Dan Weissmann
Meet Holden Karau: a San Francisco Bay Area software program engineer who created an AI device to assist enchantment insurance coverage denials.
Her venture, Fight Health Insurance, is a labor of affection. It attracts on her tech experience and years of expertise combating medical insurance: for gender-affirming care, for rehab after getting hit by a automotive, and even for her canine, Professor Timbit.
An Arm and a Leg host Dan Weissmann talked with Karau about what it took to construct the device, the way it works, and what she hopes comes subsequent.
Dan Weissmann
Host and producer of “An Arm and a Leg.” Previously, Dan was a workers reporter for Marketplace and Chicago’s WBEZ. His work additionally seems on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting.
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Transcript: Fight Health Insurance — With Help From AI
Note: “An Arm and a Leg” makes use of speech-recognition software program to generate transcripts, which can include errors. Please use the transcript as a device however verify the corresponding audio earlier than quoting the podcast.
Dan: Hey there–
Let’s begin with introductions.
Carolyn: My title is Carolyn DeSimone, and I’ve an excellent cute canine. His title is Professor Timbit. He’s a professor as a result of he’s at all times researching one thing.
Holden Karau: My title is Holden Caro, and I’m making an attempt to make medical insurance suck a little bit bit much less
Dan: Carolyn and Holden are married, and I talked with them in September as a result of listeners had been sending me hyperlinks to a narrative within the San Francisco Standard, with the headline “‘Make your health insurance company cry’: One woman’s fight to turn the tables on insurers.”
That lady was Holden. She works in tech, and the story was a few device she’d constructed, to assist folks battle medical insurance: It writes enchantment letters, utilizing AI in fact.
She’s made it accessible at a web page, “fight health insurance dot com”
I lose depend of what number of of you despatched me that hyperlink, however thanks, SO a lot.
Holden and Carolyn reside in San Francisco. I talked to them on Zoom. A neighborhood reporter, Lee Romney, helped arrange mics for the 2 of them of their lounge.
The bookshelves within the background had — together with books –heaps little stuffed creatures. When I squinted, I may see a pikachu.
Holden Karau: So there’s just a few Pikachu’s really. Um, and we’ve a, we’ve a stuffed poop. Um, it’s a wombat poop. That’s why it’s sq.. Here.
Dan: And Lee can’t assist commenting when she sees the wombat poop as a result of it’s a brown, plushie dice with a face.
Carolyn: Let me go seize it. I’ll present you.
Dan: Lee can’t assist commenting when she sees the wombat poop: it’s a brown, plushy dice, with a face.
Lee Romney: That’s a really common trying turd.
Carolyn: Wombats have sq. poops in order that they don’t roll away.
Lee Romney: Oh, I didn’t know that.
Carolyn: Yeah, they’ve like particular muscle tissue of their buttholes to make sq. poops.
Dan: This is essentially the most enjoyable zoom I’ve ever been on, really.
Dan: And we had been simply getting began.
This is An Arm and a Leg, a present about why well being care prices so freaking a lot, and what we will perhaps do about it.
I’m Dan Weissmann. I’m a reporter, and I like a problem.
So the job we’ve chosen right here is to take some of the enraging, terrifying, miserable elements of American life, and convey you a present that’s entertaining, empowering, and helpful.
As you may think, Holden’s determination to create Fight Health Insurance attracts on each her vital skilled experience — she’s labored for Google, IBM, Apple, and now Netflix, and has written a number of technical books about programming —
and her private expertise combating medical insurance– additionally vital.
And the reserves of anger and cussedness she received from these experiences.
Holden Karau: I attempt to be a pleasant individual, however medical insurance doesn’t deliver out the very best in me.
Carolyn: I don’t suppose it brings out the very best in anybody.
Holden Karau: Certainly, definitely nobody that I do know.
Dan: Holden’s gender transition supplied a number of expertise.
Holden Karau: Being a trans individual in America, it’s a must to navigate medical insurance.
Dan: For occasion, early on, Holden says she realized one thing that I didn’t perceive till I’d been engaged on this present for some time:
If you get medical insurance out of your employer, it’s fairly seemingly that your state’s insurance coverage legal guidelines don’t apply to your plan.
Instead, your plan will get regulated by the federal division of Labor, beneath a federal regulation referred to as ERISA. Holden is aware of a LOT about ERISA and needed to suppose for a minute about when she picked it up.
Holden Karau: When did I study ERISA? I feel I knew what an ERISA plan was from IBM.
Carolyn: Oh yeah, trigger IBM received you boobs.
Holden Karau: Yeah. IBM paid for my boobs. Originally I used to be going to get a tattoo saying like sponsored by, however – I – no.
Dan: Holden says her fighting-insurance sport — and people reserves of anger– leveled up in 2019.
Holden Karau: Yeah. When I received hit by a automotive is after I like began studying medical insurance laws as a result of I didn’t have rather a lot else to do and it was additionally actually necessary that I determine it out.
Dan: Holden had been driving a brand-new Vespa. She was on sixteenth Street in San Francisco’s Mission District. Carolyn picks up the story right here…
Carolyn: A lady pulled out of the parking zone of the Safeway to show left with out trying.
Holden Karau: Yeah, throughout 4 lanes of visitors.
Dan: Holden says she had two damaged wrists, and a few damaged bones in her legs. It didn’t take lengthy for her to start out occupied with medical payments. Even although she was on very sturdy painkillers.
Holden Karau: I feel whereas I used to be nonetheless on fentanyl, I used to be occupied with insurance coverage.
Dan: She was pondering, that is gonna be… rather a lot.
Carolyn: Out of the trauma bay, however probably not once you had been out of the ER, was the primary time we thought of, what’s this gonna value?
Dan: But they are saying the precise haggling with insurance coverage didn’t begin for just a few days, when it was time for Holden to depart the hospital. And head to rehab. Her insurance coverage, she says, had a spot in thoughts.
Holden Karau: They actually needed to ship me someplace actually, actually shitty.
Carolyn: We regarded on the evaluations of them.
Holden Karau: Yeah. And it’s like, they’re actively being investigated by the state…
Carolyn: …for like hitting their sufferers with issues.
Holden Karau: Yeah. It was like, no, I don’t wish to go there.
Dan: Carolyn stated she pitched in to assist get Holden to a greater rehab, however then they are saying there have been battles over how a lot remedy she’d really get. By that point, Carolyn says, Holden was able to go proper at it.
Carolyn: Once you bought to the rehab, I feel you began studying the kinds for enjoyable.
Holden Karau: I didn’t have rather a lot occurring at that time, and I used to be nonetheless on opiates, however the opiates had been much less sturdy, so my mind was beginning to work once more.
Carolyn: You received bored.
Holden Karau: Yeah.
Dan: Holden says her mind was working, however not her physique. She couldn’t maintain a laptop computer, or actually sort. Or get away from bed to choose up her telephone if it fell to the ground. But even with damaged wrists, she was able to battle for the rehab remedy she wanted.
Holden Karau: it ended up figuring out okay, and a part of that was my willingness to only, like, take issues to an unreasonable size. I used to be like, actually, I’ve nothing to lose right here, so I’ll sue you. I’m bored.
Dan: Holden says it helped that she may afford a superb lawyer.
Especially as a result of there have been extra fights forward. She says she needed to battle for particular crutches – trigger she couldn’t use common ones with damaged wrists — and for extra bodily remedy when she received residence.
And there was an epic battle to verify medical payments didn’t utterly devour any settlement from the driving force’s automotive insurance coverage. This was a next-level authorized training.
Holden says it took three years to get all of the authorized points resolved. And, Meanwhile, she found that she’d developed a super-power — or name it a particular curiosity.
She seen: If somebody at a celebration, say, began speaking about an issue they had been having with medical insurance, she was prepared — keen– to take them down the rabbit gap.
Holden Karau: they’d be like, complaining a few factor, and it’s like, oh no, like, yeah, yeah, yeah, this sucks, they usually completely try this, however like, there’s really a factor that you are able to do, it was like, okay, like, this can be a factor that I understand how to do. I like serving to folks
Dan: But conversations at events weren’t a lot of an outlet.
Holden Karau: Like, I don’t get invited to lots of events, as a result of not lots of people are like, I’d love to hang around with that girl that retains speaking about ERISA laws or the Affordable Care Act.
Dan: And then, in January of 2023, Holden was speaking with a buddy at a tech convention.
Holden Karau: He has household that additionally has maybe a non customary degree of expertise with insurance coverage, and so like we had been speaking about generative AI…
Dan: Generative AI. Chat GPT had been launched lower than two months earlier than.. Holden and her buddy ended up pondering.. .
Holden Karau: You know what, we may use this to truly, like, make the world suck rather less.
Dan: Could use these new generative-AI instruments to battle medical insurance. Like by having it write enchantment letters when claims received denied. An thought was one factor. Making one thing would take extra. Holden used what she knew about herself to make that occur.
Holden Karau: There’s, there’s completely different sorts of motivation, proper? There’s like, uh, deadline pushed, uh, programming, which is like once you agree to provide a chat at a convention, you’re like, okay, I would like to do that by this date. Otherwise I’m going to look actually dangerous in entrance of a bunch of individuals. Uh, so I’ll try this rather a lot, however the different equally sturdy motivation, I feel, is hate. And I hate insurance coverage firms. Because they’ve identical to, they’ve been so imply to me and my associates.
Dan: Then, just a few months later, one other convention supplied a chance to mix these motivations: A hackathon — a contest the place engineers and builders get a restricted period of time to place a venture collectively. .
Holden Karau: I used to be like, okay, I’m gonna work on this for the hackathon.
Dan: That gave her a deadline: 30 days. Her venture got here in third.
Holden Karau: which, not unbelievable, however, like, not horrible, you understand.
Dan: Third out of greater than 50. Plus, it labored! Kind of.
Holden Karau: So like it will say issues like, this process needs to be lined due to the llama llama virus, and it’s identical to, oh, properly that, that’s not an actual factor, however like, good strive, good strive, proper? And it was like, you understand, like, it’s attention-grabbing, and like, it type of kind of works, nevertheless it’s additionally, it’s not nice, proper?
Dan: Getting to the subsequent stage would require a brand new method, and a few motivation — extra rage — which got here from a shocking supply.. That’s subsequent…
This episode of An Arm and a Leg is a co-production with KFF Health News. That’s a nationwide nonprofit newsroom producing in-depth journalism about well being points. Their reporters do wonderful work — and win all types of awards yearly. We’re honored to work with them.
So Holden got here out of that hackathon with one thing that type of labored. Kind of.
Then she says she discovered herself in a battle on behalf of another person in her family.
Holden Karau: Timbit, our canine, who’s wonderful, I like him, had a bunch of dental work carried out and the pet medical insurance folks had been jerks about that.
Carolyn: They stated he didn’t want anesthesia to have tooth pulled. They rejected the anesthesia. He’s 11 kilos. He can’t be awake throughout…
Holden Karau: I don’t even know if like, don’t, I don’t know anybody could be awake for that. And so I used to be like, okay, cool, how can I put the screws to them? Because you had been imply to my canine. I’m used to medical insurance firms being imply to me to the extent that I’m virtually numb to it at this level. But like, my canine is valuable and ideal. I learn the plan paperwork as a result of I’m a nerd. And like, this isn’t, Your obligation, like, you might be obligated to do extra. You must show that this isn’t needed, and I don’t suppose you are able to do that.
Dan: Holden says she additionally learn up on state laws for pet insurance coverage, and let the corporate know she’d discovered grounds for some potentially-serious challenges.
Holden Karau: and that, together with, uh, another, maybe lower than well mannered phrases, did end in them altering their opinion about whether or not or not he needs to be awake for getting his tooth pulled out.
Dan: Well carried out. Well carried out.
Holden Karau: And then it s was like, okay, you understand what? Yeah, I ought to put within the time to complete this, proper?
Dan: Finish the device to battle insurance coverage firms.
Holden Karau: Like, I’ve received this factor that’s like type of half baked, however I ought to, I ought to take this over the end line. Like, screw these insurance coverage firms.
Dan: To try this, she was going to want some information to coach her AI — the technical time period is “large language model” — or “model” for brief.
Holden Karau: Because the massive drawback, and a part of why we received this like, llama llama virus factor, is like once you don’t have information to coach a mannequin, it’s dangerous, proper? It’s like rubbish in, rubbish out. And that is additionally a part of why like, lots of giant fashions on the web are dangerous, they’re like educated on Reddit..
Dan: Yeah, in order that they be taught HOW folks use language. But they don’t be taught information. They’re like a extremely sensible 18 yr outdated who hasn’t carried out the studying however is nice at bullshitting. Because they know what “an answer” appears like on this context.
Holden wanted to coach her mannequin on a bunch of factual information for medical insurance appeals and denials. And she discovered it. Thanks to the California Department of Insurance. If your insurance coverage denies a declare, and it’s regulated by the state of California, you’ll be able to request an impartial medical evaluation from the Department of Insurance.
Which decides whether or not your process was medically needed. Every determination will get printed on-line. Describing the information. The prognosis. The process. And the reasoning behind the choice.
Holden Karau: And, like, that’s the data that you really want, proper? You wish to know, like, for a prognosis and process, why is that this needed? Why ought to the insurance coverage firm must cowl this?
Dan: And all that info was on this information — for a lot of hundreds of appeals, many hundreds of selections.
Holden Karau: I discovered the impartial medical evaluation information. And I used to be like, okay, cool. I can use this to make the mannequin higher.
Dan: Holden began whipping the mannequin into form. After about six months, she paid a developer to work up an online model — one thing that you just don’t must be a tech individual to truly use. She purchased {hardware} — servers. All instructed, she thinks she spent perhaps ten thousand {dollars}, plus a yr of nights and weekends.
In August of this yr, she had one thing prepared to indicate the world.
She emailed a neighborhood reporter who had been writing about medical insurance.
Holden Karau: I’m like, this native child who’s been engaged on this factor. It looks as if it could be, like, kinda in your beat. If not, like, completely no stress, however, like, let me know. And when you wanna chat about it, like, I’m comfortable to leap on my Vespa and like, swing over and I can discuss with you about it and present it to you. And, um, and he or she emailed me again and was like, yeah, that sounds cool.
Dan: What Holden confirmed that reporter — just about what you see now at battle medical insurance dot com — isn’t a magic wand. It doesn’t do EVERYTHING for you.
You’ve gotta make a scan of the denial letter out of your insurance coverage firm, and run it by “optical character recognition” — flip it from a picture of textual content into precise textual content. Oh, and zap personally-identifiable info — like your title and tackle — from the doc. So none of that will get captured by any machines.
You also can write up a story with any particulars — that’s elective, however looks as if a good suggestion. And you’ll be able to add your paperwork out of your insurance coverage firm that describe your advantages. That additionally appears sensible.
You feed it every thing, and it offers you again a draft of an enchantment letter — really, multiple, so you’ll be able to choose and select, and make edits.
So, there’s some homework. And all of it nonetheless seems kinda early-stage. The website isn’t super-pretty. And you know the way early, not-quite-officially-released software program will get referred to as a “beta” launch? This one says “alpha” — sooner than that.
So, no ensures. But it’s one thing.
Holden confirmed it to that reporter, and the outcome was the article {that a} bunch of listeners began sending me.
By the time I talked with Holden and Carolyn, about three weeks later, Holden stated about 300 folks had used it. She’d been keeping track of the way it carried out.
Holden Karau: It appears to generate issues that look good, proper? Which, that is necessary to me. Um, I additionally get emails from folks saying like, cool, thanks, thanks for doing this, um, in order that’s fairly rad.
But like, I assume that you just get a few of the similar tales there’s some folks the place they attain out, they’re like, Hey, that is my particular scenario. Like, what can I do? And it’s usually identical to, I want I may assist you. But like, that is simply utterly fucked.
Dan: I do get these, in fact. It by no means will get simpler. [And, I should say: If you’ve written me and I haven’t responded, don’t assume it’s because your situation is completely fucked. It’s just as likely that I can’t keep up with my email, but I REALLY APPRECIATE you writing to me, no matter what. I learn so much. Including things that don’t suck, like when a bunch of you wrote to me about Holden and her project.]
When we talked, Holden stated she hadn’t gotten a lot details about whether or not these appeals had been working. Insurance firms usually give themselves a month to reply to appeals. And it hadn’t been that lengthy.
Meanwhile, there was the query of the place this venture may go subsequent.
Holden Karau: Do I do it for like, greater than evenings and weekends?Or do I do it for evenings and weekends? And I don’t, I don’t know what the reply to that’s but.
Dan: Holden had concepts about methods it may earn earnings — perhaps by charging docs and different suppliers, however protecting the service free for sufferers?
When I requested how a lot it will value to take Fight Health Insurance to the subsequent degree, make it accessible and helpful to — you understand, all people who may want it– and maintain it updated, and maintain it dependable and steady — she began pondering, and the numbers saved going up: 100 thousand, two, 4, 5, extra.
Just a few weeks later, Holden got here to Chicago, the place I reside, for a convention. I went to fulfill her! And I received an replace from her.
Holden Karau: there’s some individuals who, who like despatched of their appeals and, and issues received permitted, and that’s fairly superior. I’m, I’m fairly stoked with that. I suppose the, the opposite factor is like, folks appear usually optimistic and comfortable. So yeah…
Dan: Thank you for this factor that didn’t exist earlier than.
Holden Karau: when the choice is simply giving up hope, like, that is so a lot better than simply going, like, God rattling it.
Dan: She was nonetheless puzzling over how Fight Health Insurance may develop. She stated when she requested a buddy with expertise within the startup world for recommendation about speaking with enterprise or enterprise capital people, the buddy’s response was fairly fast.
Holden Karau: What are you doing? No, no. They are gonna like, they’re, hm… they’re gonna lead you down the trail that you’re making an attempt actually onerous to keep away from.
Dan: Charge sufferers cash, perhaps harvest their information for who-knows-what icky functions. Basically flip into one other shark.
Holden Karau: This might be simply my naivety, however I actually I’ve this perception that the buyer model needs to be free at all times. And so one of many tips is discovering somebody that agrees with that, who’s prepared to provide us cash. Because, in any other case, It’s like, nah, it’s cool. But then the second query is, like, is there a method to shift the economics of denials, such that, like, insurance coverage firms, like, it simply prices them extra to be dicks, proper?
Dan: Assuming she finds the correct of associate, there’s a query of how Fight Health Insurance would earn earnings to maintain itself going.
She’s nonetheless within the thought of promoting a paid model to docs and different practitioners, and once we talked she’d heard from some people in that world.
Holden Karau: Of the professionals reaching out, lots of them had been from the psychological well being discipline. That’s one thing the place, that’s an space that I really feel strongly about. Like, I’d not be right here if it was not for entry to psychological well being.
Dan: Meanwhile, she says she’s squeezing in a few day every week for the venture, in between her full-time job and the remainder of her life.
Holden Karau: It’s in all probability not tremendous wholesome. Um, yeah. There’s this complete buying and selling sleep factor, which is, in the long term, not an awesome discount.
Dan: So you’ve been pondering, in some unspecified time in the future, there’ll be some selections to make.
Holden Karau: Yeah, I imply realistically in all probability January will probably be after I know if I can like work on this extra full time or not. Otherwise it’ll live on because the factor that I do when I’ve free time and nobody’s trying too carefully.
Dan: For now, Holden’s taking issues one step at a time.
Holden Karau: One of the opposite issues that I’m reminded of what certainly one of my therapists jogs my memory of so steadily is that we’re not liable for fixing the world, however we should take part on this planet’s therapeutic.
Dan: Yep.
I feel that for a few of us, our existence is sufficient, however once we can, I feel it’s good to seek out the small issues we will do as a result of in any other case we might do nothing.
Dan: Can I please say, Amen.
If you give Holden’s device a strive, I’m SUPER curious to listen to the way it seems.
If you do, I ought to point out: The privateness coverage on Holden’s website says that if the enterprise ever, say, will get offered, then whoever buys it may find yourself with any information you give it.
So Holden really suggests: perhaps create a short lived e mail tackle for working together with her website. Just in case some shark finally ends up with these things. (It wants AN e mail to ship you its outcomes. The website asks for a reputation too. You may think about using a pretend one.)
We’ll have hyperlinks to battle medical insurance — and to directions for creating a short lived e mail tackle — wherever you’re listening to this.
And we’ll be again in just a few weeks with a brand-new episode.
Till then, care for your self.
This episode of An Arm and a Leg was produced by me, Dan Weissmann, with assist from Emily Pisacreta — and edited by Ellen Weiss.
Adam Raymonda is our audio wizard. Our music is by Dave Weiner and Blue Dot Sessions. Gabrielle Healy is our managing editor for viewers.
Lynne Johnson is our operations supervisor. Bea Bosco is our consulting director of operations.
An Arm and a Leg is produced in partnership with KFF Health News. That’s a nationwide newsroom producing in-depth journalism about well being points in America and a core program at KFF, an impartial supply of well being coverage analysis, polling, and journalism.
Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this present.
And due to the Institute for Nonprofit News for serving as our fiscal sponsor. They permit us to simply accept tax-exempt donations. You can be taught extra about INN at INN.org.
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“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.
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