receive the most innovative procedures available. We believe that patients should have access to cutting-edge medical technology, and we work closely with medical device companies and surgeons to make this a reality. At Nemedic, we are passionate about creating better partnerships between all stakeholders in the healthcare ecosystem to improve patient outcomes and promote innovation in the industry.
At Nemedic, we use AI and deep knowledge of health insurers’ algorithms to design a better process for finding and scheduling patients. By pre-qualifying patients with humans-in-the-loop and AI, we ensure that patients coming in, need, want, and can afford surgery and can better qualify for procedures. We have designed a better process of finding and scheduling patients. Patients that hopefully pass the denial process and automatically get approved. Patients that do not require a peer-to-peer meeting. Patients that can qualify for innovative procedures. Our process is better for everyone… Patients, Surgeons, and Medical Device. It not only saves valuable time for surgeons but also helps to reduce the number of rejections and denials from health insurers.
It’s just like if you were selling your home. Would you ever show your home to someone who was not pre-qualified for a loan? Of course not. It is too much hassle. Just like showing your house to the right home buyer, we add the right kind of cases to the surgical practices we work with. Too much hassle is what is going on in surgery right now and it is crushing case volumes.
Managing the Mix of New Procedures
By helping manage the mix of new procedures, we help innovative surgeons get back to doing what they love while making more and creating a better practice life. With over 9,000 surgical patients triaged we know we have a successful process that works. Instead of arguing at the end of the process, why not start seeing a more qualified patient that is easier to approve.
Optimizing the Prior Authorization Process
A Personal AI Note Assistant has several advantages:
Efficiency: Intelligent algorithms can now rewrite surgical notes to meet stringent insurance criteria, significantly reducing the wait time for authorizations.
Simplicity: Say goodbye to the back-and-forth with insurers. Optimized notes mean fewer peer-to-peer reviews and less administrative burden.
Speed: Faster authorizations lead to quicker patient care. With an AI Note Assistant, you’re not just improving processes; you’re enhancing lives.
Now is the Time
At Nemedic, we take the randomness out of delivering innovative surgical care, while bringing in more patients who want innovative procedures. If you are a surgeon or a key decision maker in the medical device industry and would like to start making a greater impact in the lives of patients, sign up now.
With an AI note assistant on your side you can take back your Prior Authorizations.