This AI startup helps patients fight insurance denials

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IIndustry watchers predict that generative AI could lead to an administrative crisis battle between the bots between doctors and health insurers about healthcare decisions. That leaves patients in limbo without access to medications or other treatments, while institutions hand out prior authorization and denial letters via fax, phone or algorithm. Warris Bokhari is trying to change that by putting the power of AI in the hands of patients.

Bokhari, a physician executive who has worked at Amazon, Apple and Anthem (now Elevance Health), saw that large language models like GPT-4 could be useful for summarizing information for patients at different reading levels. The idea behind it Duehis startup that launched on Wednesdayis to use these models to flip the script. Or in his words, “taking a patient story and turning it into something attractive to an insurance company.”

The company starts by partnering with rheumatology clinicsbecause many patients with conditions such as arthritis take expensive medications known as biologics, which often require prior authorization. For Bokhari this struggle is personal, his mother had rheumatoid arthritis, but because he grew up in England his family did not have to go bankrupt to afford medicines.

While building in stealth mode, he discovered that health insurers often issue denials because guidelines for certain diseases are significantly outdated. Bokhari said Claimable is pushing and refining GPT-4 with the latest clinical guidelines from the American College of Rheumatologyas well as all FDA labels and trial data for specific medications, to generate appeal letters for a flat fee of $39.95.

After testing the technology and generating “hundreds and hundreds” of letters with a human-in-the-loop for quality assurance, the software’s fully automated pilot phase has generated approximately 50 appeal letters for real patients, with an 80% denial rate . rate, Bokhari said. Most cases are resolved within ten days. With a seed round led by Walkabout Companies (he declined to disclose the amount), Claimable hopes to add more than 100 conditions by 2025 for patients with multiple sclerosis, heart disease, diabetes, obesity, asthma and certain cancers. “We think we can achieve a lot just by making the patients heard,” says Bokhari.

How Epic’s 81-year-old founder plans to keep her health data empire private forever

Judy Faulkner, who founded the electronic health records giant Epic in 1979, has bucked convention from day one, starting with the company’s dress code: “When there are visitors, you must wear clothes.”

While competitors like Cerner (now Oracle Health), Allscripts (now Veradigm), and Athenahealth grew by taking on venture capital money, doing mergers and acquisitions, going public first, and then going private again, Faulkner has spent every outside interference is avoided. And she wants to keep it that way. Faulkner said Forbes she has set in motion a plan to ensure that Epic remains private, independent, and employee-owned in perpetuity with a unique trust structure.

Read more here.

Pipeline and deal updates

Health insurance: Centivo, a startup that offers employers a primary care-focused health plan aimed at lowering costs, has increased $75 million in equity and debt financing from investors including Cone Health Ventures, MemorialCare Innovation Fund and Morgan Health (a division of JPMorgan Chase).

AI for Clinical Trials: Astrazeneca has concluded an agreement with Immunai to use its AI models to optimize clinical trials for oncology products. Immunai will receive $18 million for the first phase of the collaboration.

Cancer care: VieCure, which is building an AI-powered cancer care platform to make it easier for community hospitals to adopt personalized care options, announced that it $45 million in financing.

Immune disorders: Triveni Bio, which develops antibody treatments for inflammatory and immune diseases, announced it has closed an oversubscription $115 million Series B round.

Quantum drug discovery: Quantum computer company D-Wave has announced that this is the case entered into a research collaboration with Japan Tobacco’s pharmaceutical division to develop AI-driven drug discovery processes using quantum computing.

Cardio Imaging: Boston-based Elucid’s cardiovascular imaging software, PlaqueID, was approved by the FDA. The software classifies plaques to help doctors understand the best treatment options for their patients.

Cell therapy: Prime Medicine did that entered into a collaboration with Bristol Myers Squibb to develop reagents for use in T cell therapies. Prime will receive $110 million in upfront payments and potentially up to $3.5 billion in milestone payments.

Metabolic disorders: Kailera Therapeutics, which develops next-generation medicines for obesity and related metabolic disorders, has announced the launch with $400 million in support.

Genetic medicine: Flagship Groundbreaking has launched a new companyMirai Bio, with $50 million in support to develop an end-to-end genetic medicine platform.

The Forbes400

The richest people in America have never been richer. Forbes’ definitive ranking of America’s richest people, released this week, found the following 400 richest are worth a record $5.4 trillion, almost an increase $1 trillion from last year.

• The top dog: The highest-ranked healthcare billionaire at number 29 was 86-year-old Thomas First, Jr., who co-founded the profitable hospital chain HCA Healthcare with his father in 1968 for an estimated $31.5 billion.
• The returnee: 80-year-old pharmaceutical billionaire Robert Duggan returned to the 400 list this year with a net worth of $9.3 billion after falling back in 2021. Duggan’s fortunes soared as shares of his biotech company Summit Therapeutics soared on good news about a drug candidate to treat a type of lung cancer. (Read more here.)
• The heirs: Three grandchildren of Homer Stryker, who founded the medical device company Stryker Corporation in 1941, are all in the Forbes 400. Ronda Stryker, 70, worth $8.2 billion; Jon Stryker, 66, worth $5.4 billion and Pat Stryker, 68, worth $3.9 billion.

Read more here.

Other healthcare news

Healthcare software company Epic is facing its first antitrust lawsuit over alleged monopoly activities

‘Conversion therapy’ puts LGBTQ+ people at greater risk of mental health disorders, new study suggests

Judge strikes down Georgia’s six-week abortion ban

Before 2025, insurers are pulling back slightly on Medicare Advantage footprints

CVS Health is cutting 2,900 jobs, but mom is in danger of splitting up

About Forbes

ForbesHow Palantir Became the S&P’s Most Expensive Stock and Earned CEO Alex Karp a Spot on the Forbes 400By means of Phoebe LiuForbesThis tech entrepreneur is the richest black person in AmericaBy means of Jabari YoungForbesThis ex-shoe salesman built a $5.5 billion fortune in outdated apartment buildingsBy means of Giacomo Tognini

What else we read

Deadly Marburg virus: Scientists rush to test vaccines amid outbreak (Nature)

A hospital kept a brain-damaged patient on life support to improve statistics. His sister is now suing for malpractice. (ProPublica)

California sues hospital after patient is denied emergency abortion (The New York Times)