Joani Reisen was in her 40s when she was diagnosed — along with her son — with attention-deficit/hyperactivity disorder (ADHD), and for about a decade she treated it with a prescription drug called Concerta.
“It focuses me,” she told CBS News Philadelphia [1] in a story published Sept. 15. “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.”
But back in April, when she went to refill her prescription, she was told it was no longer covered by her health insurance, according to the broadcaster. That’s because the drug contains methylphenidate, which the insurer had classified as “experimental.”
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Methylphenidate is the same active ingredient found in similar ADHD medications such as Daytrana, Ritalin and Aptensio XR.
Reisen was told by her insurer, Independence Blue Cross (IBX), that she’d have to switch to a generic version of the drug. But she says that version didn’t work for her; instead, the drugs made her fall asleep.
“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.”
When she lost her appeal on two separate attempts, which included assistance from her doctors, she then turned to a different resource: artificial intelligence (AI).
How AI can help
HealthCare.gov insurers denied nearly 1-in-5 claims (19%) for in-network services in 2023, according to an analysis from the Kaiser Family Foundation (KFF) [2]. Fewer than 1% of these denials were appealed, and 56% of appealed denials were upheld.
Millions of Americans have been diagnosed with ADHD. It can be expensive to treat, especially without health insurance. The cost of Concerta, in particular, could be prohibitively expensive. According to Drugs.com, 100 tablets could cost from $1,267 to $1,457 depending on the dosage [3].
To help her access the medication that worked for her, Reisen says she turned to a free AI platform called Counterforce Health, which aggregates research and regulations related to specific drugs or treatments to write data-backed appeal letters for patients. It’s a free service made possible through grants from the National Institutes of Health and the University of Pennsylvania.
“We’ve trained it on tens of thousands of successful appeals,” Counterforce Health co-founder and chairman Neal Shah explained to CBS News Philadelphia. “It’ll know the right strategy for you, and then spit something out.”
Reisen’s third appeal, which used AI, included an 11-page appeal with cited research. A process that might normally take hours could be completed in minutes.
“I would never have been able to send all that research in, especially without medicine,” she said. “Trying to sit down and write a report like that would have been insane for me.”
Reisen sent the letter to the Pennsylvania Insurance Commission’s external review panel, which approved her appeal, reports the broadcaster. Now, she says, she’s going through the same process to get her son’s ADHD medication approved as well.
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CBS News Philadelphia reports a statement from IBX claims Reisen’s initial request was denied because it didn’t include a diagnosis, and that an external physician who reviewed the first appeal overlooked it.
“A second external physician reviewer ultimately identified the diagnosis in the medical records and appropriately approved the medication for coverage,” the statement continued. “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.”
A few cautions
Counterforce Health is one of several AI-based platforms developed to help Americans appeal a claim. Other platforms include Claimable and Fight Health Insurance.
While AI can be incredibly useful for digging through data and making evidence-based arguments, there’s still a need for human intervention — on both sides of the health insurance spectrum.
Indeed, some insurers, including UnitedHealth, Humana and Cigna, were served class-action lawsuits over claims that denials for coverage have been influenced by the use of automated algorithms powered by AI.
And algorithms aren’t infallible.
“Algorithms are only as good as the data they are trained on. If the training data reflects biases, the AI will perpetuate them. For example, claims from certain demographics or geographic areas may face higher rates of denial due to skewed data,” according to the law office of Gianelli & Morris in California [4].
But for consumers using AI to draft appeal letters, human oversight is equally as important. Make sure your personal details and medical information are accurate and check citations and links to look for inconsistencies or inaccuracies.
If you’re using an AI platform, check their security and privacy policy (Counterforce Health says it uses a HIPAA-compliant infrastructure to protect patient data).
But other generative AI tools may not be as self-regulating, which can pose privacy and security risks. Never share personal identifiable information or medical information with a chatbot (and you doctor shouldn’t, either).
Also, inaccuracies could mean your claim could be denied, so don’t completely rely on AI.
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Article sources
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[1]. CBS News Philadelphia. “Philadelphia area woman believes AI helped her fight health insurance denial”
[2]. Kaiser Family Foundation. “Claims Denials and Appeals in ACA Marketplace Plans in 2023”
[3]. Drugs.com. “Concerta Prices, Coupons, Copay Cards & Patient Assistance”
[4]. Gianelli & Morris. “How AI Is Failing Insureds: The Dark Side of Automation in Health Insurance”
This article provides information only and should not be construed as advice. It is provided without warranty of any kind.