When a medical insurance claim is denied, patients often face a difficult choice: abandon needed care or navigate a complex appeals process alone. Most choose the former, with industry data suggesting fewer than 1% of denied claims are appealed, despite patients having a legal right to challenge such decisions. This gap in the healthcare system has prompted innovative solutions, including AI-powered platforms designed to level the playing field between individuals and large insurance companies.
One such platform is Claimable Inc., co-founded by Zach Veigulis, who serves as the company’s Chief AI Officer. Veigulis brings experience from his previous role as chief data scientist at the U.S. Department of Veterans Affairs Innovation Center, where he worked on applying data science to improve veteran services. His background informs Claimable’s approach to using artificial intelligence to help patients generate evidence-based appeal letters for denied medical claims.
The platform analyzes a patient’s medical history, relevant clinical guidelines, and applicable legal protections to create customized appeal documents. According to information shared by the company and verified through multiple news sources, Claimable reports achieving approximately an 80% success rate in reversing denials for certain conditions, though specific disease categories were not detailed in the available sources. This success rate suggests that AI-assisted appeals may significantly improve outcomes compared to self-filed appeals, which historically have lower success rates.
Recent media coverage highlights growing interest in AI tools for healthcare navigation. A segment featured on NBC News discussed how artificial intelligence is helping patients fight insurance company denials, noting that such technologies can reduce the administrative burden on both patients and healthcare providers. Similarly, the Corridor Business Journal reported on AI-powered platforms assisting patients in challenging denied claims, emphasizing the potential for these tools to improve access to prescribed treatments.
In Iowa, where Claimable has operational roots according to local reporting, the Des Moines Register explored whether an AI startup with regional connections could help patients win battles with insurance companies. The article noted that Veigulis’ work bridges his government experience with private-sector innovation, aiming to create tools that are both technically robust and practically useful for individuals facing coverage denials.
The scale of the problem Claimable addresses is substantial. In the United States, billions of medical claims are processed annually by private insurers, Medicare, and Medicaid. While exact denial rates vary by payer and service type, government reports and industry analyses consistently indicate that a significant portion of claims receive initial denials. For example, data from the Kaiser Family Foundation indicates that in 2021, about 18% of in-network claims were denied by ACA marketplace plans, with denial rates varying widely among insurers.
Despite these denials, appeal rates remain low. A Government Accountability Office report found that fewer than 0.5% of denied claims in Medicare Advantage plans were appealed in 2021, suggesting many patients either do not know their appeal rights or find the process too daunting. This care abandonment can lead to worsened health outcomes, increased long-term costs, and inequitable access to treatment, particularly for chronic conditions requiring ongoing therapy or medication.
Claimable’s platform aims to reduce these barriers by automating the initial stages of appeal preparation. Users input basic information about their denied claim and medical condition, and the AI generates a draft letter citing specific clinical guidelines (such as those from the American Medical Association or specialty societies), relevant provisions of federal laws like the Employee Retirement Income Security Act (ERISA) or the Affordable Care Act, and state-specific protections where applicable. The platform does not replace legal counsel but provides a starting point that patients can review, customize, and submit to their insurer.
For healthcare organizations, Claimable offers a version designed to assist providers in managing prior authorization denials on behalf of patients. This tool integrates with electronic health record systems to pull relevant clinical data, potentially reducing the time physicians and staff spend on administrative appeals. By streamlining this process, the platform seeks to alleviate a well-documented pain point in medical practice: the growing burden of insurance-related paperwork that detracts from direct patient care.
The involvement of employers or regulators, as mentioned in the platform’s description, refers to situations where Claimable may suggest escalating a denied claim beyond the initial insurer appeal. For self-funded employer health plans, this could mean contacting the employer’s benefits administrator. For potential regulatory violations, the platform might guide users toward filing complaints with state insurance commissioners or the U.S. Department of Labor, depending on the nature of the denial and the health plan type.
While AI shows promise in healthcare navigation, experts caution that such tools should complement—not replace—human judgment. The American Medical Association has emphasized that prior authorization reform requires systemic changes, including real-time decision support for physicians and stricter timelines for insurer responses. AI-assisted appeals represent one piece of a broader effort to reduce unnecessary delays in care access.
As of the date of this article, Claimable continues to refine its algorithms based on feedback from users and outcomes data. The company states that its models are trained on anonymized, aggregated appeal outcomes to improve relevance and accuracy over time. Still, specific details about model training data sources, update frequency, or independent validation studies were not available in the verified sources consulted for this report.
Patients interested in exploring AI-assisted appeal tools should verify any platform’s data privacy practices, particularly regarding how personal health information is stored and used. Under the Health Insurance Portability and Accountability Act (HIPAA), companies handling protected health information must adhere to strict security and confidentiality standards. Reputable services will typically provide clear explanations of their compliance measures and user rights regarding data access and deletion.
The conversation around AI in healthcare administration is evolving rapidly. Recent legislative efforts in several states have focused on prior authorization reform, including bills that would require insurers to use interoperable technology for faster decisions or limit the use of automated systems for denials without human review. These developments suggest that while AI may help individuals navigate current systems, policymakers are also examining how to develop those systems fairer and more transparent from the outset.
For readers seeking official information about their appeal rights, several government resources provide guidance. The Centers for Medicare & Medicaid Services (CMS) offers detailed instructions for appealing Medicare coverage decisions through its website. The U.S. Department of Labor oversees ERISA appeals for private employer-sponsored plans and maintains a database of consumer assistance programs. State insurance commissioners, accessible via the National Association of Insurance Commissioners website, also provide state-specific guidance on health insurance complaints and appeals.
As artificial intelligence continues to be applied to healthcare challenges, tools like Claimable illustrate how technology can empower individuals to exercise existing rights within complex systems. By translating clinical guidelines, legal frameworks, and personal health data into actionable appeal documents, such platforms aim to reduce the asymmetry of information and resources that often disadvantages patients in insurance disputes.
The ongoing work in this space underscores a broader trend: using AI not to replace human expertise in medicine, but to handle repetitive, data-intensive tasks that currently consume significant time and energy from both patients and providers. When designed thoughtfully and deployed ethically, these tools have the potential to improve access to care while allowing healthcare professionals to focus on what they do best—diagnosing, treating, and supporting patients.
If you’ve experienced a denied medical insurance claim or have insights about navigating healthcare bureaucracy, we encourage you to share your perspective in the comments below. Your experiences can help inform others facing similar challenges. Please consider sharing this article with anyone who might benefit from understanding their options when confronting an insurance denial.