How to Use AI to Take Control of Your Health Insurance
You can use AI to help you fight health insurance claim denials, pick a policy, understand your coverage and more.
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However, AI can make mistakes. Always do your own research directly with your health insurance company and with experts, and use AI to help you understand the big picture.
How you can use AI with your health insurance
Fight health insurance claims denials with AI
AI tools can help you fight your insurance company if they won't pay for your care.
- You can use tools such as Fight Health Insurance, Counterforce Health and Claimable to help you fight a claim denial.
- You upload your health insurance info to the AI tool, and then it drafts an appeal letter specifically for your situation.
- Some AI tools, like Counterforce and Claimable, say they have a 75%-80% success rate at getting companies to pay medical bills.
When your health insurance doesn't pay for your medical care, it can be frustrating. Even worse, it can leave you with devastating bills you might not be able to afford.
If your health insurance claim gets denied, filing an appeal could help. Filing an appeal means you're asking your health insurance company to take another look and decide if you have coverage or not.
Most health plans allow you to formally appeal a denial, and in some cases, request an independent review. But the process can feel technical and overwhelming. AI tools can help you simplify the process by organizing your documents and drafting a clear, structured appeal.
Health insurance claims can be denied for a lot of reasons.
If you truly don't have coverage for a procedure, such as elective surgery, appealing the denial won't help you get your bills paid.
But claims are sometimes denied because of administrative errors, and some are even denied without a firm reason being given. This is where AI tools can help.
AI can review your policy and find reasons why your care should have been covered. It might also be able to suggest different documentation you can get from your doctor, such as proof that a treatment was medically necessary.
About 20% of all health insurance claims from marketplace plans were denied in 2023, according to KFF.
Most people don't challenge denied claims. But when a claims denial is challenged, it's possible that you can get your bills covered. Around 44% of denials were overturned when challenged, which means the health insurance company paid for the medical care they originally denied.
But AI isn't a perfect solution. The tools can still make mistakes, and you have to make sure you give them accurate info. You also have to make sure you understand your health insurance company's rules. Filing an AI-assisted appeal after the deadline has passed won't help you get your bills paid.
Use AI to pick a health insurance plan
AI can be a helpful tool when comparing health insurance plans.
You can use a tool such as ChatGPT, Claude or Gemini to help you understand how each plan you're considering might pay for your health care bills. Choosing a plan isn't just about choosing the cheapest monthly rate, although price is definitely important. You also need to think about a plan's:
- Deductible
- Copays
- Coinsurance
- Out-of-pocket maximum
- Prescription drug coverage
- Network of doctors
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You can upload details about a plan's coverage to an AI tool along with your expected medical needs. For example, let the tool know if you have regular doctor visits, what medications you take and if you have a chronic condition. The tool can review your medical needs and the plan's coverage to see if a plan is a good fit for you.
Even after that, I ran a few calculations of my own, and they confirmed the conclusions that the AI tool had come to. I was able to pick a plan with more confidence after having seen AI model different scenarios for me."
You'll never know exactly how much or what kind of medical care you'll need in a given year. But AI can help you understand how much you'll have to pay with certain plans and your typical medical needs.
Understand your policy benefits with AI
Health insurance is complex, but AI can help you make sense of your policy.
After you upload your policy, you can ask AI to:
- Summarize your costs, such as your deductible and copays
- Explain what counts toward your deductible
- Outline coverage for things such as mental health care or physical therapy
- Clarify if you need referrals for certain doctors
- Identify medical care that requires prior authorization
You can also ask specific questions, like whether or not your policy covers a certain medication or treatment.
But AI isn't always right. It's possible that an AI tool could tell you something about your policy that isn't true, such as the cost for a medication or whether or not a specific treatment is covered.
Before making plans to get certain medical care, or if you want to make sure you understand your specific coverage, call and talk directly to your insurance company.
Use AI to estimate your health care costs
AI might be able to help you figure out how much your medical care could cost.
You can upload your policy documents to an AI tool, for example, and ask how much you would have to pay for a routine doctor visit or a specialist visit for a specific medical issue. The tool can estimate average medical costs in your area and compare them to your plan's coverage.
You could even ask AI to model different scenarios for you, such as how much a procedure would cost before and after you've met your deductible. If the care you need isn't urgent, having this info could help you decide when it's best to start treatment.
Be careful and cautious when using AI to estimate your medical bills.
AI tools can review your health insurance plan and give you some guidance on what a certain procedure will cost, but health care billing is complex. It's not likely that AI can give you an exact breakdown of a bill.
If you completely trust AI's answer on what a medical service costs, you could be left with major bills to pay if the AI was wrong. If you need or are considering expensive medical care, talk to your insurance company first to understand how much you might have to pay.
Make sense of your medical bills with AI
Medical bills can be complex and confusing. AI can be a helpful tool to break them down.
You can paste a bill into an AI tool and ask it to clearly explain each charge.
AI tools may be able to:
- Translate billing codes
- Explain different fees on your bill
- Find errors and duplicate charges
- Draft questions for you to ask your doctor's billing department
However, when it comes to specific financial questions, especially those around medical care, you should talk to your doctor or hospital's billing department for the most accurate info. An AI tool can give you guidance and even help you figure out what questions to ask the billing department. But you shouldn't rely on it solely to decode your bills.
Sources
Sources for this article include KFF, Claimable, Counterforce Health and Fight Health Insurance.
About the Author
Insurance Writer
Cate Deventer is a ValuePenguin writer who specializes in health insurance, Medicare, auto and home insurance. She's been a licensed insurance agent since 2011.
She started her insurance career working as a customer service agent for State Farm. She later moved to an independent agency, where she worked with several insurance companies and hundreds of clients. She quoted policies, filed claims and answered insurance questions. In 2021, she pivoted her career and began writing about insurance for Bankrate. She moved to ValuePenguin in 2023 and began writing about health insurance and Medicare.
Cate has a passion for helping readers choose insurance to fit their needs. She enjoys knowing that her research and knowledge help people choose insurance products that make a positive difference in their lives.
How insurance helped Cate
Cate used her health insurance knowledge to navigate a surgery in 2023. Understanding how her policy worked let her focus on recovery instead of worrying about bills.
Expertise
- Health insurance
- Medicare & Medicaid
- Auto insurance
- Home insurance
- Life insurance
Credentials
- Licensed Life, Accident & Health Insurance Agent
- Licensed Property & Casualty Insurance Agent
Referenced by
- CBS
- NBC
- Wall Street Journal
Education
- BA, Theatre, Purdue University
- BA, English, Indiana University
Editorial note: The content of this article is based on the author's opinions and recommendations alone. It has not been previewed, commissioned or otherwise endorsed by any of our network partners.
