Recent tool will help fight medical insurance denials

Health-care payments company Waystar on Monday announced a recent generative artificial intelligence tool that will help hospitals quickly tackle considered one of their most expensive and tedious responsibilities: fighting insurance denials. 

Hospitals and health systems spend nearly $20 billion a yr attempting to overturn denied claims, in accordance with a March report from the group purchasing organization Premier. 

“We expect if we are able to develop software that makes people’s lives higher in an otherwise stressful moment of time after they’re getting health care, then we’re doing something good,” Waystar CEO Matt Hawkins told CNBC.

Waystar’s recent solution, called AltitudeCreate, uses generative AI to robotically draft appeal letters. The corporate said the feature could help providers drive down costs and spare them the headache of digging through complex contracts and records to place the letters together manually. 

Hawkins led Waystar through its initial public offering in June, where it raised around $1 billion. The corporate handled greater than $1.2 trillion in gross claims volume in 2023, touching about 50% of patients within the U.S. 

Claim denials have change into a hot-button issue across the nation following the deadly shooting of UnitedHealthcare CEO Brian Thompson in December. Americans flooded social media with posts about their frustrations and resentment toward the insurance industry, often sharing stories about their very own negative experiences. 

When a patient receives medical care within the U.S., it kicks off a notoriously complex billing process. Providers like hospitals, health systems or ambulatory care facilities submit an invoice called a claim to an insurance company, and the insurer will approve or deny the claim based on whether or not it meets the corporate’s criteria for reimbursement. 

If a claim is denied, patients are sometimes liable for covering the associated fee out of pocket. Greater than 450 million claims are denied annually, and denial rates are rising, Waystar said. 

Providers can ask insurers to reevaluate claim denials by submitting an appeal letter, but drafting these letters is a time-consuming and expensive process that does not guarantee a special end result.

Hawkins said that while there’s been lots of discussion around claims denials recently, AltitudeCreate has been within the works at Waystar for the last six to eight months. The corporate announced an AI-focused partnership with Google Cloud in May, and automating claims denials was considered one of the 12 use cases the businesses planned to explore.

Waystar has also had a denial and appeal management software module available for several years, Hawkins added.

AltitudeCreate is one tool available inside a broader suite of Waystar’s AI offerings called AltitudeAI, which the corporate also unveiled on Monday. AltitudeCreate rolled out to organizations which are already using Waystar’s denial and appeal management software modules earlier this month at no additional cost, the corporate said. 

Waystar plans to make the feature more broadly available in the long run. 

“Within the face of all of this administrative waste in health care where provider organizations are understaffed and do not have time to even follow up on a claim when it does get denied, we’re bringing software to bear that helps to automate that have,” Hawkins said.