In Constant Battle With Insurers, Doctors Reach for a Cudgel: A.I.

Excerpt – For a growing number of doctors, A.I. 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. [..]

Doctors are turning to the technology even as some of the country’s largest insurance companies face class-action lawsuits alleging that they used their own technology to swiftly deny large batches of claims and cut off seriously ill patients from rehabilitation treatment.

Some experts fear that the prior-authorization process will soon devolve into an A.I. “arms race,” in which bots battle bots over insurance coverage. Among doctors, there are few things as universally hated. [..]

Doctors and their staff spend an average of 12 hours a week submitting prior-authorization requests, a process widely considered burdensome and detrimental to patient health among physicians surveyed by the American Medical Association.

With the help of ChatGPT, Dr. [Utah radiation oncologist Jonathan] Tward now types in a couple of sentences, describing the purpose of the letter and the types of scientific studies he wants referenced, and a draft is produced in seconds. [..]

Dr. [Illinois rehabilitation medicine physician Azlan] Tariq said Doximity GPT, a HIPAA-compliant version of the chatbot, had halved the time he spent on prior authorizations. Maybe more important, he said, the tool — which draws from his patient’s medical records and the insurer’s coverage requirements — has made his letters more successful.

Since using A.I. to draft prior-authorization requests, he said about 90 percent of his requests for coverage had been approved by insurers, compared with about 10 percent before.

Generative A.I. has been particularly useful for doctors at small practices, who might not ordinarily have time to appeal an insurer’s decision — even if they think their patient’s treatment will suffer because of it.

Nearly half of doctors surveyed by the A.M.A. said that when they didn’t appeal a claim denial, it was at least in part because they didn’t have the time or resources for the insurance company’s lengthy appeals process.

Dr. Michael Albert, an obesity medicine specialist in Oklahoma, said A.I. had enabled his small, resource-strapped telehealth practice to go from almost never appealing insurance denials to sending 10 to 20 appeals per week.

Now, Dr. Albert said he could “operate at the same level as companies that have essentially infinite resources.” [..]

As doctors use A.I. to get faster at writing prior-authorization letters, Dr. Wachter said he had “tremendous confidence” that the insurance companies would use A.I. to get better at denying them.

“You have automatic conflict,” said Dr. [chair of the medicine department at the University of California, San Francisco Robert] Wachter, who wrote a book about digital technology in medicine. “Their A.I. will deny our A.I., and we’ll go back and forth.”

T Rosenbluth, New York Times, 2024.7.10