Hospitals and health care professionals are increasingly relying on artificial intelligence (AI) technology to help with efficiency and to improve care. But there may be ways for you to use it as a tool for better understanding your coverage and avoiding unnecessary payments, too.
In a recent WebMD Reddit AMA, Erin Bradshaw, executive vice president for the advancement of patient services and navigation from the Patient Advocate Foundation, addressed user questions about how to lower health care costs. Here, she explores the ways in which AI could help in that pursuit.
“AI is advancing diagnoses and the ability to review charting and helping doctors dictate their notes so they can spend more quality time with their patients,” says Bradshaw. “So I feel like that's the same way that we need to approach it from the consumer place.”
She believes in savvy use of AI. This means using it as a tool to make the process more efficient and you a more informed consumer while being aware of how these products are using and storing your personal information. AI may help you get answers faster, organize information more efficiently, and better understand what you're looking at. But when it comes to making important decisions or resolving complicated problems, you still need to talk to a person.
"I look at AI as taking the knowledge of a skilled advocate and allowing technology to accelerate the review and identification of what's in the material and coming back with outcomes faster," Bradshaw says. "That allows a human interaction to then invest the time to review and modify as needed for accuracy."
Below, she explores some ways you can use AI as a stepping stone to better self-advocacy as you navigate your health care coverage.
Help Translating Complicated Terms
Every medical service, prescription, and insurance claim can involve different sets of paperwork and rules. You may receive a bill from a provider, an explanation of benefits from your insurance company, notices about deductibles or coinsurance, and documents outlining what your health plan does and does not cover.
You might pay a bill without realizing a charge was processed incorrectly. You might miss an opportunity to appeal a denial because you don't understand the insurer's reasoning. Or you may avoid asking questions altogether because the language feels overwhelming and you don’t understand it.
"It's a very complicated topic," Bradshaw says. "Health care information is scattered across many layers."
Many people pay more than necessary simply because they don't fully understand how their health insurance works. Deductibles, copays, coinsurance, formularies, prior authorizations, and provider networks all affect what you'll ultimately pay out of pocket, but the rules can be difficult to navigate.
"Cost comes down to a lot of that," she says. "It's lack of knowledge and understanding that can lead to higher cost because it's all based on a contractual design of the plan, which gets very complicated."
AI may help by translating insurance language into plain language. Instead of reading through dozens of pages of plan documents, you can ask direct questions about what a term means, whether a service may be covered, or how your deductible works. Some insurance companies have even started incorporating AI-powered assistants into their apps and websites to help members understand their benefits.
Bradshaw says she has experimented with some of these tools and believes they can be useful for answering basic questions and helping understand the fundamentals of your coverage.
Reviewing Bills and Insurance Documents With AI
Even when you have both a bill and an explanation of benefits in front of you, it can be difficult to tell whether the numbers match or whether a charge has been applied correctly. Bradshaw says AI may be able to help identify potential issues by comparing documents and highlighting areas that deserve a closer look.
"It could flag something in the billing between a bill and an explanation of benefit that does not look accurate," she says.
That doesn't mean AI can tell you with certainty that a charge is wrong. Instead, it can function as an extra set of eyes. If the tool identifies a mismatch, you can use that information as a starting point for a conversation with your insurance company or your provider's billing department.
The key is to think of AI as a screening tool rather than an expert authority. You don’t want to rely on AI to make decisions for you, says Bradshaw. Instead, it can help you spot questions to ask.
Help Starting Insurance Appeals
When insurance denies a claim, often it comes with a lengthy letter filled with policy language and medical terminology. AI can help you organize this information and prepare for an appeals process. For example, you can use your denial letter along with supporting medical records and ask an AI tool to summarize the situation, identify key issues, or draft an appeal letter.
"If I have a denial letter, and I have a bunch of medical charts and I want to contest what they're denying, I would hope that with all the information that's provided, that AI could provide me a first-round output of how we could argue this," she says.
But she stresses that AI-generated appeals shouldn’t be used as final documents. Instead, you should use them as a starting point to help you understand your case before speaking with insurers, clinics, or advocates who can help move the process forward.
In many situations, the most valuable outcome may not be that AI solves the problem, but that it helps you understand the problem well enough to advocate for yourself more effectively.
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SOURCE:
Erin Bradshaw, executive vice president, advancement of patient services and navigation in program development, Patient Advocate Foundation, Hampton, Virginia.
