Insurance denials seem to be a persistent reality – even when the medical need seems clear.  Many initial denials are in fact generated by a computer algorithm — so now there is a company that has trained an AI large language model to help write appeals – with significant success.

NBC News did a story recently  on Claimable, a company founded by a team of healthcare and insurance insiders, data scientists and technologists who are committed to challenging the 850 million denied U.S. health claims each year uisng the same technology insurance companies do to minimize expenses.  They follow the case of Stephanie Nixdorf in Davidson, NC and her successful appeal of denials.

Watch the story here:

AI is helping patients fight insurance company denials

Claimable website:

Getclaimable.com

Blue Cross authorized mastectomies and breast reconstructions for women with cancer but refused to pay the full doctors’ bills. A jury called it fraud and awarded the practice $421 million.

Read the full article on ProPublica:

“Slow Pay, Low Pay or No Pay”

Quick Summary:

• Blue Cross Green-lighted, then underpaid: Blue Cross Blue Shield of Louisiana (“BCBSLA”) approved over 7,800 mastectomies and breast reconstruction surgeries—but paid just 9% of the billed charges for them, averaging roughly $43 million on $500 million billed.

• Jury verdict: In September 2024, a Louisiana jury found BCBSLA committed fraud by authorizing procedures without ever intending full payment. They awarded the Center for Restorative Breast Surgery and St. Charles Surgical Hospital $421.5 million .

• Insurance tactics:

  • BCBSLA maintained that prior authorization didn’t guarantee payment and often bundled payments without provider agreement .

  • They flagged the center on “Targeted” and “Blocked” provider lists, which triggered deeper scrutiny and payment cuts.

  •  Thousands of pre-authorized claims were never paid at all.
  • BCBSLA received a “kickback” reward from other BCBS when it paid less for out-of-state patients..

  • Notably, BCBSLA signed one-off deals to fully cover treatment specifically for the wives of their own executives — highlighting inconsistent practices .

A Los Angeles-based company that owns more than a dozen hospitals in four states filed for bankruptcy late Saturday night, the second major system acquired by private equity to collapse in less than a year.  Prospect Medical Holdings, Inc., which owns hospitals in California, Pennsylvania, Delaware, and Rhode Island, says that operations will continue “as normal” during the Chapter 11 procedings, but can make no guarantees of the outcomes. Several facilities closed a couple of years ago, leaving areas without health care.

Read the CBS story:
Prospect Medical Holdings files for bankruptcy after owners took hundreds of millions in payouts

The bankruptcy is very reminicent of the collapse of Steward Health last year, another system which had been acquired by a private equity firm. Private equity firm Leonard Green & Partners controlled a majority stake in Prospect Medical.  Exactly like Steward, the Prospect management sold off most of its real estate and buildings to external real estate companies, which then rented the facities back to the hospitals at crippling rates.  Despite the fact that this maneuver resulted in an unsustainable situation for every one of the facilities, the management rewarded leadership a $457 million dividend in 2018; the Prospect Medical CEO, Sam Lee, took home about $90 million while Leonard Green shareholders were paid $257 million.

CBS News reported on the early impact of this maneuver, which resulted in the shutdown of several facilities:  CBS Mornings: Pennsylvania hospital shutdown spurs questions about private equity in health care

Read about the Steward Health Care Bankruptcy:
Steward Health Care Declares Bankrupcty Amidst Controversy

You may have missed the story that almost 25% of hospital emergency rooms are now owned by private equity firms – and are structured to focus on profit rather than health care:
Private Equity Gobbles Up Emergency Rooms

While this corrupt procedure is probably technically “legal,” in our opinion it should be against the law and individuals who knowingly cripple health care systems for their own personal enrichment should be jailed.

The Winston-Salem Journal picked the Debt Jubilee Project as the front page story on December 26, 2024. Richard Craver wrote an excellent article profiling our Christmas campaign, paired with an article on how other states can borrow NC’s new model for medical debt reduction.  This state program requires hospital systems to agree to forgive debts for qualifying low-income patients back to 2014 to obtain expanded Medicaid payments.

Read the full article:

Triad church paying off $2 million in medical debt in 12 counties – Winston-Salem Journal

Read about the NC DHHS program:

NC launches website for sharing medical debt relief plan with other states – Winston-Salem Journal

NC’s first-in-the-nation medical debt forgiveness program — inspired in part by our Debt Jubilee Project – is now being shared with other states that could follow suit.  The NC Department of Health and Human Services has created a website with a template that other states can borrow.

Under the plan, hospitals would forgive more than a decade of existing medical debt for eligible residents and work to prevent the accumulation of new debt going forward. Past medical debt that exceeds 5% of a person’s annual income will be relieved.  In exchange, hospitals receive higher levels of Medicaid reimbursement under the federal Healthcare Access and Stabilization Program (HASP).  Participating hospitals are required to curb aggressive debt collection practices for low-income patients, such as debt sales, excessive interest rates and home foreclosures.  Hospitals are required to meet and report on these and other milestones, as well as publicly post debt relief policies.

Several other states has encouraged hospitals to work with Undue Medical Debt, usually using state funds (as Pensylvania did) to purchase the debts at a steep discount through the charity.  However, NC’s plan of leveraging HASP funds was a new concept, and proveds the “carrot” to entice hospital systems to sign on.

Read more about it in the Winston-Salem Journal: NC Sharing Debt Relief Template With Other States

DHHS Website Press Release: NCDHHS Introduces Toolkit for States to Take Action on Medical Debt

Download NC DHHS Template PDF

Did you know that NC has the highest health care costs in the nation? 

Here are some ideas on how we can solve that from the Affordable Healthcare Coalition of North Carolina.

https://www.carolinajournal.com/opinion/nc-has-americas-most-expensive-healthcare-heres-how-we-fix-that/