A Reader’s Guide to the CookCare AI Audit

In 2012, I suffered a workplace injury while teaching a customer at an Apple Store. Over the years that followed, my workers’ compensation claim was administered by Apple and its claims administrator, Sedgwick.

During that time I preserved administrative and medical records related to the claim, including treatment requests, utilization review decisions, denial letters, medical documentation, regulatory references, and communications reporting concerns about the claim.

This project examines those records to compare two things:

What the documents say

and

why treatment was denied.

Modern language-model tools were used to assist in reviewing the records examined in this project and highlighting where explanations diverge from the written record.

What Makes This Different

Most public discussions of healthcare or workers’ compensation denials rely primarily on personal experience.

This project is different.

It analyzes the written record of a workers’ compensation case over more than a decade, including:

• treatment requests from treating physicians

• utilization review decisions

• denial letters and claim correspondence

• medical history and treatment documentation

• regulatory language governing Requests for Authorization (RFAs)

• communications reporting concerns about the claim

Rather than examining these materials individually, the analysis compares the reasoning used in denial decisions with the medical history and regulatory language contained in the record.

What the Analysis Examines

The project focuses on a simple question:

Do the explanations used to deny treatment match what the documents actually say?

When medical histories, treatment requests, regulatory language, and denial explanations are reviewed together, inconsistencies in reasoning become easier to identify.

In some instances, statements in denial decisions conflict with the medical history or regulatory language contained elsewhere in the record.

Why This Matters

Workers’ compensation cases are typically handled by many different actors over time.

Claims examiners, utilization review physicians, attorneys, and administrators often see only part of the record at any given moment.

This project asks a different question:

What becomes visible when those records are examined together?

About the Project

The project builds on concerns reported over many years regarding the handling of the claim and examines how the reasoning used to deny treatment compares with the written record.