AI for PA

As health plans increasingly rely on technology to deny treatment, physicians are fighting back with chatbots that synthesize research and make the case.

At his rehabilitation medicine practice in Illinois, Dr. Azlan Tariq typically spent seven hours a week fighting with insurance companies reluctant to pay for his patients’ treatments.

He often lost.

There was the 45-year-old man who spent five months in a wheelchair while his insurer denied appeal after appeal for a prosthetic leg. Or the stroke survivor who was rehospitalized following a fall after his insurer determined his rehab “could be done at home.”

Over the course of Dr. Tariq’s 12-year career, these stories had become more common: The list of treatments that needed pre-approval from insurers seemed ever broadening, and the denials seemed ever rising.

So in an effort to spare his patients what he deemed subpar care, and himself mountains of paperwork, Dr. Tariq recently turned to an unlikely tool: generative A.I.

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.

“We haven’t had legislative tools or policymaking tools or anything to fight back,” Dr. Tariq said. “This is finally a tool I can use to fight back.”

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.

“If you want to see a physician go apoplectic at a cocktail party, mention prior authorizations,” said Dr. Robert Wachter, the chair of the medicine department at the University of California, San Francisco.

The process was designed by insurance companies to keep health care costs down by reining in doctors’ use of unnecessary and expensive treatments.

But Dr. Jonathan Tward, a radiation oncologist based in Utah, said insurers often demanded so much exhaustive documentation and paperwork — even for standard cancer treatments — that he felt he was on the losing side of a “war of attrition.”

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. 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.

Then, he can tell the chatbot to make it four times longer. “If you’re going to put all kinds of barriers up for my patients, then when I fire back, I’m going to make it very time consuming,” he said.

Dr. 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.”

While A.I. is still primarily used by individual, tech-savvy doctors, a growing number of companies are trying to bring the technology into the mainstream.

Epic, one of the largest electronic health record companies in the country, has rolled out a prior-authorization tool that uses A.I. to a small group of physicians, said Derek De Young, a developer working on the product.

Several major health systems are piloting Doximity GPT, created to help with a number of administrative tasks including prior authorizations, a company spokeswoman said.

But the insurance companies aren’t sitting still, either. Chris Bond, a spokesman for America’s Health Insurance Plans, said insurers welcomed attempts to streamline the process, including those involving the “appropriate use of A.I.”

Dr. Jeff Levin-Scherz, a health policy expert at the Harvard T.H. Chan School of Public Health, said he believed that most health plans were at least evaluating how to use artificial intelligence in their claims review process, if they weren’t using it already.

At the same time, these A.I. tools may make it easier for ill-intentioned players to bill for medically unnecessary treatments, Dr. Levin-Scherz noted.

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. 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.”

Dr. Wachter said he hoped that some day, with more advanced A.I. technology, insurers and providers could create a new system that relies less on sending letters back and forth and more on automation.

Insurance coverage could be automatically approved based on an algorithm’s analysis of the most up-to-date scientific literature, for example. An A.I. tool might also notify a doctor that the $100,000 drug she’s about to prescribe could be substituted with a similarly effective $250 pill.

Until then, many doctors are enjoying a newfound, if temporary, foothold in the battle over insurance claims.

“It is definitely an A.I. race,” Dr. Tariq said, “but I think it wouldn’t be fair if the physicians didn’t have A.I.”

https://www.nytimes.com/2024/07/10/health/doctors-insurers-artificial-intelligence.html?