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Larner Associate Professor of Pediatrics Deirdre O’Reilly, M.D., M.P.H., was quoted in a Guardian story about health insurance denials.

Two of her three sons have severe food allergies, so O’Reilly was worried about sending one of them out of state to college. When he had a reaction, he went to the emergency room like usual. But this time, the insurance company denied coverage for the entire visit—nearly $5,000, according to a denial letter reviewed by the Guardian. O’Reilly tried to appeal four times, and each time, the insurer, BlueCross BlueShield of Vermont, gave her a different reason, she said.

“My son didn’t have a choice—he was going to die if he didn’t go to the nearest emergency room,” O’Reilly said.

She should know; she’s an intensive care physician at �պ�����. She has seen denials like these happen to her own patients, such as premature infants who have oxygen equipment denied.

“It’s gotten out of control. It’s changed a tremendous amount in the 20 years I’ve been a physician,” she said. “I can’t believe that people have to go through this just to get healthcare covered—things that are basic needs.”

And many people don’t have the same medical expertise and the time or resources for lengthy appeal processes.

“I was tenacious,” she said. “But at some point, I could only fight so much.”

AI can help make sure forms are coded and formatted according to each insurer’s specifications, making sure the requests aren’t kicked back for being incomplete. It could also be used by insurance companies to approve insurance requests more quickly.

Most denials happen because of mistakes in filling out or filing the form, a UnitedHealthcare spokesman said, estimating that 85 percent of denied claims could be avoided “through technology in a more standardized approach across the industry.”

But having human oversight of automated processes is a needed change, experts said.

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