Source: SFStandard.com By Jillian D’Onfro
For San Francisco tech worker Holden Karau, paperwork had become a hobby.
Specifically, the forms and letters required to fight back when her health insurance provider denied a claim for a covered service, surgery, or pharmaceutical.
As a trans woman who loves motorcycles, she has required gender-affirming care and treatments for an accident in recent years, and received a spate of insurance denials along the way.
Instead of passively accepting the providers’ decisions, she’d spend hours writing letters and filling out forms to appeal. It usually worked: Out of roughly 40 denials, she won more than 90% of her appeals, she estimates. (She also successfully fought an insurance denial for her dog, Professor Timbit.)
“Part of that is an unreasonable willingness to take things too far,” Karau said. “There’s an enjoyment in getting a counterparty to follow the rules that they don’t seem to want to have to follow.”
“Most of the time, my relationship with my health insurance company is more adversarial than collaborative,” she said. “You’re trying to force them to comply with the rules, and they’re trying to spend the least amount of money.”
A Fight Health Insurance user can scan their insurance denial, and the system will craft several appeal letters to choose from and modify.
The “dirty secret” of the insurance industry is that most denials can be successfully appealed, according to Dr. Harley Schultz, a patient advocate in the Bay Area.
“Very few people know about the process, and even fewer take advantage of it, because it’s rather cumbersome, arcane, and confusing, by design,” he said. “But if you fight hard enough and long enough, most denials get overturned.”
It’s often assumed that only doctors can file appeals, but patients can do it too, he added. Insurers reject about 1 in 7 claims for treatment (Schultz estimates that it could be as high as 25% for some companies), and the reality is that physicians just don’t have time for all that filing.
“I was in practice for many years, and if I fought every insurance denial, there wouldn’t be any time to do anything else,” Schultz said.
While some doctors have turned to artificial intelligence themselves to fight claims, Karau’s service puts the power in the hands of patients, who likely have more time and motivation to dedicate to their claims.
“In an ideal world, we would have a different system, but we don’t live in an ideal world, so what I’m shooting for here is incremental progress and making the world suck a little less,” she said.
So far, dozens have used the platform to generate an appeal, and Karau is assessing their feedback to fine-tune the platform and make it more effective and easier to use.
She estimates that she has spent about $10,000 building the platform. It’s free for users, though she might eventually charge for added services like faxing appeals.
At this point, she’s not planning on leaving her tech job to work on the platform full time (she has held gigs at IBM, Apple, Google, and Netflix, where she currently works) but hopes it can become a self-sustaining business, in addition to a cause about which she’s wildly passionate.
“The best-case scenario — which is, admittedly, incredibly unlikely — is that this increases the accessibility of appeals to the point that insurance companies stop denying so much tiny bullshit,” she said. “I suspect that they would still try to be dicks about big things, but hopefully we can get them to stop being dicks about small things.”
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