How AI Helped a Woman Overcome Health Insurance Company Gridlock for Lifesaving Arthritis Treatment

Jennifer Braunagel, 52, a bus dispatcher and receptionist, is a fighter.

Jennifer Braunagel. (CREDIT: Ashley Gilbertson)

The pain Jennifer Braunagel endured during an eight-month battle with her insurance company over rheumatoid arthritis medication was physical. The insurer’s denial of the only drug that offered hope in fighting Braunagel’s chronic illness meant ongoing bouts of severe pain in her hands, back, ankles and other joints, as well as vision problems and difficulty breathing.

But the rejection, after countless calls and pleas to try the advanced infusion drug Actemra prescribed by her doctor, also wore her down emotionally.

“I have been in a flare just because of stress and being just so totally upset and floored that an insurance company can do this to you and can just push you to the side. Like I'm nobody. And I just don't get that,” Braunagel said.

Unfortunately, Braunagel’s gut-wrenching case is not unique. Although the health care debate in America often focuses on the uninsured, the reality is that millions who do have health insurance face problems when they try to use it – especially when approval is needed for increasingly expensive prescription drugs.

A 2023 survey by the health site KFF found that roughly six out of 10 patients reported an issue with an insurance claim – often during the process known as prior authorization, when an insurance company like Braunagel’s carrier, Aetna subsidiary Meritain Health, must approve a medical procedure or a new drug treatment ahead of time. The vast majority of patients whose requests for approval are rejected don’t file a formal appeal, either because they don’t understand their right to do so, don’t feel well enough to fight a denial, or just think it would be too time-consuming or futile to even try.

Braunagel’s problem may have been numbingly familiar, but her solution was a new high-tech approach that could offer hope to other U.S. patients who face insurance company gridlock.

Jennifer Braunagel, 52, a bus dispatcher and receptionist, at her desk. (CREDIT: Ashley Gilbertson)

After those months of frustrating calls and failed appeals, Braunagel and her doctor’s office turned to a startup company called Claimable that is using artificial intelligence, or AI, to rapidly write appeal letters meant to push the buttons that will get a big insurance company to change its mind. They used AI both to mine the most salient facts in Braunagel’s case and also to pull language from previous successful appeal letters.

In this case, it worked.

The appeal letter crafted by Claimable was also forwarded to the Department of Labor in Braunagel’s home state of Illinois, which took up her case and sparked action in just five days. Today, Braufagel’s every-four-week injection of Actemra – which would have cost $589 out-of-pocket – is covered, and the treatment is working.

“The AI is the mechanism, but this is really about helping people who have been marginalized,” said Warris Bokhari, the medical doctor who launched Claimable and serves as its CEO. Braunagel was lucky to have advocates like her suburban St. Louis arthritis clinic, he said, but most patients are outgunned by Big Insurance and lack the time to make appeals and the know-how to win. So, most don’t aggressively challenge a prior-authorization rejection, even when a medical procedure or a new treatment regimen could substantially improve their quality of life.

Cigna, where I was a vice president before I became an industry whistleblower, was the subject of a damning 2023 investigation by ProPublica that found a medical director who rejected 60,000 claims in just one month and who typically did not even read them. ProPublica found that just 0.1 percent of patients rejected under prior authorization tackled the appeal process an appeal.

Jennifer Braunagel with a boxing glove hanging from her rearview mirror. (CREDIT: Ashley Gilbertson)

But Braunagel, 52, a bus dispatcher and receptionist, is a fighter. She had already been fighting off breast cancer when her rheumatoid arthritis symptoms added a new complication to a series of ongoing health problems. She said the pain started in her hands and then spread. “It hurt to breathe,” she recalled. “My elbows, my legs. I was getting cramps, these awful cramps in the back of my leg that every time I moved my toes a different way…I would wake up in the middle of the night.”

The doctors treating Braunagel at the Arthritis Center in the St. Louis suburb of Bridgeton didn’t have much success with the initial medications, which is why they prescribed Actemra, an expensive infusion medicine that offered more promise. Meritain Health initially denied the Actemra request in favor of a less expensive type of medicine – a practice known as step therapy, in which a patient is asked to spend weeks or months on a less costly medicine that doctors fear won’t be as effective.

Julie Baak, the practice manager at the Arthritis Center, said 85% of her job is working on appeals like the Braunagel case, and it’s a source of great frustration for her.

“My 25-person support team – for one physician – exhausts the 'normal' insurance and [pharmacy benefit managers] channels, which work just as they are designed, to delay and deny patient care,” Baak said. “It takes 10 to 25 hours for me, an expert advocate, to work one case successfully.” That involves communicating with the patients and their employers, and even posting on popular social media sites like YouTube or TikTok to shame big insurance companies. 

So neither Braunagel nor Baak’s team at the Arthritis Center were willing to take ‘no’ for an answer. The insurance company’s initial rejection touched off a flurry of phone calls and, over six months, two formal appeals and four separate letters of medical necessity requesting the more aggressive treatment. Meritain Health was not budging from its position, so Braunagel’s doctors took the novel step of asking Claimable to craft a new appeal.

Bokhari, who’d worked previously on the cutting edge of digital medicine, saw in the rapid advances of AI in the 2020s an opportunity to make the appeals of prior-authorization rejections go faster and – more importantly – with a better chance for success. Said Bokhari: “We’ve created a system that’s obsessed with protecting a payment model” – and not with solving the problems of patients.

It took Claimable less than a day to file an appeal using AI. Its letter said that Meritain Health had violated its own guidelines in recommending step therapy when it had already been shown to be inadequate and pointed out that Braunagel was entitled to a decision in just 72 hours. The new appeal was copied to company executives and to regulators, including the state labor official who intervened on Braunagel’s behalf.

 “It took 30 minutes for Jennifer to tell her story to Claimable,” Bokhari recalled. “We tried to highlight the humanity and the social isolation,” as well as her physical symptoms and her failed attempts at using other medications. He said the state official who read the letter was “astounded” at the lack of support Braunagel was receiving from her insurer.

Jennifer Braunagel at her desk. (CREDIT: Ashley Gilbertson)

Once the insurer approved Actemra, the results for Braunagel were dramatic – just as her doctors had hoped.

”After my first [infusion], I guess I wasn't paying attention.” she recalled. “It was on a Friday and I was flip-flopping in bed, and I woke up and I was like, ‘Oh, my back's not hurting. Oh my gosh!’ It was the most amazing thing. That pain that I have had for – I don't even know how long – out of my back and the stiffness. And I felt good.”

 Baak, who devotes so much of her working day to insurance claims and appeals, sees enormous potential in Claimable’s ability to streamline the process. She praised it as a way to give “physicians the time to focus on what they are trained to do – get the right patient on the right drug.”

Remarkably, Meritain sent another letter to Braunagel this summer, telling her it had not received the medical reports it needed to continue approving her treatment, but this time the hold-up was temporary and her infusions every four weeks resumed. Although stress – like the kind from dealing with insurance companies – still triggers occasional arthritis flares, Braunagel said she’s been able to visit her three grandchildren in San Diego, with plans to return in a few weeks.

Braunagel was shaken by her experience with her insurer and wonders how older patients can deal with all the roadblocks. “This country is supposed to be the greatest country in the world,” she said, “and people are suffering because of these insurance companies.”