Philadelphia area woman believes AI helped her fight health insurance denial
When Joani Reisen said her health insurance suddenly cut off coverage for her critical medication, she turned to an unlikely source for help.
Independence Blue Cross (IBX) is the leading health insurer in southeastern Pennsylvania, serving approximately 3.5 million people. For months, it denied repeated requests by Reisen's doctors to cover Concerta, the brand name for the prescription drug methylphenidate, which is used to treat attention-deficit/hyperactivity disorder (ADHD).
The Delaware County woman said she's relied on the medication for more than a decade.
"It focuses me," she said. "I didn't get diagnosed till I was in my 40s, when my son got diagnosed, and I remember taking my first medication pill and going, 'Wow, is this what normal people feel like?' It was like all the noise shut down around in my brain."
She said it also helps her manage her business.
"I run live e-commerce shows on Whatnot, and it's fast-moving, fast-paced," Reisen said. "You're going at it and concentrating on selling just that one item. … I tried to do it without medicine, and it was a disaster."
Dealing with denial
But when Reisen went to refill her prescription in April, she said she was told it was no longer covered. In a letter from her detailing the denial, IBX said it classified the drug as "experimental." Reisen was told she'd have to switch to a generic version of the drug instead.
"I would love to be able to take the generic more than anybody, just not only for a financial reason, but for ease that I don't have to go through this battle," she said. "It just doesn't work. It made us fall asleep out of nowhere."
Nearly one in five Americans with health insurance have had a health care claim denied. When even her doctor's assistance wasn't enough to win her appeal on two separate attempts, Reisen used artificial intelligence to help make her case.
"I can't even tell you the hours that I've spent on the phone just trying to get this medicine," she said. "I was at my wits' end, and my husband said, 'Oh my God, Joani, I recorded this thing for you, there's this company.'"
The company is called Counterforce Health. The AI platform generates customized appeal letters based on a patient's insurance, aggregated research and record of successful appeals related to the drug or treatment. It's a free service made possible through grants from the National Institutes of Health and the University of Pennsylvania, said co-founder and chairman Neal Shah.
"The average person would have to take eight to 10 hours and go parse through hundreds of medical journals, parse through databases and do a lot of manual research, labor and writing," Shah said. "The AI system can do this in less than two minutes."
Your right to appeal
Patients rarely appeal denied health insurance claims, Shah said, citing this analysis from the Kaiser Family Foundation showing fewer than 1% of denied claims appealed.
But when claims are appealed, it's often in the patient's favor. KFF found that in 44% of cases, the original decision was overturned.
"Patients don't fight back, they don't appeal, they don't know their rights, they don't know how to do it," Shah said. "Denials are a roadblock to care, and if people simply took the time to appeal, or if people made it easier to appeal, more people would do so."
Shah said he envisions a world where appealing an insurance denial is as easy as purchasing something on Amazon.
"We've trained it on tens of thousands of successful appeals," he explained. "It'll know the right strategy for you, and then spit something out."
His mission is personal after Shah said he, too, was forced to navigate the appeals process while he cared for his wife as she battled cancer.
"Everybody should know about it"
Reisen used Counterforce's software on a third appeal to the Pennsylvania Insurance Commission's external review panel. The software generated an 11-page letter with cited research and hyperlinks.
"It had everything proving why this is not experimental," she said. "I would never have been able to send all that research in, especially without medicine; trying to sit down and write a report like that would have been insane for me."
Reisen said she hoped sharing her experience would help others.
"Everybody should know about it," she said.
CBS News Philadelphia contacted IBX about Reisen's case. In an emailed statement, the company refuted Reisen's claim that AI influenced the outcome of her appeal.
IBX claims Reisen's requests for coverage were initially denied because her diagnosis was not included. An external physician then reviewed her appeal, "but unfortunately overlooked the correct diagnosis of ADHD," an emailed statement read. "That led to a notice of non-coverage, which we understand was disappointing and frustrating."
The statement from IBX went on to read: "A second external physician reviewer ultimately identified the diagnosis in the medical records and appropriately approved the medication for coverage. We are reviewing this error with the external physician responsible for the incorrect denial of the expedited appeal and are exploring ways to strengthen oversight to prevent such an error from occurring again. Our members' health and how they experience health care is our top priority, and we are committed to continuously improving our process. While we do expect that use of AI will play a growing role in healthcare, it did not influence the outcome of this particular case."
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