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‘Make your health insurance company cry’: One woman’s fight to turn the tables on insurers (sfstandard.com)

submitted 2 months ago by kalkulat@lemmy.world to c/health@lemmy.world

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"... The “dirty secret” of the insurance industry is that most denials can be successfully appealed..."

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[–] moktor@lemmy.world 27 points 2 months ago* (last edited 2 months ago)

Gave it a go. Seems like it has potential. I'm still working through an appeal. My wife ended up in the ER in May and was directly admitted to the hospital for emergency surgery. Ten days afterwards we received a letter from the insurance company saying they had decided it wasn't medically necessary so they wouldn't be paying the $67k bill.

It has been a journey trying to get the appeal together. I had hoped the hospital would at least assist with a letter from one of the many physicians that attended her, but nope. We got laughed at by the surgeons office and told condescendingly "Yeah, that's not how any of this works. "

My biggest concern from the AI generated appeals are being able to confirm the statements it is making isn't just a LLM hallucination. As a lay person, much of the things necessary to make an argument are paywalled out of reach. For example, the insurance company cited the "2023 InterQual criteria for Surgical Conditions" as the reason why they are denying it. The AI appeal that was generated states that per the 2023 InterQual criteria for surgical conditions that hospitalization was medically necessary.

The only way it seems you can actually get access to InterQual is as a medical provider / payer.